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PubMed1997

High-flow laparoscopic insufflators.

In this Update of our July 1995 Evaluation (Health Devices 24[7]), we tested three high-flow laparoscopic insufflators not covered in the original study. In this issue, we are again using the Product Profile Evaluation format that we introduced in our August 1996 (25[8]) Update Evaluation of automated external defibrillators; see the inset on page 14 for a detailed explanation of this new format. In brief, we evaluated the three new units using the same criteria and test methods as in the July 1995 study and rated and ranked the units according to the same overall scheme. Because our criteria and test methods have not changed since the original study, we have not repeated them in this issue; readers should refer to the July 1995 issue for that information. Instead, in a series of Product Profiles, we present the characteristics, test results, and ratings for each newly evaluated unit individually. Following the profiles, a comprehensive Conclusions section details how the newly evaluated units compare with those evaluated in our original study. One of the units evaluated in this issue is rated Acceptable. The other two are rated Conditionally Acceptable because of their inability to provide adequate pressure relief; a secondary gas source should not be applied in the pneumoperitoneum while these units are in use. Of the 16 units we have evaluated to date, nine are rated Acceptable and seven are rated Conditionally Acceptable.

Equipment Design↗
PubMed1998

[A case of air embolism during tubal insufflation].

Air embolism occurred immediately after tubal insufflation in a 40-yr-old female patient following abdominal total hysterectomy under general anesthesia. Abrupt decreases in Etco2, Spo2, and blood pressure were observed. Blood gas analysis revealed a marked difference between PaCO2 and EtCO2. The patient recovered soon and was extubated in the operating room. The post operative course was uneventful. Monitoring of EtCO2 was effective for early detection of air embolism.

Adult↗
PubMedDate not supplied

Changes in splanchnic blood flow and cardiovascular effects following peritoneal insufflation of carbon dioxide.

Laparoscopic surgery has rapidly become a popular and widely used technique. Although this procedure has been shown to be generally safe, cardiovascular derangement related to carbon dioxide pneumoperitoneum has been reported. There are few data available on the relationship between systemic and regional hemodynamics in cases of pneumoperitoneum. Changes in splanchnic blood flow and cardiovascular effects following a moderate increase of intraabdominal pressure (IAP) to 16 mmHg during a 3-h period were analyzed in six anesthetized dogs. After insufflation, cardiac output and blood flow in the superior mesenteric artery and portal vein decreased progressively and returned to the preinsufflation values following deflation. Hepatic arterial blood flow did not change significantly, perhaps due to compensatory mechanisms for maintenance of hepatic blood flow. Mechanical compression of the splanchnic capillary beds due to the elevated IAP may possibly reflect the increase in systemic vascular resistance causing the decrease in cardiac output. To prevent this impairment, intermittent decompression of gas during surgical laparoscopy is recommended.

Animals↗
PubMed1996

Intraperitoneal cell movement during abdominal carbon dioxide insufflation and laparoscopy. An in vivo model.

PURPOSE: Possible mechanisms of movement of malignant cells within the peritoneal cavity during CO2 insufflation and laparoscopy involve direct transfer via laparoscopic instruments or dispersion of cells by CO2 or water vapor. An in vivo model has been developed to study these mechanisms. METHODS: Laparoscopy was performed on an animal model (domestic white pig). Cells derived from colorectal cancer cell line Lim 1215 were injected to lie free within the peritoneal cavity. A polycarbonate filter system with a 5-micron pore diameter was used to examine CO2 expelled from the peritoneal cavity, during laparoscopy and manipulation of abdominal viscera, for malignant cells. Laparoscopic instruments and laparoscopic ports were washed independently, and fluid was centrifuged and examined for malignant cells. RESULTS: Malignant cells were identified on 1 of 30 filters used to examine exhaust carbon dioxide. Malignant cells also were identified from 2 of 10 washings from laparoscopic ports and from 4 of 10 washings of laparoscopic instruments. CONCLUSIONS: These results suggest that movement of cells throughout the peritoneal cavity during laparoscopy is via contaminated instruments, but local cell movement by dispersion possibly within water vapor from the port may also occur.

