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PubMed2003

Variations in dynamic lung compliance during endoscopic thoracic sympathectomy with CO2 insufflation.

Endoscopic thoracic sympathectomy (ETS) is the preferred surgery for treatment of intractable palmar hyperhidrosis (PH). General anesthesia with onelung collapsed ventilation (OLCV) using single-lumen tracheal tube (SLT), is our preferred anesthetic technique for ETS. Intrapleural CO(2) insufflation (capnothorax) was used to ensure lung collapse. The current study examined the effects of capnothorax on dynamic lung compliance (DLC) of the ventilated lung during ETS. After obtaining written informed consent, 10 adult male patients ASA I&II undergoing ETS were studied. Their average age and weight were 25 +/- 7 yr and 67 +/- 8 kg. General anesthesia with SLT and OLCV technique was used. Capnothorax with intrapleural pressure (IPP) of 10 mmHg was initially used, then it was reduced and maintained at 5 mmHg throughout the operation. Anesthesia delivery unit (Datex Ohmeda type A_Elec, Promma, Sweden) was used where airway pressures and DLC were displayed during OLCV. A computer program (SPSS 9.0 for Windows; SPSS Inc., Chicago, IL) was used for statistical analysis of the data obtained. One way analysis of variance (ANOVA) was used for analysis of data before, during and after OLCV. P<0.05 was considered significant. The mean values of the DLC were 52 +/- 6, 30 +/- 3, 39 +/- 5 and 53 +/- 9 ml/cmH(2)O before, during (at 10 and 5 mmHg IPP) and after OLCV respectively with significant differences before and at 10 and 5mmHg IPP. In conclusions, during OLCV and capnothorax for ETS, DLC tends to decrease with increasing of intrapleural CO(2) insufflation pressure. However, in short procedures it has no deleterious postoperative effect. To the best of our knowledge this is the first study performed to investigate DLC changes during OLCV with capnothorax.

Adult↗
PubMed1995

Fetal endoscopic ('Fetendo') surgery: the relationship between insufflating pressure and the fetoplacental circulation.

Application of video-endoscopic surgery to the gravid uterus provides a new treatment option for the fetus with a correctable congenital anomaly. "Fetendo" surgery requires temporary enlargement of the uterine cavity to create a working space. Volume expansion of the amniotic space raises intrauterine pressure, which could increase placental vascular resistance and thereby reduce placental blood flow. To test this hypothesis, the authors developed a fetal sheep model to examine the relationship between insufflating pressure and flow in the placental circulation. Fetoplacental blood flow was measured via ultrasonic flow probes placed around the fetal common umbilical artery and the maternal uterine artery in five anesthetized 120-day-gestation ewes. Invasive feto-maternal monitoring permitted synchronous measurement of fetal mean arterial pressure, fetal central venous pressure, maternal mean arterial pressure, amniotic pressure, and fetal oxygen saturation, with calculated values for fetal and maternal placental vascular resistance. Amniotic pressure was raised from 10 mm Hg to 40 mm Hg in 5-mm Hg increments by a combination of saline amnioinfusion and external uterine compression. At amniotic pressures of 20 mm Hg or less, placental blood flow was preserved; however, elevation of amniotic pressure above 20 mm Hg resulted in a significant decrease in placental flow, with concomitant fetal hypoxia. The authors conclude that the relationship between intrauterine pressure, flow in the placental circulation, and fetal oxygen delivery must be considered when selecting intrauterine insufflation pressures for hysteroscopic intervention.

Amnion↗
PubMed1990

Transtracheal O2 insufflation (TOI) as an alternative method of ventilation during cardiopulmonary resuscitation.

We examined the efficiency of continuous transtracheal O2 insufflation (TOI) as a method of ventilation during cardiopulmonary resuscitation (CPR) in a canine model. The tip of the insufflation catheter was placed 1 cm above the carina. The effects of TOI at flow rates of 0.2, 0.5, and 1.0 l/kg per min during and after CPR were examined in dogs with induced ventricular fibrillation. During CPR, adequate oxygenation and ventilation were maintained with TOI at flow rates of 0.5 and 1.0 l/kg per min, but not at 0.2 l/kg per min. After CPR, TOI was adequate to maintain oxygenation, but not ventilation. TOI alone did not prevent post-CPR hypercarbia in successfully resuscitated animals. Still, this study suggests that TOI might be useful as a temporary measure for emergency ventilation during CPR, especially in situations such as upper airway abnormalities, when mask ventilation or endotracheal intubation is not feasible.

