Anesthesia for Pediatric Laparoscopic Cholecystectomy Michael T. Walsh, MD,* Thomas R. Vetter, MD-f Department of Anesthesiology, Akron, OH.
We report the general anesthetic events and clinical concerns encountered with a laparoscopic cholecystectomy in a 19-monthold toddler. Carbon dioxide was insufflated to create a pneumoperitoneum, with resulting intra-abdominal pressures ranging from 5 to 1 I mmHg. The end-tidal partial pressure of carbon dioxide (Pe,CO,) rose as high as 48 mmHg (a 10 mmHg increase from baseline), requiring a 68Yo increase in minute ventilation to achieve preinsufflation values. Careful monitoring of ventilation, PErCOY, and intra-abdominal pressure are recommendedfor optimal anesthetic management of the pediatric laparoscopic cholecystectomy patient.
Keywords: Laparoscopy, pediatric;
pediatric; anesthesia, pediatric.
cholecystectomy,
Introduction Laparoscopic cholecystectomy has gained wide acceptance since its initial reported use by Dubois in 1990.’ An abundance of surgical literature has proposed a number of advantages of the laparoscopic approach over traditional open cholecystectomy, with a similar significant complication rate of less than 1%. These reported advantages include a shorter hospital stay, earlier return to work, decreased postoperative pain, overall decreased cost, and improved cosmesis.2J The patient age of previously reported cases has ranged from 8 to 98 years.
*Chief
Resident
in Anesthesiology,
Cleveland
Clinic Foundation
tAssistant Professor of Anesthesiology, Northeastern Ohio Universities College of Medicine; Attending Anesthesiologist, Children’s Hospital Medical Center of Akron Address reprint requests to Dr. Vetter at the Department of Anesthesiology, Children’s Hospital Medical Center of Akron, 281 Locust Street, Akron, OH 44308, USA. Received for publication January 8, 1992; revised manuscript cepted for publication March 13, 1992. 0 1992 Butterworth-Heinemann J. Clin. Anesth. 4:406-408,
406
J. Clin. Anesth.,
1992.
vol. 4, September/October
1992
ac-
Children’s
Hospital
Medical Center
This is the first reported case of anesthesia topic cholecystectomy in a toddler.
of Akron,
for laparos-
Case Report A 19-month-old,
10 kg boy presented for elective laparoscopic cholecystectomy because of asymptomatic cholelithiasis. The child was otherwise healthy preoperatively. He received no preoperative medication and had been fasted for at least 6 hours for solids and 3 hours for clear liquids, per departmental guidelines of Children’s Hospital Medical Center of Akron for a child between 6 months and 2 years of age. In the operating room (OR), routine monitors (electrocardiogram, pulse oximeter, noninvasive blood pressure cuffs, and precordial stethoscope) were applied, and a 24-gauge intravenous (IV) catheter was inserted in the dorsum of the hand. Anesthesia was induced with thiopental sodium 5 mg/kg and atracurium 0.5 mg/kg, followed by 1.5% isoflurane by mask. The trachea was intubated with a 4.0 mm internal diameter (ID) uncuffed oral endotracheal tube, allowing for an audible leak at peak inspiratory pressures between 20 and 30 cm H,O. Anesthesia was maintained with oxygen, air, 1% to 2% isoflurane, and atracurium. Nitrous oxide (NLLO) was avoided throughout the case because of surgical concern that it would increase bowel gas, thereby potentially compromising laparoscopic exposure. After induction, a second 20-gauge IV catheter was placed in the dorsum of the hand to allow for more effective volume administration. An IV bolus dose of 20 mVkg of 5% albumin was given