Animals↗
PubMed2006

Inclusion of an S-nitrosylating agent in the insufflating gas does not alter gastric activity in rats following pneumoperitoneum.

BACKGROUND: We have previously shown that mixing the S-nitrosylating agent ethyl nitrite with carbon dioxide can attenuate pneumoperitoneum-induced decreases in splanchnic blood flow, but it was unclear if this agent would alter gastric function. This question was answered using rats by assessing gastric emptying and gastrointestinal transit times following gavage with radioactive chromium. METHODS: There were five experimental groups: absolute control, anesthesia control, and carbon dioxide alone or with 100 or 300 parts per million ethyl nitrite. The period of insufflation was 1 h, and all animals were euthanized 6.5 h after chromium administration. RESULTS: The mean amount of radioactivity remaining in the stomach ranged between 16% and 27% of the total administered; these differences were not statistically significant (p > 0.05). Modest differences in chromium distribution were identified in the gastrointestinal tract, but for all treatments, the peak amount of radioactivity was located in the distal portion. Location of the peak, expressed as a percentage of total tract length, varied between 70% and 85% (p = 0.366). CONCLUSIONS: This study found no adverse effect of ethyl nitrite on postoperative gastric emptying or gastrointestinal transit time following pneumoperitoneum. The findings support continued assessment of the clinical utility of ethyl nitrite in the setting of laparoscopic surgery.

Animals↗
PubMed2001

A randomized controlled trial assessing the effect of heated carbon dioxide for insufflation on pain and recovery after laparoscopic fundoplication.

BACKGROUND: Insufflation with heated gas for laparoscopy may reduce postoperative pain. This study assessed the effect of heated gas on outcome after fundoplication. METHODS: A blinded, randomized trial compared the effect of heated or standard carbon dioxide (CO2) on core temperature, postoperative pain, analgesic requirement, and postoperative recovery. Pain scores were assessed with a 100 mm visual analog scale (VAS). Recovery was assessed with a patient diary and clinical follow-up assessment at 8 days and 1 month postoperatively. RESULTS: For this study, 40 patients were randomized to heated CO2 (n = 19) and standard CO2 (control) (n = 21) groups. The heated CO2 group increased core body temperature from 35.9 degrees to 36.1 degrees C, (p = 0.008), whereas the control group maintained core temperature at 35.8 degrees C. The control group had lower analgesic requirements and pain scores, significant at 12 h (VAS: 20 vs 36 mm; p = 0.04). There was no difference between the groups in terms of late recovery. The heated CO2 group showed a significant correlation between operative duration and requirement for postoperative morphine (p = 0.01). CONCLUSIONS: Heated gas provides no benefit for patients and may be associated with increased early pain. The elevation of core body temperature observed with heated CO2 is of little clinical significance.

Adult↗
PubMed1991

Respiration by tracheal insufflation of oxygen (TRIO) at high flow rates in apneic dogs.

Tracheal insufflation of oxygen (TRIO) is a technique in which oxygen is introduced into the trachea at a constant flow rate via a catheter advanced to the level of the carina. We studied the effects of flow rates (0.5, 1.0, 1.5 and 2.0 l.kg(-1).min(-1)) on arterial blood gases during TRIO in 6 apneic dogs. The constant flow was administered through the tip of a catheter (I.D. 2.0 mm) advanced to a site of 1 cm above the carina. After 30 min of TRIO, the mean Pa(CO)(2) at the flow rates of 0.5, 1.0, 1.5 and 2.0 l.kg(-1).min(-1) were 88 +/- 20, 76 +/- 20, 64 +/- 23 and 52 +/- 18 mmHg, respectively. CO(2) elimination increased as the flow rates increased from 0.5 to 2.0 l.kg(-1).min(-1). Based on the above study, we examined the effects of TRIO at a flow rate of 3 l.kg(-1).min(-1) in another 5 apneic dogs. TRIO, at a flow rate of 3 l.kg(-1).min(-1), was able to maintain normocarbia over 4 hr. The mean Pa(O)(2) and Pa(CO)(2) at 4.0 hr were 465 +/- 77 and 41 +/- 4 mmHg. Although the mechanism of pulmonary gas exchange during TRIO is unclear, our study is the first to document that normocarbia can be maintained by high-flow TRIO in apneic dots.

