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Ann Thorac Surg 2000;70:1098-1099
© 2000 The Society of Thoracic Surgeons

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Supplement: cardiothoracic techniques & technologies

Hemodynamic effects of carbon dioxide insufflation during endoscopic vein harvesting

^a Maimonides Medical Center and State University of New York, Downstate Medical Center, Brooklyn, New York, USA

Address reprint requests to Dr Reddy, Department of Cardiovascular and Thoracic Surgery, State University of New York, Downstate Medical Center, 450 Clarkson Ave, Box 40, Brooklyn, NY 11203-2098
e-mail: ramreddy{at}aol.com

Presented at the Sixth Annual Cardiothoracic Techniques and Technologies Meeting 2000, Ft Lauderdale, FL, Jan 27–29, 2000.

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. A prospective study was performed assessing the hemodynamic effects of carbon dioxide (CO₂) insufflation during endoscopic vein harvesting (EVH) using the Guidant Vasoview Uniport system.

Methods. Five hemodynamic and respiratory parameters (end-tidal carbon dioxide, arterial partial pressure of carbon dioxide, mean arterial pressure, mean pulmonary arterial pressure, and cardiac output), were measured in 100 consecutive patients undergoing EVH with CO₂ insufflation. Data were obtained prior to commencement of EVH, 15 minutes after commencement, and 5 minutes after completion of the vein harvesting.

Results. No adverse hemodynamic effects were observed during CO₂ insufflation. Specifically, average mean arterial pressure went from 88.77 ± 9.64 to 89.13 ± 8.60 to 88.24 ± 8.71 mm Hg before, during, and after endoscopic vein harvesting (p = 0.291). Likewise, average mean pulmonary artery pressures were 19.76 ± 4.75, 20.05 ± 4.48, and 20.05 ± 4.62 mm Hg (p = 0.547); and average cardiac output was 4.25 ± 0.74, 4.22 ± 0.73, and 4.23 ± 0.69 L/min (p = 0.109) at those three intervals. Additionally, there was no evidence of significant systemic absorption of CO₂ as reflected in average arterial PCO₂, which remained steady at 37.42 ± 5.19, 37.51 ± 4.59, and 38.10 ± 4.80 mm Hg (p = 0.217); and average end-tidal CO₂, which was 32.10 ± 3.66, 32.50 ± 3.47, and 32.38 ± 3.33 mm Hg (p = 0.335). In a subset of 20 patients with elevated pulmonary arterial pressure (more than 32 mm Hg), there was also no significant change in any of the parameters.

Conclusions. Carbon dioxide insufflation during EVH leads to no adverse hemodynamic consequences or systemic CO₂ absorption. The technique appears to be safe and well tolerated.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Since the initial reports of endoscopic vein harvesting (EVH), this technique has been demonstrated to be safe and effective and is now being widely applied [1]. There are several techniques of EVH. Our choice has been the use of the Vasoview Uniport EVH system (Guidant Corp, Menlo Park, CA), which involves CO₂ insufflation into the perivenous plane, thereby creating an optical cavity that enables the dissection to proceed and eliminates the need for mechanical retraction.

Patients undergoing CO₂ pneumoperitonium with concomitant cardiopulmonary disease have been shown to retain CO₂ gas and develop arterial hypercapnia and subsequent arterial acidosis [2]. This retention has also been documented to a lesser extent in otherwise healthy individuals [3]. CO₂-related cardiopulmonary dysfunction and hypercapnia have also been shown to occur with extraperitoneal and subcutaneous insufflation [4, 5].

This prospective clinical study was performed to determine the possible adverse hemodynamic effects of subcutaneous CO₂ insufflation in our increasingly elderly and sick patients undergoing coronary artery bypass grafting (CABG).