for intravascular expansion. A nasogastric tube also was placed, aspirated, and left open to air. Mechanical ventilation was maintained via a pediatric semiclosed circle system. End-tidal partial pressure of carbon dioxide (P&02) was monitored using in-line infrared capnography. Tidal volume, respiratory rate, and minute ventilation were measured by a Narkomed 2B ventilator (No. American Drager, Telford, PA). Pulse oximetry was maintained throughout anesthesia. The patient’s temperature was monitored with a nasopharyngeal probe. Tidal volume, respiratory rate, minute
Anesthrsiu
for
pediatric-
kaparoscopic
cholrr?.\tr’cto??ls:
WcLlsh and
Vrttcr
The anesthetic concerns associated with laparoscopic surgery stem mainly from the creation of a pneumoperitoneum, usually achieved with CO, insufflation. Establishment of this pneumoperitoneum causes significant physiologic changes and potential complications. Introduction of a needle or a trochar to create the pneumoperitoneum can perforate a blood vessel, bowel, or solid viscera, requiring immediate and sometimes urgent open laparotomy. lnsufflation of the peritoneal space results in increased intra-abdominal pressure, which can affect both respiration and hemodynamics. Decreased functional residual capacity and increased peak airway pressures have been reported..’ This increased intraabdominal pressure also may predispose the patient to
passive reflux of gastric contents and aspiration.” The use of cuffed endotracheal tubes and the placement of an oral or nasogastric tube are recommended. AS intravena cava inferior abdominal pressure increases, compression may develop, resulting in decreased SYStemic venous return, decreased preload and thus hyused to create the potension. 6 CO, is most frequently pneumoperitoneum, and its absorption from the peritoneum has been demonstrated, with an increase in arterial carbon dioxide tension (PaCO,) from 15% to 25%’ above baseline in adults.’ This hypercarbia may predispose the patient to arrhythmias or hypotension.” Lastly. rare cases of massive CO, gas embolus with cardiovascular collapse have been reported.” I” Cholecystectorny via a laparoscope poses some additional anesthetic considerations.“-” ‘Fhe patient is usuall) placed in a reverse Trendelenberg position, which ma) improve respiratory parameters but also potentiatt hemodynamic compromise. Intraoperative and postoperative bleeding, due to failure to control the cystic artery, may be massive (in excess of 4 liters in adults) and postrequire emergent reoperation.’ ’ More common operative complications include either superficial wound infection or biliary duct damage. Pediatric laparoscopic surgery and its pediatric anesthetic implications have not been described previously. Important differences appear to exist between adults and children involving required intra-abdominal gas volumes, acceptable pressures generated during insufflation, and resulting increased ventilatory requirements. In adults, reported insufflation volumes necessary to create an initial pneumoperitoneum have varied from 2,500 to 5,000 ml (35 to 70 ml/kg).-‘-“The associated intraabdominal pressures have ranged from 15 to 30 mmHg. In our 10 kg patient, an initial volume of 900 ml (90 ml’ kg) was necessary to insufflate the peritoneal space adequately. Intra-abdominal pressures were maintained between 5 and 11 mmHg, as intra-abdominal pressures of 15 to 30 mmHg have been associated with a progressively decreasing cardiac index in piglets.” Similarly, intra-abdominal pressures of greater than 15 mmHg have
Table 1.
