142
ANESTHESIA AND ANALGESIA . . . Current Researches VOL.54, NO.1, JAN.-FEB., 1975
Acute Hypotension During Laparoscopy: A Case Report CHONG M. LEE, M.D.* Hershey, Pennsylvaniaf
A 27-year-old, generally healthy, woman became acutely hypotensive during a diagnostic laparoscopy. Her blood pressure returned t o preoperative Ievels and remained stabie after
decrease in intra-abdominal pressure. The author suggests five possible causes of hypotension during laparoscopy.
S
oxygen (3:2). The patient was monitored by a blood pressure cuff and precordial stethoscope, and respiration was controlled manually throughout. After she was placed in lithotomy position and examination under anesthesia and dilatation and curettage were completed, the insufflation of carbon dioxide ( CO, ) was started via Verres cannula, introduced into the peritoneal cavity percutaneously. A C02-PNEU C 0 2 insufflator was used.
INCE laparoscopy has
become an accepted procedure widely used for gynecologic diagnosis, treatment, and surgery,l acute hypotension has been mentioned as one of the complications of this procedure.l-3 An additional case of acute hypotension during diagnostic laparoscopy is reported herein.
CASE REPORT A 27-year-old Caucasian woman was admitted for evaluation of amenorrhea and primary sterility. Her past medical history was unremarkable. She was 160 cm. tall, weighing 50 kg. Blood pressure was 120180 mm. Hg, pulse 78 beatslmin. and regular. Physical examination and routine laboratory studies were essentially negative. As part of her evaluation of amenorrhea, a dilatation and curettage and laparoscopy were scheduled. Premedication included 75 mg. of hydroxyzine and 0.4 mg. of atropine intramuscularly 1 hour before induction of anesthesia. On arrival in the operating room, the patient appeared well sedated, with normal vital signs. Anesthesia was induced with 225 mg. of 2.5 percent thiopental, and her trachea was intubated with the aid of 60 mg. of succinylcholine intravenously. Anesthesia was maintained by a mixture of 2 percent enflurane with nitrous oxide-
The patient was placed in steep Trendelenburg position and approximately 3 L. of CO, was insufflated. Her vital signs remained normal, but her abdomen appeared to be markedly distended. A minute or two after a trocar was introduced, it was noticed that the heart sounds became remote, with apparently no changes in rate or rhythm, and a blood pressure reading was unobtainable. At this time, the pressure registered on the CO, insufflator was 40 mm. Hg. The possible compression of the inferior vena cava secondary to high intraperitoneal pressure was suspected. Immediately after the release of intra-abdominal pressure by evacuation of C 0 2 from the peritoneal cavity, her blood pressure returned to 120180 mm. Hg and heart sounds became strong and regular, with a rate of 110 beats/min.
*Assistant Professor of AnesthesioIogy. tDepartment of Anesthesiology, The MiIton S. Hershey Medical Center, The Pennsylvania State University, Hershey, Pennsylvania 17033. Paper received: 5/14/74 Accepted for publication: 6/3/74
Acute Hypotension.
. . Lee
Pressure in the peritoneal cavity was maintained at 15 to 20 mm. H g thereafter during the laparoscopy, and vital signs remained normal. The patient recovered from anesthesia with no residual complications, the remainder of the hospital course was uneventful, and she was discharged in good condition.
DISCUSSION Improvements in instrumentation and in technics have led to increased use of laparoscopy in gynecologic practice. An essential preliminary procedure to laparoscopy is the installation of pneumoperitoneum involving an increase in intra-abdominal pressure, which, as illustrated in the above case, can lead to cardiovascular disturbances. Arthe9 and Desmond and Gordon:' have witnessed cardiac arrest during laparoscopy. Review of the literature reveals five possible causes of hypotension during laparoscopy: (1) cardiac arrhythmia due to retention of CO.,, because of inadequate ventilation;4 (2) reflex increase of vagal tone, from excessive stretching of peritoneum;5 (3) compression of inferior vena cava by intraabdominal pressure;F (4) C 0 2 embo1ism;T ( 5 ) hemorrhage.x The patient described here became hypotensive with no evidence of bradycardia or arrhythmia under controlled ventilation. Her blood pressure returned to normal and remained stable immediately after the decrease in intra-abdominal pressure, and she made an uneventful recovery from anesthesia and operation. These facts suggest that the increased intra-abdominal pressure had compressed the inferior vena cava and obstructed venous return, which resulted in a decrease in cardiac output and a fall in blood pressure. Lovedays indicated that hypotensive effects from compression of the inferior vena cava occurs when the intra-abdominal pres-
143 sure is too high. Corson and BolognesefJ observed that most patients require 15 to 25 mm. Hg of pressure for adequate exposure, while Hodgson and coworkersl~suggest that the pressure should not exceed 20 mm. Hg. Constant attention to every detail of CO, insuffIation, with close surveillance of intraabdominal pressure, as well as monitoring of blood pressure, heart rate, and rhythm should always be employed during laparoscopy, to avoid dangerous hypotension and its compIications.