Journal Article↗
PubMed1989

Effects of tracheal insufflation of oxygen (TRIO) on blood gases during external cardiac compressions in dogs under ventricular fibrillation.

Tracheal insufflation of oxygen (TRIO) is a form of constant-flow ventilation. We studied the effect of TRIO at a flow rate of 2 L/kg/min on arterial blood gases during external cardiac compressions in dogs with ventricular fibrillation. During the combined application of TRIO and external cardiac compressions, all animals were adequately oxygenated and hyperventilated except in cases where lung edema developed in the course of cardiopulmonary resuscitation (CPR). No pulmonary barotrauma was observed. The findings suggest that TRIO might be used as a temporary measure for emergency ventilation when CPR is performed in certain situations such as upper airway abnormalities or cardiac arrest outside the hospital setting, where intermittent positive pressure ventilation is not feasible.

Journal Article↗
PubMed1993

Outpatient pediatric oesophagoscopy using a flexible fibreoptic bronchoscope. Design of an insufflation-aspiration adaptor.

The design of an adaptor for use with fibre-optic flexible endoscopes with a single instrument channel is described that enables them to be used for oesophagoscopy. The adaptor enables both aspiration of secretions as well as gas insufflation to expand the oesophagus distal to the tip of the endoscope down the single channel. When the adaptor is used on a pediatric bronchoscope it is possible to perform oesophagoscopy in an outpatient setting on the awake child. This application is particularly useful for the assessment of children who have ingested corrosive agents and enables rational management decisions to be based on precise knowledge of the extent of the mucosal injury.

Ambulatory Care↗
PubMed1991

Recurrent pneumoperitoneum following vaginal insufflation.

The authors report a case of a 24-year-old nulligravida woman who presented to the hospital with complaints of severe abdominal pain and radiographic evidence of pneumoperitoneum. She had two prior nondiagnostic laparotomies for similar complaints and radiographic findings. After a careful sexual history was taken the patient revealed that she had sexual intercourse preceding every similar episode including this one, during which her partner forcefully blew air into her vagina. Pneumoperitoneum associated with vaginal insufflation has been previously reported in two multigravida patients with and without anatomic abnormalities. When pneumoperitoneum is present in the absence of gastrointestinal symptoms or trauma, a meticulous sexual history should be made to avoid unnecessary laparotomies.

Adult↗
PubMed1986

Relief of sleep-related oropharyngeal airway obstruction by continuous insufflation of the pharynx.

Sleep-related upper airway obstruction was treated by continuous insufflation of the pharynx (CIP) in 20 children. All had symptoms but only 1 qualified for a diagnosis of the obstructive sleep apnoea syndrome. Passage of warm humidified air through a thin nasopharyngeal tube at 2-10 litres/min (mean 3.5) relieved obstruction immediately in all patients. Relief was always clinically apparent and accompanied by reduced pleural pressure excursions during breathing. An index of the work of breathing (the product of breathing frequency and pleural pressure change per breath) fell by nearly 60% while patients were on CIP. Transcutaneous oxygen tension was monitored in 5 patients and was improved by CIP in each instance. Side-effects of CIP were minor and preventable with up to 72 days of continuous use. CIP is thus a simple and safe method that rapidly relieves severe oropharyngeal airway obstruction in children during sleep. Whether CIP is useful in domiciliary care or for adults has still to be established.