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
One hundred consecutive patients undergoing CABG were studied prospectively during May and June 1999. The mean age of the patients was 69.8 years. Sixty-two percent of the patients were men. All patients were intubated with a single-lumen endotracheal tube and placed in the usual supine position with their lower extremities in a semi-frog position. Invasive monitoring was initiated with a radial or femoral artery catheter and a pulmonary artery catheter (Baxter Edwards, Irvine, CA). Anesthetic management included induction with versed, sufetanil, and rocuronium bromide. Anesthesia was maintained using isoflorane (0.2% to 0.8%) in oxygen, versed, sufetanil, and rocuronium bromide. No specific attempts were made to alter hemodynamic changes from occurring as the result of CO₂ insufflation such as through the administration of volume expanders, or the infusion of vasoactive medications. Cardiac output was determined by the thermodilution technique using three values within 10% of each other. End-tidal carbon dioxide (ETCO₂) was measured using an in-line capnometer and blood gas analysis was performed using a blood gas analyzer (Radiometer, Copenhagen, Denmark). All five hemodynamic measurements (ETCO₂, arterial partial pressure of CO₂ [PCO₂], cardiac output, mean arterial pressure [MAP], and mean pulmonary arterial pressure [MPAP]) were recorded in the base line state, prior to any manipulations.

Concomitantly to the sternotomy, a 2-cm incision was made in the lower thigh to perform the EVH. After the saphenous vein was identified, a 12-mm blunt-tipped trocar was inserted into the incision to create a seal for CO₂ insufflation through a side port in the trocar. A low flow of CO₂ (4 L/min), was begun to maintain a cavity pressure of 12 mm Hg. The insufflator (Karl Storz-electronic endoflator #2643050, Tuttingen, Germany), was capable of regulating the gas flow and maintaining a constant positive pressure in the closed space.

Values for each of the five hemodynamic variables were obtained at base line, 15 minutes into the EVH procedure, and 5 minutes after completion of EVH. Statistical analysis was performed using repeated-measures analysis of variance. All values are expressed as the mean ± standard deviation.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Endoscopic vein harvesting was completed in all 100 patients with the assistance of CO₂ insufflation. All patients tolerated the procedure well and there were no perioperative complications associated with CO₂ insufflation.

The institution of CO₂ insufflation did not produce a significant alteration in MAP. The MAP was 88.77 ± 9.64 mm Hg at base line. After the initiation of CO₂ insufflation, the MAP was 89.13 ± 8.60 mm Hg, and at the conclusion of EVH it was 88.24 ± 8.71 mm Hg (p = 0.291).

The ETCO₂ was not significantly altered by the insufflation of CO₂. The mean base line ETCO₂ was 32.10 ± 3.66 mm Hg. It was 32.50 ± 3.47 mm Hg after the initiation of CO₂ insufflation and 32.38 ± 3.33 mm Hg at the conclusion of EVH (p = 0.335).

The PCO₂ at base line was 37.42 ± 5.19 mm Hg. It was 37.51 ± 4.59 mm Hg after beginning CO₂ insufflation and at the conclusion of EVH; it was 38.10 ± 4.80 mm Hg (p = 0.217).

There was no significant change in MPAP during CO₂ insufflation. At base line the MPAP was 19.76 ± 4.75 mm Hg. It was 20.05 ± 4.48 mm Hg during CO₂ insufflation and 20.05 ± 4.62 mm Hg at the conclusion of EVH (p = 0.547).

Cardiac output remained stable throughout the EVH procedure. The cardiac output at base line was 4.15 ± 0.74 L/min. During CO₂ insufflation it was 4.22 ± 0.73 L/min and 4.23 ± 0.69 L/min at the conclusion of EVH (p = 1.09).

In the subset of 23 patients with elevated PAP (higher than 35 mm Hg) similar analysis of all of the parameters again failed to reveal any significant changes attributable to CO₂ insufflation. The PA systolic pressures at the three time periods were 39.25 ± 4.30, 38.4 ± 4.02 and 39 ± 4.93 mm Hg, respectively (p = 0.255). The PA diastolic pressures were 20.95 ± 3.43, 20.5 ± 3.56, and 19.95 ± 4.80 mm Hg with a p value of 0.183. Also, the PaCO₂ values were 38.33 ± 6.38, 39.14 ± 6.20, and 39.62 ± 6.14 mm Hg, respectively (p = 0.10).