ACKNOWLEDGMENT The author thanks Dr. Allen E. Yeakel for his help in manuscript preparation.
REFERENCES 1. Steptoe P: Gynecological laparoscopy. J Reprod Med 10:211-226, 1973 2. Arther H: Hazard of laparoscopy. Brit Med
J 4:492-493, 1970 3. Desmond J. Gordon RA: Ventilation in Datients anaesthetized for laparoscopy. Canad Anaesth SOCJ 7:378-387, 1970 4. Alexander GD, Noe FE, Brown EM: Anesthesia for pelvic laparoscopy. Anesth & Analg 48: 1418, 1969 5. Carmichael DE: Laparoscopy--cardiac consideration. Fertil Steril 22:69-70, 1971 6. Seed RF, Shakespeare TF, Multon MJ: Carbon dioxide homeostasis during anaesthesia for laparoscopy. Anaesthesia 25:223-231, 1970 7. Kelman GR, Swapp GH, Smith J, et al: Cardiac output and arterial blood gas tension during laparoscopy. Brit J Anaesth 44:1155-1161, 1972 8. Loveday R: Laparoscopy hazard. Brit Med J 1:348, 1971
9. Corson SL, Bolognese RJ: Laparoscopy: an overview and results of a large series. J Reprod Med 9:148-157, 1972 10. Hodgson C, McClelland RMA, Newton JR: Some effects of the peritoneal insu€flation of carbon dioxide at laparoscopy. Anaesthesia 25:382-390, 1970
For employee success, loyalty and integrity are equally as important as ability. -Harry F . Banks
ANESTHESIA AND ANALGESIA . . . Current Researches VOL.54, NO.1, JAN.-FEB., 1975
Acute Hypotension During Laparoscopy: A Case Report CHONG M. LEE, M.D.* Hershey, Pennsylvaniaf
A 27-year-old, generally healthy, woman became acutely hypotensive during a diagnostic laparoscopy. Her blood pressure returned t o preoperative Ievels and remained stabie after
decrease in intra-abdominal pressure. The author suggests five possible causes of hypotension during laparoscopy.
S
oxygen (3:2). The patient was monitored by a blood pressure cuff and precordial stethoscope, and respiration was controlled manually throughout. After she was placed in lithotomy position and examination under anesthesia and dilatation and curettage were completed, the insufflation of carbon dioxide ( CO, ) was started via Verres cannula, introduced into the peritoneal cavity percutaneously. A C02-PNEU C 0 2 insufflator was used.
INCE laparoscopy has
become an accepted procedure widely used for gynecologic diagnosis, treatment, and surgery,l acute hypotension has been mentioned as one of the complications of this procedure.l-3 An additional case of acute hypotension during diagnostic laparoscopy is reported herein.
CASE REPORT A 27-year-old Caucasian woman was admitted for evaluation of amenorrhea and primary sterility. Her past medical history was unremarkable. She was 160 cm. tall, weighing 50 kg. Blood pressure was 120180 mm. Hg, pulse 78 beatslmin. and regular. Physical examination and routine laboratory studies were essentially negative. As part of her evaluation of amenorrhea, a dilatation and curettage and laparoscopy were scheduled. Premedication included 75 mg. of hydroxyzine and 0.4 mg. of atropine intramuscularly 1 hour before induction of anesthesia. On arrival in the operating room, the patient appeared well sedated, with normal vital signs. Anesthesia was induced with 225 mg. of 2.5 percent thiopental, and her trachea was intubated with the aid of 60 mg. of succinylcholine intravenously. Anesthesia was maintained by a mixture of 2 percent enflurane with nitrous oxide-
The patient was placed in steep Trendelenburg position and approximately 3 L. of CO, was insufflated. Her vital signs remained normal, but her abdomen appeared to be markedly distended. A minute or two after a trocar was introduced, it was noticed that the heart sounds became remote, with apparently no changes in rate or rhythm, and a blood pressure reading was unobtainable. At this time, the pressure registered on the CO, insufflator was 40 mm. Hg. The possible compression of the inferior vena cava secondary to high intraperitoneal pressure was suspected. Immediately after the release of intra-abdominal pressure by evacuation of C 0 2 from the peritoneal cavity, her blood pressure returned to 120180 mm. Hg and heart sounds became strong and regular, with a rate of 110 beats/min.