Adenoidectomy↗
PubMed1991

Efficacy of tracheal insufflation of oxygen during oleic acid-induced pulmonary edema.

STUDY OBJECTIVES: To determine whether tracheal insufflation of oxygen (TRIO) might be useful in field resuscitation of casualties with lung dysfunction. DESIGN: Physiological measurements of cardiac and respiratory function were compared before and after oleic acid lung injury. SETTING AND PARTICIPANTS: Beagles were studied in a laboratory. INTERVENTIONS: Oleic acid (0.06 mL/kg) was injected over four minutes into the central venous port of a pulmonary artery catheter. Measurements were made during 30 minutes of TRIO before and after acute lung injury. MEASUREMENTS: Hemodynamic and respiratory measurements, including intravascular pressures, heart rate, cardiac output, blood gases, respiratory system compliance, and O2 consumption were recorded during conventional mechanical ventilation and TRIO. RESULTS: Before acute lung injury, PaO2 (mean +/- SD) increased (P less than .05) from 96 +/- 7.4 (13 +/- 1.0 kPa) during conventional mechanical ventilation to 360 +/- 123 mm Hg (48 +/- 16.4 kPa) after TRIO. PaCO2 (mean +/- SD) increased (P less than .05) from 39.5 +/- 1.1 (5.3 +/- 0.1 kPa) to 102 +/- 27.4 mm Hg (13.6 +/- 3.6 kPa). Arterial and mixed venous pH values decreased in proportion to PCO2. After acute lung injury, compliance decreased. PAO2 decreased (P less than .05) to 58 +/- 8.4 mm Hg (7.7 +/- 1.1 kPa) during conventional mechanical ventilation and increased (P less than .05) to 84 +/- 19.6 mm Hg (11.2 +/- 2.6 kPa) after 30 minutes of TRIO. CONCLUSION: Despite poor gas exchange after acute lung injury, TRIO maintained adequate oxygenation and may be useful for emergency ventilation even when pulmonary edema complicates resuscitation.

Animals↗
PubMed1999

Abdominal wall lift versus carbon dioxide insufflation for laparoscopic resection of ovarian tumors.

STUDY OBJECTIVE: To evaluate and compare changes in pulmonary mechanics and stress hormone responses between abdominal wall lift (gasless) and carbon dioxide (CO2) insufflation laparoscopic surgery during controlled general anesthesia. DESIGN: Prospective, randomized clinical study. SETTING: Operating rooms at a university medical center. PATIENTS: 12 ASA physical status I and II female patients undergoing laparoscopic resection of ovarian tumors. INTERVENTIONS: Patients were divided into two groups of six each: the abdominal wall lift group and the CO2 pneumoperitoneum laparoscopic group. Following induction of anesthesia, patients were paralyzed and the trachea was intubated. Anesthesia was maintained with isoflurane and nitrous oxide (N2O) in oxygen. Throughout the procedure, patients were mechanically ventilated with a tidal volume of 10 ml/kg and a respiratory rate of 10 breaths per minute. MEASUREMENTS AND MAIN RESULTS: During the laparoscopic procedure, arterial blood gases, acid-base balance, pulmonary mechanics, stress-related hormones, and urine output were measured and recorded. In the CO2 pneumoperitoneum group, arterial CO2 tension increased (p < 0.01), dynamic pulmonary compliance decreased (p < 0.01), peak inspiratory airway pressure increased (p < 0.01), and plasma epinephrine (p < 0.05), norepinephrine (p < 0.05), dopamine (p < 0.01), and antidiuretic hormones (p < 0.05) increased significantly during the laparoscopic procedure as compared to the abdominal lift group. Adrenocorticotropic hormone and cortisol increased as compared to baseline value in both groups (p < 0.05). Urine output was significantly less (p < 0.01) in the CO2 pneumoperitoneum group than in the abdominal wall lift group. CONCLUSIONS: Abdominal wall lift laparoscopic surgery is physiologically superior to CO2 pneumoperitoneum laparoscopic surgery as seen during the conditions of this study. Abdominal wall lift laparoscopic surgery provides normal acid-base balance and a lesser degree of hormonal stress responses, it maintains urine output, and it avoids derangement of pulmonary mechanics.