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Endoscopic vein harvesting was well tolerated and successful in all 100 patients. It was performed with the assistance of CO₂ insufflation using the technique described. On our measurements, there was no appreciable change in either the ETCO₂ or hemodynamics related to the insufflation of CO₂ into the lower extremity. The methodology involved comparison of base line measurements in each patient to measurements during the insufflation and at the completion of the procedure. Thus each patient served as their own control.

Our results are relatively consistent with the literature. Rudston-Brown and colleagues [5] showed in a porcine model that subcutaneous insufflation of CO₂ was indeed associated with hypercapnia and respiratory acidosis. They, however, found that the extent of the subcutaneous emphysema and certainly the extent of the hypercarbia and acidosis were related to the total volume of CO₂ insufflated [5]. Clearly the use of low flow CO₂ insufflation at 4 L/min and a pressure of 12 mm Hg may be an important reason why there was minimal change seen in our patients. Also given the fact that instrument changes intermittently caused the collapse of the cavity and therefore the removal of CO₂ from the subcutaneous space probably helped to keep the effects to a minimal level. It is conceivable that if higher flows and higher pressures are used, the CO₂ gradient across the tissue would be sufficient to cause a rise in the CO₂ and possibly hemodynamic alterations. It would therefore be our recommendation that careful attention be paid to the flow rate and the pressure of CO₂ insufflation while performing EVH.

Hypercapnia has been shown to occur following CO₂ pneumoperitoneum, as well as following extraperitoneal procedures and other subcutaneous insufflations as well [2, 4–6]. Furthermore, the hypercapnia associated with laparoscopy has been shown to be increased in patients who have severe subcutaneous emphysema, suggesting that subcutaneous absorption of CO₂ must occur and is an important component of the production of hypercapnia [5]. Because hypercarbia stimulates the sympathetic nervous system and affects the blood pressure and heart rate and causes a risk of dysrhythmia, it clearly should be avoided in elderly debilitated patients undergoing cardiopulmonary procedures [2]. Rudston-Brown and coworkers [5] demonstrated a 30% increase in CO₂ load simply from absorption in young healthy adults. It is clear that in patients with advanced emphysema, the results would be particularly troubling and there have indeed been reports of CO₂ retention in these patients. Of our 100 patients there were 20 with elevated PAP (higher than 35 mm Hg) under anesthesia. It is instructive to see that even in these patients there was no major rise in CO₂ or alterations in hemodynamic parameters.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Lumsden A.B., Eaves F.F., Ofenlock J.C., Jordan W.D. Subcutaneous, video assisted saphenous vein harvest; report of the first 30 cases. Cardiovasc Surg 1996;4:771-776.[Medline]
2. Junhgans T., Bohm B., Gundel K., Schwenk W. Effects of pneumoperitoneum with carbon dioxide, argon, or helium onhemodynamic and respiratory function. Arch Surg 1997;132:272-278.[Abstract/Free Full Text]
3. Bozkur P., Kaya G., Yekler Y., Tunali Y., Altnas F. The cardiorespiratory effects of laparoscopic procedures in infants. Anaesthesia 1999;54:831-834.[Medline]
4. Ng C., Gill I., Tak Sung G., Whalley D.G., Graham R., Scheizer D. Retroperitonescopic surgery is not associated with increased carbon dioxide absorption. J Urol 1999;162:1268-1272.[Medline]
5. Rudston-Brown B., MacLennan D., Warriner B., Phang T. Effect of subcutaneous carbon dioxide insufflation on arterial pCO₂. Am J Surg 1996;171:460-463.[Medline]
6. Kronowitz S.J. Endoscopic subcutaneous surgery. Ann Plast Surg 1999;42:357-364.[Medline]

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