*Assistant Professor of AnesthesioIogy. tDepartment of Anesthesiology, The MiIton S. Hershey Medical Center, The Pennsylvania State University, Hershey, Pennsylvania 17033. Paper received: 5/14/74 Accepted for publication: 6/3/74
Acute Hypotension.
. . Lee
Pressure in the peritoneal cavity was maintained at 15 to 20 mm. H g thereafter during the laparoscopy, and vital signs remained normal. The patient recovered from anesthesia with no residual complications, the remainder of the hospital course was uneventful, and she was discharged in good condition.
DISCUSSION Improvements in instrumentation and in technics have led to increased use of laparoscopy in gynecologic practice. An essential preliminary procedure to laparoscopy is the installation of pneumoperitoneum involving an increase in intra-abdominal pressure, which, as illustrated in the above case, can lead to cardiovascular disturbances. Arthe9 and Desmond and Gordon:' have witnessed cardiac arrest during laparoscopy. Review of the literature reveals five possible causes of hypotension during laparoscopy: (1) cardiac arrhythmia due to retention of CO.,, because of inadequate ventilation;4 (2) reflex increase of vagal tone, from excessive stretching of peritoneum;5 (3) compression of inferior vena cava by intraabdominal pressure;F (4) C 0 2 embo1ism;T ( 5 ) hemorrhage.x The patient described here became hypotensive with no evidence of bradycardia or arrhythmia under controlled ventilation. Her blood pressure returned to normal and remained stable immediately after the decrease in intra-abdominal pressure, and she made an uneventful recovery from anesthesia and operation. These facts suggest that the increased intra-abdominal pressure had compressed the inferior vena cava and obstructed venous return, which resulted in a decrease in cardiac output and a fall in blood pressure. Lovedays indicated that hypotensive effects from compression of the inferior vena cava occurs when the intra-abdominal pres-
143 sure is too high. Corson and BolognesefJ observed that most patients require 15 to 25 mm. Hg of pressure for adequate exposure, while Hodgson and coworkersl~suggest that the pressure should not exceed 20 mm. Hg. Constant attention to every detail of CO, insuffIation, with close surveillance of intraabdominal pressure, as well as monitoring of blood pressure, heart rate, and rhythm should always be employed during laparoscopy, to avoid dangerous hypotension and its compIications.
ACKNOWLEDGMENT The author thanks Dr. Allen E. Yeakel for his help in manuscript preparation.
REFERENCES 1. Steptoe P: Gynecological laparoscopy. J Reprod Med 10:211-226, 1973 2. Arther H: Hazard of laparoscopy. Brit Med
J 4:492-493, 1970 3. Desmond J. Gordon RA: Ventilation in Datients anaesthetized for laparoscopy. Canad Anaesth SOCJ 7:378-387, 1970 4. Alexander GD, Noe FE, Brown EM: Anesthesia for pelvic laparoscopy. Anesth & Analg 48: 1418, 1969 5. Carmichael DE: Laparoscopy--cardiac consideration. Fertil Steril 22:69-70, 1971 6. Seed RF, Shakespeare TF, Multon MJ: Carbon dioxide homeostasis during anaesthesia for laparoscopy. Anaesthesia 25:223-231, 1970 7. Kelman GR, Swapp GH, Smith J, et al: Cardiac output and arterial blood gas tension during laparoscopy. Brit J Anaesth 44:1155-1161, 1972 8. Loveday R: Laparoscopy hazard. Brit Med J 1:348, 1971
9. Corson SL, Bolognese RJ: Laparoscopy: an overview and results of a large series. J Reprod Med 9:148-157, 1972 10. Hodgson C, McClelland RMA, Newton JR: Some effects of the peritoneal insu€flation of carbon dioxide at laparoscopy. Anaesthesia 25:382-390, 1970
For employee success, loyalty and integrity are equally as important as ability. -Harry F . Banks