Laparoscopic
ventilation, airway pressures, intra-abdominal pressure, and P,,-CO, were recorded at baseline (prior to incision) and at 5-minute intervals following incisioniinsufflation of the peritoneal cavity (Table 1). Surgery was performed using an open-laparoscopic technique that included the introduction of an infraumbilical trochar and four ports using standard size (5 to 10 mm) trochars. Carbon dioxide (CO,) was insufflated via a #3500 Wiest Laparoflator Electronic insufflator (Wiest, Munich. Germany) to create a pneumoperitoneum. The resulting intra-abdominal pressures ranged from 5 to 11 mmHg as recorded by continuous direct manometry through the visualizing cannula. The patient was placed in a ‘LO-degree reverse Trendelenberg position during the procedure. Upon completion of the surgery, neuromuscular blockade was reversed with neostigmine 0.07 mgikg and atropine 0.02 mgikg, and the patient was extubated in the OK. Total surgical time was 1 hour 55 minutes, and blood loss was estimated at 20 ml. The patient required a total of 19 mg of meperidine over the first 12 hours postoperatively. The child tolerated a regular diet by the morning of the first postoperative day, and he was discharged later that afternoon. Discussion
Elapsed
Respiratory
and Hemodynamic
Changes
during
(Iholecystectom)
Time (min) 0
Position Temperature HR @pm) SBP (mmHg)
(“C)
5
15
20
25
35
K-r
KI-
Kl‘
36.7
36.8
36.9
12X 95 7
117 104 7
120 !+I li
12‘‘ )_ 91 x
37.3 120 107 0
10 160 22 25 3.4
38 160 “4 26 3.7
:47 I60 24 L) _.,r 3.6
37 1.50 “4 25 3.6
3x 160 24 25 2.6
SUP
SUP
SUP
36.4
36.3
36.3
SUP 36.6
XI‘ 36.6
128 103
140 100
155 91
150 120
123 99
7
7
6
P,,CO, (mmHg) TV (ml) RR (breathsimin) PIP (cmH,O)
38 I60 15 27
3: 140 14 23
40 130 14 23
48 140 14
46 130 18
MV (liters/min)
2.2
1.8
1.8
22 1.8
24 2.4
IAP (mmHg)
0
SUP = supine; RT = reverse Trendelenberg; HR = heart rate; bpm = beats per minute; abdominal pressure; P,,CO, = end-tidal partial pressure of carbon dioxide; T\’ PIP = peak inspiratory pressure; MV = total minute ventilation.
J. Clin. Anesth.,
50
60
80
100
El-
SUP
37.2
SBP = systolic blootl pressure; 1.4~ = intr:!. = tidal volume: RR = respiratory rate;
vol. 4, September/October
1992
407
CaseReports been reported to reduce significantly renal, hepatic, and intestinal blood flow in neonatal lambs.*5 Peritoneal insufflation with CO, in adults has been historically reported to cause a modest (average 5 mmHg) rise in P&02,16 reflecting an average increase of 7 to 10 mmHg in PaCO,. 4.7 Mild hyperventilation has been recommended to offset this phenomenon and to avoid the risks of arrhythmia associated with hypercapnea. In contrast to these earlier reports, a recent study of adult laparoscopic cholecystectomy patients found a 62% to 78% increase in minute ventilation requirements for the maintenance of normocarbia.17 In our pediatric patient, PErCO, rose as high as 48 mmHg (a 10 mmHg increase from baseline) and required a 68% increase in minute ventilation to achieve preinsufflation P&O, values. Other pediatric anesthetic considerations include using an uncuffed endotracheal tube that, while age-appropriate in size, with an ID estimated to be equal to (patient’s age + 16) + 4, nonetheless allows for a leak only at peak inspiratory pressures of 20 to 30 cm H,O. This endotracheal tube sizing formula should help prevent aspiration should gastric reflux result from the increased intra-abdominal pressure. An excessively large endotracheal tube cannot be recommended because of the possibility of tracheal mucosal damage and the lack of increased peak inspiratory pressures observed in the current case. Moreover, it has been previously observed that the lower esophageal sphincter displays an adaptive response to peritoneal insufflation that essentially negates the risk of aspiration posed by the increased intragastric pressure.lX Adequate IV access, preferably draining above the level of the diaphragm (in light of the increased intraabdominal pressures causing varying degrees of inferior vena cava compression), should be ensured to allow rapid volume administration if needed. We empirically administered an initial 20 ml/kg IV bolus dose of 5% albumin to offset the possible hemodynamic effects of the decreased systemic venous return associated with the pneumoperitoneum. A balanced solution such as lactated Ringer’s solution or normal saline represents a cheaper, equally effective alternative to albumin. Isoflurane may be preferred over halothane for pediatric laparoscopic cholecystectomy because of a greater sensitization of the myocardium with halothane, which, in the presence of hypercarbia, results in a greater risk of arrhythmias. A second concern is the further reduction in hepatic blood flow resulting from the pneumoperitoneum and surgical manipulation of the portal triad. Considering the complex association among hepatitis, halothane, and reduced hepatic blood flow and hepatocyte oxygenation, isoflurane may effectively circumvent the issue. We avoided N,O because of our surgeons’ concern that any expansion of preexisting intraluminal intestinal gas would impede laparoscopic visualization. This concern about N,O was, however, not substantiated by a recent randomized, blind study of surgeons’ subjective perceptions of surgical conditions during adult laparostopic cholecystectomy with and without N,O.lg