Animals↗
PubMed1986

Carbon dioxide and room air insufflation of the colon. Effects on colonic blood flow and intraluminal pressure in the dog.

The potential advantages of carbon dioxide over room air to insufflate the bowel during colonoscopy include its nonexplosive nature and rapid absorption. To evaluate whether this rapid absorption would minimize any reduction in colonic blood flow resulting from the distention, we measured inferior mesenteric artery flow before, during, and after insufflation of the canine colon with room air and carbon dioxide under conditions of transient and constant elevations of intraluminal pressures. Intraluminal pressures remained elevated for briefer periods after carbon dioxide administration, and blood flow was far less compromised. At lower levels of transient (40 mm Hg) and constant (60 to 70 mm Hg) intraluminal pressure elevation, colonic blood flow was actually increased. Because it is nonexplosive and rapidly absorbable and interferes only minimally with colonic blood flow, carbon dioxide is the preferable agent to use during colonoscopy, especially in patients with suspected or proven colon ischemia in whom prolonged distention and diminished blood flow are to be avoided.

Air↗
PubMed2000

Plasma catecholamine responses during laparoscopic gynecologic surgery with CO(2) insufflation.

STUDY OBJECTIVE: To compare adrenergic-sympathetic responses during pelvic laparoscopic surgery with CO(2) insufflation with those during laparotomy. DESIGN. Prospective study (Canadian Task Force classification II-1). SETTING: Tertiary care university hospital. PATIENTS: Twenty-one infertile women with a clinical diagnosis of endometriosis. INTERVENTION: Plasma norepinephrine (NE) and epinephrine (E) levels were measured in patients undergoing laparoscopic or open pelvic surgery. MEASUREMENTS AND MAIN RESULTS: During laparoscopic surgery, increases in NE and E levels were correlated with arterial tension of CO(2) (PaCO(2)) and were greater in patients with a larger increase in PaCO(2) than in those undergoing laparotomy. Hemodynamic changes were also more evident during laparoscopic surgery, with larger PaCO(2) increases. CONCLUSION: The PaCO(2) increases due to CO(2) insufflation are associated with adrenergic-sympathetic activation and hemodynamic changes during laparoscopic pelvic surgery.

Adult↗
PubMed1995

Maternal and fetal effects of laparoscopic insufflation in the gravid baboon.

STUDY OBJECTIVE: To test the hypothesis that intraabdominal pressures (IAP) associated with abdominal insufflation for laparoscopic procedures can alter pulmonary and hemodynamic values in the pregnant baboon and hemodynamic values in the fetus. DESIGN: A descriptive physiologic study. SETTING: Animal research facility at Scott and White Memorial Hospital, Temple, TX. PARTICIPANTS: Four pregnant baboons at 120 +/- 7 days' gestation. INTERVENTIONS: The baboons underwent general anesthesia, Swan-Ganz and arterial catheter placement, and abdominal insufflation at 10 and 20 mm Hg IAP for 20-minute intervals at each pressure. The following end points were measured: maternal heart rate (MHR), mean arterial pressure (MAP), cardiac output (CO), pulmonary capillary wedge pressure (PCWP), pulmonary artery pressures (PAP), central venous pressure (CVP), systemic vascular resistance (SVR), ventilator rate (VR), oxygen saturation, and end-tidal carbon dioxide (CO2). Fetal heart rate and fetal growth values were measured, and umbilical artery Doppler flow studies were performed. MEASUREMENTS AND MAIN RESULTS: The PCWP (p <0.026), CVP (p <0.0012), and PAP (p <0.046) were significantly increased at 20 mm Hg IAP; CO decreased as IP increased. The MAP, MHR, and SVR did not change significantly with increased IAP. The only significant change in pulmonary values was the increase in peak airway pressure (p <0.001). The VR was increased from an average of 18 to 41 breaths/minute in an attempt to maintain adequate oxygen saturation and to normalize end-tidal CO2 when IAP was increased to 20 mm Hg. Respiratory acidosis (pH <7. 35, partial pressure of carbon dioxide >50 torr) was demonstrated in three of four animals within 20 minutes at an IAP of 20 mm Hg. Results of Doppler flow studies on the effects of the fetuses were unaltered immediately after this procedure compared with baseline measurements. Normal interval growth was demonstrated 2 weeks after the procedure. CONCLUSION: The baboon mothers and fetuses had no adverse effects at an IAP of 10 mm Hg, but may have significant cardiovascular and respiratory alterations associated with IAP of 20 mm Hg.