Abdominal Muscles↗
PubMed2000

Tracheal gas insufflation.

Tracheal gas insufflation (TGI) is an adjunct to mechanical ventilation that reduces CO (2) present in the anatomic deadspace. This is accomplished by flowing fresh gas (typically 6-10 lpm) directly into the trachea via a catheter placed into the endotracheal tube positioned at the distal end or by an embedded catheter in the wall of a specially designed endotracheal tube. This is thought to improve gas mixing because of the turbulent flow created at the tip of the catheter. There are two methods of gas flow delivery and cycling. Gas flow may be delivered directly toward the carina or in a reverse flow fashion. Cycling of TGI flow may be just during exhalation or during both inhalation and exhalation. A system integrated into the monitoring and controls of a mechanical ventilator could eventually prove the safest and most effective. However, currently there are no FDA-approved devices for TGI administration. It is critical to monitor the adverse effects (triggering, auto-PEEP [positive end expiratory pressure], air trapping, and patient comfort) created by the additional flow introduced into the ventilator circuit, while balancing the CO (2) clearance. There are limited data, mostly from animal studies. However, the trials done in both animal and humans are promising with regard to effective CO (2) elimination and avoidance of unacceptably high peak airway pressures. Available equipment has limited studies with infants. Even within the adult population, much work needs to be done to determine the optimal catheter position, the most appropriate TGI flow characteristics, and improve the safety of TGI.

Journal Article↗
PubMed1998

Untoward cardiac changes during CO2 insufflation in laparoscopic cholecystectomies in low-risk patients.

In the past decade, laparoscopic cholecystectomy has become the gold standard treatment for gallbladder disease. A debate has arisen about using CO2 to distend the abdomen because of negative effects on venous return to the heart and declining cardiac output. Some authors have supported the use of pulmonary artery catheters for intraoperative monitoring while others have recommended gasless techniques to avoid these negative effects for high-risk patients. In this study, four cases of bradycardia and/or asystole during CO2 pneumoinsufflation at the beginning of planned, elective laparoscopic cholecystectomies are described. These patients were ASA category II, without history of cardiac disease. To determine the frequency and any underlying common denominators, we analyzed these laparoscopic cholecystectomies. Each patient experienced bradycardia shortly after the start of the laparoscopic cholecystectomy. None had known cardiac disease or symptoms. Two were on antihypertensive medications, and one had experienced an episode of unexplained bradycardia 6 years earlier. These cases occurred during 725 laparoscopic cholecystectomies (0.6% approximately). Using the senior author's conversion rate of 10% to open cholecystectomies, the entire group would be approximately 800, and the risk of bradycardia upon induction of CO2 is 4 per 800, or 0.5%. Although cardiovascular changes were noted during laparoscopic gynecologic surgery approximately 20 years ago, only in the last few years have cardiovascular changes been reported during laparoscopic cholecystectomies. This study reviews four cases of bradycardia during CO2 insufflation in patients that were considered to be low-risk. Surgeons should be prepared to encounter such cardiovascular changes even with low-risk patients.

Adult↗
PubMed1987

Inflation pressure, gastric insufflation and rapid sequence induction.

An investigation was carried out into the relationship between the inflation pressures of normally compliant lungs and the airways pressure necessary to produce the insufflation of gas to the stomach. This relationship was examined during manual ventilation with a mask, using a rapid sequence induction technique. In the absence of cricoid pressure the lungs of all the patients could be ventilated "gently" satisfactorily by hand without gas entering the stomach. In only half of the patients could gas be redirected to the stomach when maximal inflation pressures were generated. It was not possible to cause gas to enter the stomach in any patient with a patent airway when cricoid pressure was applied.

Adolescent↗