408
J. Clin.
Anesth.,
vol. 4, September/October
1992
Laparoscopic cholecystectomy has expanded tremendously in the past year. As expertise and acceptance in the surgical community increase, the indications for this procedure can be expected to include younger children, as reported here. Additional pediatric cases are needed to validate the overall efficacy of this procedure in children, but as this case demonstrates, laparoscopic cholecystectomy can be performed safely in toddlers and, quite likely, infants. Careful monitoring of ventilation, P, ,C02, and intra-abdominal pressure is recommended. A prospective study is needed to determine the optimum ventilatory and fluid requirements needed to offset the physiologic changes caused by pneumoperitoneum.
References 1. Dubois F: Coelioscopic cholecystectomy: Preliminary report of 36 cases. Ann Surg 1990;2 11:60-2. 2. Grace PA, Quereshi A, Coleman!, et al: Reduced postoperative hospitalization after laparoscoptc cholecystectomy. Br ,/ Surg 1991;78:160-2. 3. Cadacz TR, Talamini MA: Traditional versus laparoscopic cholecystectomy. AmJ Surg 1991;61:336-8. 4. Alexander CD, Noe FE, Brown EM: Anesthesia for laparoscopy. An&h Anulg 1969;48: 14-8. 5. Duffy BL: Regurgitation during pelvic laparoscopy. BrJ Anae.\&h1979;5 1 : 1089-90. 6. Lee CM: Acute hypotension during laparoscopy: a case report. Anesth Analg 1975;54: 142-3. 7. Hodgson C, McClelland RMA, Newton JR: Some effects of the peritoneal insufflation of carbon dioxide at laparoscopy. Anae.cthesiu 1970;25:382-90. 8. Scott B, ,Julian DC;: Observations on cardiac arrhythmias during laparoscopy. Br Med J 1972;1:41 l-3. 9. Clark CC, Weeks DB, Gusdon JP: Venous carbon dioxide embolism during laparoscopy. Anesth Analg 1977;56:650-2. IO. Yacoub OF, Cardona I, Coveler LA, Dodson MG: Carbon dioxide embolism during laparoscopy [Letter]. Anesthe~iolo~ 1982;57:.533-5. 11. Creville AC, Clements AF: Anaesthesia for laparoscopic cholecystectomy using the Nd:Yag laser. Anaesthesia 1990;43:944-5. 12. Marco AP, Yeo CJ, Rock P: Anesthesia for a patient undergoing laparoscopic cholecystectomy. Anesthesialog) 1990;73: 1268-70. 13. ,Joshi P, Mahoney A, Soni NC: Other implications of laser laparoscopir cholecystectomy [Letter]. Anaesthesia 1991;46:3 18. 14. Lynch FP, Ochi T, Scully M, Williamson ML, Dudgeon DL: Cardiovascular effects of increased intra-abdominal pressure in newborn piglets. J Pediatr Surg 1974;9:621-6. 15. Masey SA, Koehler RC, Buck JR, Pepple JM, Rogers MC, Traystman RJ: Effect of abdominal distention on central and regional hemodynamics in neonatal lambs. Pediatr Res 1985;19:1244-9. 16. Seed RF, Shakespeare TF, Muldoon MJ: Carbon dioxide homeostasis during anaesthesia for laparoscopy. ilnaesthesia 1977;25:223-31. 17. Wallasvaara MT, Paloheimo M: Ventilation and body temperature during laparoscopic vs open cholecystectomy [Abstract]. Anesth Analg 1992;74:S340. 18. Jones MJ, Mitchell RW, Hindocha N: Effect of increased intraabdominal pressure during laparoscopy on the lower esophageal sphincter. Anesth Analg 1989;86:63-.5. 19. Taylor E, Feinstein R, Soper N, White PF: Effect of nitrous oxide on surgical conditions during laparoscopic cholecystectomy [Abstract]. Anesthesialog? 1991;75:A330.