Acidosis, Respiratory↗
PubMed2001

Effects of i.v. metoclopramide, atropine and their combination on gastric insufflation in children anaesthetized with sevoflurane and nitrous oxide.

METHODS: To determine effects of i.v. metoclopramide, atropine and their combination on the airway pressures at which gastric insufflation occurs in children, 45 healthy infants and children (ASA I) received an inhalational induction of anaesthesia with sevoflurane, N2O and O2. A blinded observer used a stethoscope to auscultate over the upper abdomen for any air entry. First, proximal airway pressure was slowly increased by closing the pop-off valve of the anaesthesia machine until gas was heard entering the stomach (pop-off point, control measurement). If the peak inspiratory pressure reached 40 cm H2O, the patient was to be excluded from the study. Then, all subjects randomly received i.v. atropine 0.01 mg.kg-1, metoclopramide 0.2 mg.kg-1, or atropine 0.01 mg.kg-1 plus metoclopramide 0.2 mg.kg-1 (n=15 each), and determination of the pop-off point was repeated 5 min later. The stomach was evacuated before each measurement. RESULTS: Atropine significantly decreased the pop-off point [from 21 +/- 3 to 19 +/- 2 cm H2O (mean +/- SD), P < 0.05], while metoclopramide significantly increased the pop-off point (from 20 +/- 3 to 26 +/- 6 cm H2O, P < 0.05). The combination of metoclopramide and atropine did not alter the pop-off point (from 20 +/- 2 to 19 +/- 5 cm H2O). CONCLUSION: Since metoclopramide exerts only mild effect on the pop-off point, cricoid pressure still remains the standard anaesthetic practice to prevent gastric insufflation in children. Prophylactic i.v. metoclopramide may be restricted to, and its clinical usefulness should be determined in, symptomatic patients with gastro-oesophageal reflux.

Anesthesia, General↗
PubMed1999

Pain after small bowel meal and pneumocolon: a randomized controlled trial of carbon dioxide versus air insufflation.

AIM: To determine whether the use of CO2 rather than air insufflation results in less pain and/or distension in patients undergoing small bowel meal (SBM) and pneumocolon (PC). MATERIALS AND METHODS: One hundred patients for SBM and PC were randomized to receive either air or carbon dioxide (CO2) as the insufflating gas. Both the patient and radiologist were blinded to the gas being used. Patients were given a questionnaire to complete the following day. The degree and duration of abdominal pain and swelling were scored on a visual analogue scale from 0 to 100. RESULTS: Seventy-nine patients replied. The mean pain score was 28.1 for patients receiving air and 20.35 for those receiving CO2 (P < 0.05). The duration of pain was 9.0 h in the air group and 6.0 h in the CO2 group (P < 0.05). The mean abdominal swelling score was 27.1 for patients receiving air and 17.1 for those receiving CO2 (P < 0.05). The duration of swelling was 8.8 h in the air groups and 7.3 h in the CO2 group (P = 0.16). CONCLUSION: In patients presenting for SBM and PC, the severity and duration of abdominal pain and distension are significantly reduced by the use of CO2 rather than air.

Abdominal Pain↗
PubMed2001

[Technique of endoscopic subfascial CO2 insufflation-dissection of perforator veins].

Endoscopic subfascial dissection of perforating veins (ESDP) represents a new additional technique for treatment of greater saphenous system varicosities. We present a modification of ESDP, entitled endoscopic subfascial insufflation-dissection of perforating veins (ESIDP). In ESIDP CO2-insufflation induced enlargement of subfascial space (subfascial pneumocave) facilitates identification and dissection of perforating veins. From 1.1.1998 to 1.7.2000, 150 procedures of ESIDP have been conducted in 127 patients (90 females, 37 males). Identification of incompetent perforating and superficial veins and assessment of deep veins were performed preoperatively using duplex sonography. In addition to a description of the surgical technique, we present an overview about indications for ESIDP and possible ESIDP-related postoperative complications.

