Comparison of hemodynamic and ventilation parameters using various methods of anesthesia for laparoscopic cholecystectomy
Laparoscopic surgical interventions are increasingly being introduced, including in the elderly with serious concomitant diseases. A retrospective study of the complications that occurred during laparoscopic surgical interventions demonstrated that their absolute majority is not related to the technique of surgery, but is due to the development of cardiac and pulmonary disorders. The study aimed to assess the effectiveness and safety of various approaches to the anesthetic management of laparoscopic cholecystectomy, based on a study of the dynamics of the main hemodynamic and ventilation parameters of homeostasis in patients in the perioperative period. Materials and methods. One hundred and twenty patients (mean age 50 (38–63) years) who underwent surgical interventions for gallstone disease and acute cholecystitis using laparoscopic cholecystectomy were examined. Patients were divided into 3 study groups: TIVA group (n = 40) — total intravenous anesthesia (TIVA) based on propofol and fentanyl with hypnotic infusion through the perfusor. Propofol infusion rate was carried out according to the bolus-infusion scheme 10–8–6 developed. The anesthetist independently chose a sufficient, to his opinion, propofol infusion rate; SEVO group (n = 40) — inhalation anesthesia based on sevoflurane low flow and fentanyl; TCI group (n = 40) — TIVA based on propofol and fentanyl with hypnotic infusion at the target concentration using the B. Braun Perfusor Space; an anesthetist was not supposed to violate the lower (3.5 μg/ml) and upper (5.5 μg/ml) boundaries of the target concentrations in the effector zones (Shneider mathematical model). Results. The hemodynamic parameters in all groups had regular fluctuations during the anesthetic preparation of patients at the stages of carbon dioxide insufflation in the abdominal cavity and desufflation. Intra-abdominal pressure in patients of all groups did not exceed 10 mm Hg. During the induction of anesthesia, a decrease in systemic and central hemodynamics was noted. Thus, the average blood pressure compared with the initial level decreased by 17.7 ± 2.33 %, especially in patients of the TIVA group (p < 0.001). Such changes are due to the fact that the drugs used to induce anesthesia reduced the tone of the sympathetic nervous system, redistributed the volume of circulating blood to the capacitive vasculature, which helped to reduce preload, as well as due to the peripheral vasodilation. At the stage of intubation, there was also a change in hemodynamic parameters in the form of a hyperdynamic type of reaction, which was due to the sympathoadrenal reaction to laryngoscopy and intubation. More pronounced changes were noted in the TIVA group. Thus, the average blood pressure compared with the previous stage increased by 22.2 ± 2.9 % (p < 0.001). Comparison of changes in hemodynamic parameters depending on the variant of anesthetic management showed their statistical comparability (p < 0.05) and less pronounced fluctuations in the TCI and SEVO groups than in the group with total intravenous anesthesia. The analysis of lung ventilation and oxygenation (SaO2, EtCO2) in conditions of pneumoperitoneum showed their stability and controllability in patients of all groups. There were no cases of increased EtCO2 over 45 mm Hg and all anesthesia were performed under moderate hyperventilation. At the same time, the medium airway pressure (Pmed) was significantly higher with total intravenous anesthesia with a target concentration of anesthetic (TCI group) and with total intravenous anesthesia (TIVA group) than with an inhaled anesthetic. This is due to the bronchodilation effect of sevoflurane, low-flow inhalation anesthesia. Conclusions. A comparative study showed insignificant differences when using sevoflurane and propofol according to the TCI. The best stability and predictability of hemodynamic changes in the intraoperative period was found in groups using inhaled low-flow anesthesia with sevoflurane and propofol infusion at the target concentration (TCI). Increased abdominal pressure up to 10 mm H2O due to carboxyperitoneum lasting up to 1 hour when using the sevoflurane inhalation agent by the low-flow method or with intravenous anesthesia with propofol, it did not cause significant changes in ventilation and oxygenation parameters and was easily amenable to correction by changing the ventilation parameter settings.
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