We report the general anesthetic events and clinical concerns encountered with a laparoscopic cholecystectomy in a 19-monthold toddler. Carbon dioxide was insufflated to create a pneumoperitoneum, with resulting intra-abdominal pressures ranging from 5 to 1 I mmHg. The end-tidal partial pressure of carbon dioxide (Pe,CO,) rose as high as 48 mmHg (a 10 mmHg increase from baseline), requiring a 68Yo increase in minute ventilation to achieve preinsufflation values. Careful monitoring of ventilation, PErCOY, and intra-abdominal pressure are recommendedfor optimal anesthetic management of the pediatric laparoscopic cholecystectomy patient.
Keywords: Laparoscopy, pediatric;
pediatric; anesthesia, pediatric.
cholecystectomy,
Introduction Laparoscopic cholecystectomy has gained wide acceptance since its initial reported use by Dubois in 1990.’ An abundance of surgical literature has proposed a number of advantages of the laparoscopic approach over traditional open cholecystectomy, with a similar significant complication rate of less than 1%. These reported advantages include a shorter hospital stay, earlier return to work, decreased postoperative pain, overall decreased cost, and improved cosmesis.2J The patient age of previously reported cases has ranged from 8 to 98 years.
*Chief
Resident
in Anesthesiology,
Cleveland
Clinic Foundation
tAssistant Professor of Anesthesiology, Northeastern Ohio Universities College of Medicine; Attending Anesthesiologist, Children’s Hospital Medical Center of Akron Address reprint requests to Dr. Vetter at the Department of Anesthesiology, Children’s Hospital Medical Center of Akron, 281 Locust Street, Akron, OH 44308, USA. Received for publication January 8, 1992; revised manuscript cepted for publication March 13, 1992. 0 1992 Butterworth-Heinemann J. Clin. Anesth. 4:406-408,
406
J. Clin. Anesth.,
1992.
vol. 4, September/October
1992
ac-
Children’s
Hospital
Medical Center
This is the first reported case of anesthesia topic cholecystectomy in a toddler.
of Akron,
for laparos-
Case Report A 19-month-old,
10 kg boy presented for elective laparoscopic cholecystectomy because of asymptomatic cholelithiasis. The child was otherwise healthy preoperatively. He received no preoperative medication and had been fasted for at least 6 hours for solids and 3 hours for clear liquids, per departmental guidelines of Children’s Hospital Medical Center of Akron for a child between 6 months and 2 years of age. In the operating room (OR), routine monitors (electrocardiogram, pulse oximeter, noninvasive blood pressure cuffs, and precordial stethoscope) were applied, and a 24-gauge intravenous (IV) catheter was inserted in the dorsum of the hand. Anesthesia was induced with thiopental sodium 5 mg/kg and atracurium 0.5 mg/kg, followed by 1.5% isoflurane by mask. The trachea was intubated with a 4.0 mm internal diameter (ID) uncuffed oral endotracheal tube, allowing for an audible leak at peak inspiratory pressures between 20 and 30 cm H,O. Anesthesia was maintained with oxygen, air, 1% to 2% isoflurane, and atracurium. Nitrous oxide (NLLO) was avoided throughout the case because of surgical concern that it would increase bowel gas, thereby potentially compromising laparoscopic exposure. After induction, a second 20-gauge IV catheter was placed in the dorsum of the hand to allow for more effective volume administration. An IV bolus dose of 20 mVkg of 5% albumin was given for intravascular expansion. A nasogastric tube also was placed, aspirated, and left open to air. Mechanical ventilation was maintained via a pediatric semiclosed circle system. End-tidal partial pressure of carbon dioxide (P&02) was monitored using in-line infrared capnography. Tidal volume, respiratory rate, and minute ventilation were measured by a Narkomed 2B ventilator (No. American Drager, Telford, PA). Pulse oximetry was maintained throughout anesthesia. The patient’s temperature was monitored with a nasopharyngeal probe. Tidal volume, respiratory rate, minute
Anesthrsiu
for
pediatric-
kaparoscopic
cholrr?.\tr’cto??ls:
WcLlsh and
Vrttcr
The anesthetic concerns associated with laparoscopic surgery stem mainly from the creation of a pneumoperitoneum, usually achieved with CO, insufflation. Establishment of this pneumoperitoneum causes significant physiologic changes and potential complications. Introduction of a needle or a trochar to create the pneumoperitoneum can perforate a blood vessel, bowel, or solid viscera, requiring immediate and sometimes urgent open laparotomy. lnsufflation of the peritoneal space results in increased intra-abdominal pressure, which can affect both respiration and hemodynamics. Decreased functional residual capacity and increased peak airway pressures have been reported..’ This increased intraabdominal pressure also may predispose the patient to