Carbon Dioxide↗
PubMed1993

Extraperitoneal endosurgical lymphadenectomy with insufflation in the staging of bladder and prostate cancer.

A new technique of endosurgical pelvic lymph node dissection was performed for the staging of 10 prostate and 8 bladder cancers. The technique, involving an exclusive extraperitoneal space development with CO2 insufflation, is described in detail. Using the standard endosurgical (laparoscopic) equipment, we performed a complete bilateral ilio-obturator lymph node dissection in 15 patients (83%). In the remaining three patients, because of technical difficulties, only unilateral dissection was performed. The average operating time was 84 minutes. Morbidity was low (one instance of sepsis). Prospective assessment of CO2 homeostasis showed that arterial CO2 pressure (PaCO2) increased significantly but could be controlled by increasing minute ventilation output. Our results show that perioperative assessment of end-tidal CO2 partial pressure is necessary and sufficient for the adaptation of minute ventilation output. Two patients with prostate cancer had positive nodes. No intraoperative or postoperative morbidity related to the procedure was observed in patients submitted to radical surgery. Extraperitoneal endosurgical pelvic lymphadenectomy with CO2 insufflation is a rapid, safe, and effective method in the staging of urologic pelvic malignancies and represents an alternative to traditional open surgery as well as to conventional transperitoneal laparoscopic lymphadenectomy.

Carbon Dioxide↗
PubMed1999

Quantification of insensible water loss associated with insufflation of nonhumidified CO2 in patients undergoing laparoscopic surgery.

A growing number of surgical procedures of increased duration are being performed using laparoscopic techniques. No study to date has quantitated the potential insensible water loss associated with laparoscopic surgical procedures as a result of intra-abdominal humidification of insufflated nonhumidified CO2 gas. The purpose of this study was to quantitate this insensible water loss by measuring the CO2 gas volume consumed and the relative humidity of the vented gas. Ten patients presenting for elective procedures were enrolled in this descriptive prospective IRB-approved study. After secondary trocar placement and attainment of the desired intra-abdominal pressure, vented laparoscopic gas was passed directly through a dewpoint monitor sensor. Determinations of dewpoint and gas temperature were made immediately after the start of the surgical procedure and every 15 minutes thereafter until completion. Dew-point temperature was converted to relative humidity, which was used to determine the water vapor content of the gas. The actual water content (absolute humidity) of the vented laparoscopic gas was then calculated from the water vapor volume. The mean relative humidity of the vented laparoscopic gas was 92.2% +/- 0.8%. The mean laparoscopic gas flow rate was 42.0 +/- 5.0 L/h. The mean volume of water (absolute humidity) loss attributed to humidification of dry CO2 was found to be less than 1 mL/h. Insufflation of dry CO2 during laparoscopic procedures therefore results in insignificant insensible water loss.

Adult↗
PubMed2005

Heated and humidified insufflation during laparoscopic gastric bypass surgery: effect on temperature, postoperative pain, and recovery outcomes.

BACKGROUND: Controversy exists regarding the efficacy of heated and humidified intraperitoneal gases in maintaining core body temperature. We performed a sham-controlled study to test the hypothesis that active warming and humidification of the insufflation gas reduces intraoperative heat loss and improves recovery outcomes. PATIENTS AND METHODS: Fifty morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass procedures using a standardized anesthetic technique were randomly assigned to either a control (sham) group receiving room temperature insufflation gases with an inactive Insuflow (Lexion Medical, St. Paul, MN) device, or an active (Insuflow) group receiving warmed and humidified intraperitoneal gases. Esophageal and/or tympanic membrane temperature was measured perioperatively. Postoperative pain was assessed at 15 minute intervals using an 11-point verbal rating scale, with 0 = none to 10 = maximal. In addition, postoperative opioid requirements, incidence of nausea and vomiting, as well as the quality of recovery, were recorded. RESULTS: Use of the active Insuflow device was associated with significantly higher mean +/- standard deviation (SD) intraoperative core body temperatures (35.5 +/- 0.5 vs. 35.0 +/- 0.4 degrees C). Postoperative shivering (0 vs. 19%) and the requirement for morphine in the postanesthesia care unit (5 +/- 4 vs. 10 +/- 5 mg) were both significantly lower in the Insuflow vs. control groups. Patients in the Insuflow group also reported a higher quality of recovery 48 hours after surgery (15 vs. 13, P < 0.05). CONCLUSION: The Insuflow device modestly reduced shivering and heat loss, as well as the need for opioid analgesics in the early postoperative period. However, it failed to improve laparoscopic visualization due to fogging, and provided improvement in the quality of recovery only on postoperative day 2.

Body Temperature↗
PubMed2002

Reliability of epigastric auscultation to detect gastric insufflation.

BACKGROUND: We studied the reliability of epigastric auscultation to detect gastric insufflation in 30 anaesthetized, paralysed intubated patients. METHODS: A 16FG gastric tube was positioned with the tip in the mid-oesophagus with the proximal end attached to an injection port with a one-way valve. Four observers participated in the study. Observers were paired and each pair studied 15 patients. Each patient underwent four test sequences in random order, two by each observer. Each test sequence comprised one observer injecting different volumes of air (0.25 ml, 0.5 ml, 1 ml, 2 ml, 3 ml, 4 ml, 5 ml, 10 ml, 15 ml and 0 ml as a control) in random order whilst the second blinded observer listened with a stethoscope over the epigastrium. Each randomized volume was injected rapidly at 5 s intervals for 1 min. The number of injections required to detect air entering the stomach was recorded. The stomach was deflated between each test sequence. RESULTS: To detect air entering the stomach with 95% confidence, 11 injections were required for 0.25 ml; 7 for 0.5 ml; 3 for 1 ml; 2 for 2 ml and 3 ml, and I for > or =4 ml. The mean (range) inter- and intraobserver reliability was 0.73 (0.71-0.75) and 0.76 (0.76-0.89), respectively. The incidence of false positives was 21% (25/120) and the incidence of false negatives was 10% (103/1080), making the specificity and sensitivity 79% and 91%, respectively. CONCLUSIONS: We conclude that epigastric auscultation can detect gastric insufflation of 0.25 ml air after 11 breaths and > or = 4 ml air after one breath with 95% confidence. Inter- and intraobserver reliability is moderate to excellent. Epigastric auscultation should be repeated to reduce the risk of false positives.

Adolescent↗
PubMedDate not supplied

Amyotrophic lateral sclerosis. Successful treatment of mucous plugging by mechanical insufflation-exsufflation.

Bronchial mucous plugging is the main precipitating factor of acute respiratory failure for patients with neuromuscular disease. Manually assisted coughing and mechanical insufflation-exsufflation can effectively eliminate airway secretions without resorting to tracheal intubation provided that bulbar muscle function is sufficient to permit assisted peak cough flows of 160 l/min or greater. We now report successful use of mechanical insufflation-exsufflation to prevent acute respiratory failure for a patient with amyotrophic lateral sclerosis with no measurable peak cough flow.

Aged↗
PubMed2003

Randomized comparison between different insufflation pressures for laparoscopic cholecystectomy.

Laparoscopy using carbon dioxide insufflation induces adverse effects in both the cardiovascular and the respiratory function. The use of low pressure pneumoperitoneum has been shown to reduce adverse hemodynamic effects. However, its effect on tissue trauma and postoperative pain and recovery remains controversial. The aim of this study was to compare tissue trauma, postoperative pain, and recovery in two groups of patients undergoing laparoscopic cholecystectomy, one at insufflation pressure of 8 (LC8) and the other at 15 mm Hg (LC15). Forty patients were randomized, 20 in each group. The characteristics of the patients were similar in the two groups. The procedure was completed in all patients in the LC15 group, but in 2 patients in the LC8 group the pressure was increased to 15 mm Hg to complete the operation. There were no significant differences in postoperative pain scores, analgesic consumption, and the incidence of nausea, vomiting, and shoulder pain between the two groups. C-reactive protein concentrations and white blood cell count rose significantly after surgery, but the increase was similar in the two groups. The median duration of surgery was similar, 23 minutes (range 15-65) in the LC8 group and 25 minutes (range 15-80) in the LC15 group. Using our technique of laparoscopic cholecystectomy, there were no advantages to tissue damage, postoperative pain, and recovery when a low pressure pneumoperitoneum was used.