passive reflux of gastric contents and aspiration.” The use of cuffed endotracheal tubes and the placement of an oral or nasogastric tube are recommended. AS intravena cava inferior abdominal pressure increases, compression may develop, resulting in decreased SYStemic venous return, decreased preload and thus hyused to create the potension. 6 CO, is most frequently pneumoperitoneum, and its absorption from the peritoneum has been demonstrated, with an increase in arterial carbon dioxide tension (PaCO,) from 15% to 25%’ above baseline in adults.’ This hypercarbia may predispose the patient to arrhythmias or hypotension.” Lastly. rare cases of massive CO, gas embolus with cardiovascular collapse have been reported.” I” Cholecystectorny via a laparoscope poses some additional anesthetic considerations.“-” ‘Fhe patient is usuall) placed in a reverse Trendelenberg position, which ma) improve respiratory parameters but also potentiatt hemodynamic compromise. Intraoperative and postoperative bleeding, due to failure to control the cystic artery, may be massive (in excess of 4 liters in adults) and postrequire emergent reoperation.’ ’ More common operative complications include either superficial wound infection or biliary duct damage. Pediatric laparoscopic surgery and its pediatric anesthetic implications have not been described previously. Important differences appear to exist between adults and children involving required intra-abdominal gas volumes, acceptable pressures generated during insufflation, and resulting increased ventilatory requirements. In adults, reported insufflation volumes necessary to create an initial pneumoperitoneum have varied from 2,500 to 5,000 ml (35 to 70 ml/kg).-‘-“The associated intraabdominal pressures have ranged from 15 to 30 mmHg. In our 10 kg patient, an initial volume of 900 ml (90 ml’ kg) was necessary to insufflate the peritoneal space adequately. Intra-abdominal pressures were maintained between 5 and 11 mmHg, as intra-abdominal pressures of 15 to 30 mmHg have been associated with a progressively decreasing cardiac index in piglets.” Similarly, intra-abdominal pressures of greater than 15 mmHg have
Table 1.
Laparoscopic
ventilation, airway pressures, intra-abdominal pressure, and P,,-CO, were recorded at baseline (prior to incision) and at 5-minute intervals following incisioniinsufflation of the peritoneal cavity (Table 1). Surgery was performed using an open-laparoscopic technique that included the introduction of an infraumbilical trochar and four ports using standard size (5 to 10 mm) trochars. Carbon dioxide (CO,) was insufflated via a #3500 Wiest Laparoflator Electronic insufflator (Wiest, Munich. Germany) to create a pneumoperitoneum. The resulting intra-abdominal pressures ranged from 5 to 11 mmHg as recorded by continuous direct manometry through the visualizing cannula. The patient was placed in a ‘LO-degree reverse Trendelenberg position during the procedure. Upon completion of the surgery, neuromuscular blockade was reversed with neostigmine 0.07 mgikg and atropine 0.02 mgikg, and the patient was extubated in the OK. Total surgical time was 1 hour 55 minutes, and blood loss was estimated at 20 ml. The patient required a total of 19 mg of meperidine over the first 12 hours postoperatively. The child tolerated a regular diet by the morning of the first postoperative day, and he was discharged later that afternoon. Discussion
Elapsed
Respiratory
and Hemodynamic
Changes
during
(Iholecystectom)
Time (min) 0
Position Temperature HR @pm) SBP (mmHg)
(“C)
5
15
20
25
35
K-r
KI-
Kl‘
36.7
36.8
36.9
12X 95 7
117 104 7
120 !+I li
12‘‘ )_ 91 x
37.3 120 107 0
10 160 22 25 3.4
38 160 “4 26 3.7
:47 I60 24 L) _.,r 3.6
37 1.50 “4 25 3.6
3x 160 24 25 2.6
SUP
SUP
SUP
36.4
36.3
36.3
SUP 36.6
XI‘ 36.6
128 103
140 100
155 91
150 120
123 99
7
7
6
P,,CO, (mmHg) TV (ml) RR (breathsimin) PIP (cmH,O)
38 I60 15 27
3: 140 14 23
40 130 14 23
48 140 14
46 130 18
MV (liters/min)
2.2
1.8
1.8
22 1.8
24 2.4
IAP (mmHg)
0
SUP = supine; RT = reverse Trendelenberg; HR = heart rate; bpm = beats per minute; abdominal pressure; P,,CO, = end-tidal partial pressure of carbon dioxide; T\’ PIP = peak inspiratory pressure; MV = total minute ventilation.