Acute-Phase Reaction↗
PubMed1994

End-tidal carbon dioxide tension during laparoscopic cholecystectomy. Correlation with the baseline value prior to carbon dioxide insufflation.

An investigation of end-tidal carbon dioxide tension changes was carried out in 19 healthy adult patients undergoing laparoscopic cholecystectomy. Following induction of anaesthesia, and throughout surgery, the end-tidal carbon dioxide tension was continuously monitored by capnography. The value following carbon dioxide insufflation increased with time to reach a maximum value after 40 min. Correlation of the individual maximum end-tidal carbon dioxide tension during laparoscopy with the corresponding baseline value prior to carbon dioxide insufflation showed a positive linear relationship (correlation coefficient 0.86). The correlation showed that an end-tidal carbon dioxide tension of 5.32 kPa (40 mmHg) can be achieved during laparoscopy when the baseline value is adjusted to around 4.0 kPa (30 mmHg).

Adult↗
PubMed1994

The effect of insufflation leaks upon ventilation. A quantified comparison of ventilators.

Some ventilator-dependent patients use uncuffed tracheostomy tubes, resulting in fluctuations in the minute volume of ventilation. Bedside measurement of ventilation is difficult because of the insufflation and exsufflation leaks. This laboratory study of five different ventilators measured the tidal volumes achieved with three insufflation leaks introduced in an increasing order of magnitude and at three levels of compliance. The largest leak reduced the peak inflation pressure from 26 to 14 cmH2O in two pressure-limited ventilators with a 35% loss of the initial tidal volume of 800 ml. The turbine-driven pressure-limited ventilator retained a peak pressure of 20.5 cmH2O and lost only 14% of the volume, whereas the volume ventilators lost 65% of the tidal volume. The loss of volume was 3% for every cmH2O decrease in airway pressure due to a leak, regardless of the ventilator or compliance. Using the Friedman test, the differences between the volume ventilators and the pressure ventilators were significant whilst the three pressure-limited ventilators did not perform significantly differently from each other.

Equipment Design↗
PubMed2005

Induction of protective serum meningococcal bactericidal and diphtheria-neutralizing antibodies and mucosal immunoglobulin A in volunteers by nasal insufflations of the Neisseria meningitidis serogroup C polysaccharide-CRM197 conjugate vaccine mixed with chitosan.

Thirty-six healthy volunteers received either a single intramuscular injection of Neisseria meningitidis serogroup C polysaccharide (MCP)-CRM197 conjugate vaccine in alum or two nasal insufflations 28 days apart of the same vaccine powder, without alum, mixed with chitosan. Nasal immunization was well tolerated, with fewer symptoms reported than after intramuscular injection. The geometric mean concentrations of MCP-specific immunoglobulin G (IgG) after one nasal immunization were 3.25 microg/ml in naïve subjects and 14.4 microg/ml in subjects previously immunized parenterally, compared with 4.30 microg/ml in naïve subjects immunized intramuscularly. The geometric mean titer of serum bactericidal antibody (SBA) rose 24-fold after two nasal immunizations in naïve subjects and was comparable to parenteral immunization (1,080 versus 1,625). All subjects achieved SBA titers associated with protection after two nasal immunizations: even those with titers of <8 at entry. A single nasal immunization boosted the SBA titer to > or =128 in 96% of previously immunized subjects, and two immunizations achieved this level in 92% of naive subjects. MCP-specific IgG levels were approximately 70% IgG2 and approximately 20% IgG1 after nasal or intramuscular immunization. Increases in CRM197-specific IgG and diphtheria toxin-neutralizing activity were observed after nasal or intramuscular immunization, with balanced IgG1/IgG2 and higher IgG4. Significant MCP-specific secretory IgA was detected in nasal wash only after nasal immunization and predominantly on the immunized side. Simple nasal insufflation of existing MCP-CRM197 conjugate vaccines in chitosan offers an inexpensive but effective needle-free prime and boost against serogroup C N. meningitidis and diphtheria.

Adult↗