J. Clin. Anesth.,
50
60
80
100
El-
SUP
37.2
SBP = systolic blootl pressure; 1.4~ = intr:!. = tidal volume: RR = respiratory rate;
vol. 4, September/October
1992
407
CaseReports been reported to reduce significantly renal, hepatic, and intestinal blood flow in neonatal lambs.*5 Peritoneal insufflation with CO, in adults has been historically reported to cause a modest (average 5 mmHg) rise in P&02,16 reflecting an average increase of 7 to 10 mmHg in PaCO,. 4.7 Mild hyperventilation has been recommended to offset this phenomenon and to avoid the risks of arrhythmia associated with hypercapnea. In contrast to these earlier reports, a recent study of adult laparoscopic cholecystectomy patients found a 62% to 78% increase in minute ventilation requirements for the maintenance of normocarbia.17 In our pediatric patient, PErCO, rose as high as 48 mmHg (a 10 mmHg increase from baseline) and required a 68% increase in minute ventilation to achieve preinsufflation P&O, values. Other pediatric anesthetic considerations include using an uncuffed endotracheal tube that, while age-appropriate in size, with an ID estimated to be equal to (patient’s age + 16) + 4, nonetheless allows for a leak only at peak inspiratory pressures of 20 to 30 cm H,O. This endotracheal tube sizing formula should help prevent aspiration should gastric reflux result from the increased intra-abdominal pressure. An excessively large endotracheal tube cannot be recommended because of the possibility of tracheal mucosal damage and the lack of increased peak inspiratory pressures observed in the current case. Moreover, it has been previously observed that the lower esophageal sphincter displays an adaptive response to peritoneal insufflation that essentially negates the risk of aspiration posed by the increased intragastric pressure.lX Adequate IV access, preferably draining above the level of the diaphragm (in light of the increased intraabdominal pressures causing varying degrees of inferior vena cava compression), should be ensured to allow rapid volume administration if needed. We empirically administered an initial 20 ml/kg IV bolus dose of 5% albumin to offset the possible hemodynamic effects of the decreased systemic venous return associated with the pneumoperitoneum. A balanced solution such as lactated Ringer’s solution or normal saline represents a cheaper, equally effective alternative to albumin. Isoflurane may be preferred over halothane for pediatric laparoscopic cholecystectomy because of a greater sensitization of the myocardium with halothane, which, in the presence of hypercarbia, results in a greater risk of arrhythmias. A second concern is the further reduction in hepatic blood flow resulting from the pneumoperitoneum and surgical manipulation of the portal triad. Considering the complex association among hepatitis, halothane, and reduced hepatic blood flow and hepatocyte oxygenation, isoflurane may effectively circumvent the issue. We avoided N,O because of our surgeons’ concern that any expansion of preexisting intraluminal intestinal gas would impede laparoscopic visualization. This concern about N,O was, however, not substantiated by a recent randomized, blind study of surgeons’ subjective perceptions of surgical conditions during adult laparostopic cholecystectomy with and without N,O.lg
408
J. Clin.
Anesth.,
vol. 4, September/October
1992
Laparoscopic cholecystectomy has expanded tremendously in the past year. As expertise and acceptance in the surgical community increase, the indications for this procedure can be expected to include younger children, as reported here. Additional pediatric cases are needed to validate the overall efficacy of this procedure in children, but as this case demonstrates, laparoscopic cholecystectomy can be performed safely in toddlers and, quite likely, infants. Careful monitoring of ventilation, P, ,C02, and intra-abdominal pressure is recommended. A prospective study is needed to determine the optimum ventilatory and fluid requirements needed to offset the physiologic changes caused by pneumoperitoneum.
References 1. Dubois F: Coelioscopic cholecystectomy: Preliminary report of 36 cases. Ann Surg 1990;2 11:60-2. 2. Grace PA, Quereshi A, Coleman!, et al: Reduced postoperative hospitalization after laparoscoptc cholecystectomy. Br ,/ Surg 1991;78:160-2. 3. Cadacz TR, Talamini MA: Traditional versus laparoscopic cholecystectomy. AmJ Surg 1991;61:336-8. 4. Alexander CD, Noe FE, Brown EM: Anesthesia for laparoscopy. An&h Anulg 1969;48: 14-8. 5. Duffy BL: Regurgitation during pelvic laparoscopy. BrJ Anae.\&h1979;5 1 : 1089-90. 6. Lee CM: Acute hypotension during laparoscopy: a case report. Anesth Analg 1975;54: 142-3. 7. Hodgson C, McClelland RMA, Newton JR: Some effects of the peritoneal insufflation of carbon dioxide at laparoscopy. Anae.cthesiu 1970;25:382-90. 8. Scott B, ,Julian DC;: Observations on cardiac arrhythmias during laparoscopy. Br Med J 1972;1:41 l-3. 9. Clark CC, Weeks DB, Gusdon JP: Venous carbon dioxide embolism during laparoscopy. Anesth Analg 1977;56:650-2. IO. Yacoub OF, Cardona I, Coveler LA, Dodson MG: Carbon dioxide embolism during laparoscopy [Letter]. Anesthe~iolo~ 1982;57:.533-5. 11. Creville AC, Clements AF: Anaesthesia for laparoscopic cholecystectomy using the Nd:Yag laser. Anaesthesia 1990;43:944-5. 12. Marco AP, Yeo CJ, Rock P: Anesthesia for a patient undergoing laparoscopic cholecystectomy. Anesthesialog) 1990;73: 1268-70. 13. ,Joshi P, Mahoney A, Soni NC: Other implications of laser laparoscopir cholecystectomy [Letter]. Anaesthesia 1991;46:3 18. 14. Lynch FP, Ochi T, Scully M, Williamson ML, Dudgeon DL: Cardiovascular effects of increased intra-abdominal pressure in newborn piglets. J Pediatr Surg 1974;9:621-6. 15. Masey SA, Koehler RC, Buck JR, Pepple JM, Rogers MC, Traystman RJ: Effect of abdominal distention on central and regional hemodynamics in neonatal lambs. Pediatr Res 1985;19:1244-9. 16. Seed RF, Shakespeare TF, Muldoon MJ: Carbon dioxide homeostasis during anaesthesia for laparoscopy. ilnaesthesia 1977;25:223-31. 17. Wallasvaara MT, Paloheimo M: Ventilation and body temperature during laparoscopic vs open cholecystectomy [Abstract]. Anesth Analg 1992;74:S340. 18. Jones MJ, Mitchell RW, Hindocha N: Effect of increased intraabdominal pressure during laparoscopy on the lower esophageal sphincter. Anesth Analg 1989;86:63-.5. 19. Taylor E, Feinstein R, Soper N, White PF: Effect of nitrous oxide on surgical conditions during laparoscopic cholecystectomy [Abstract]. Anesthesialog? 1991;75:A330.
