Interventions to improve cardiopulmonary hemodynamics during laparoscopy in a porcine sepsis model.
BACKGROUND
Laparoscopy is increasingly used in severely ill and acutely septic patients. In animals undergoing laparoscopy, the hemodynamic response to sepsis is blunted. Specific interventions to augment the hemodynamic potential may make laparoscopic intervention a safer alternative in septic patients. We compared different interventions to improve hemodynamic performance during exploratory laparoscopy in a porcine endotoxic shock model.


METHODS
Domestic pigs (n = 12) received intravenous lipopolysaccharide injection and underwent surgical abdominal exploration using either laparoscopy or conventional laparotomy. For comparison, pigs exposed to endotoxin underwent laparoscopy with these interventions: intravenous infusions of prostacyclin (n = 5) or indomethacin (n = 4), intravenous crystalloid resuscitation (n = 5), pulmonary hyperventilation (n = 4), or abdominal insufflation with air (n = 5). Hemodynamic measurements and blood gas analyses were obtained using Swan-Ganz and arterial catheters.


RESULTS
Septic animals treated with prostacyclin undergoing laparoscopy had a higher cardiac index (CI, p < 0.01), stroke volume (SV; p < 0.001) and oxygen delivery (p < 0.05) than the untreated group. Likewise, treatment with indomethacin was associated with a higher CI (p < 0.001), SV (p < 0.005), and oxygen delivery (p < 0.005) compared with the untreated group. These effects may be secondary to a decreased pulmonary vascular resistance, demonstrated in the animals that received either prostacyclin (p < 0.05) or indomethacin (p < 0.05). In addition, animals given aggressive fluid resuscitation had a significantly higher CI (p < 0.05) and SV (p < 0.001) than those with normal fluid resuscitation during laparoscopy. Manipulation of arterial pH by insufflation of the abdomen with air to create the pneumoperitoneum, or by aggressively hyperventilating the animals, did not improve CI.


CONCLUSIONS
Adverse effects of laparoscopy on cardiovascular hemodynamics in the septic state may be mediated by increased pulmonary vascular resistance, diminished venous return, or both. Specific interventions to reverse these variables may ameliorate hemodynamic changes seen.
Grief
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WM
Harvard Center for Minimally Invasive Surgery and the Department of Surgery, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, USA.
Forse
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RA
D000704:Analysis of Variance; D000818:Animals; D000959:Antihypertensive Agents / Q000494:pharmacology; D002317:Cardiovascular Agents / Q000494:pharmacology; D004195:Disease Models, Animal; D019446:Endotoxemia; D011464:Epoprostenol / Q000494:pharmacology; D004926:Escherichia coli; D005440:Fluid Therapy; D006439:Hemodynamics / Q000187:drug effects; D006863:Hydrogen-Ion Concentration; D007213:Indomethacin / Q000494:pharmacology; D010535:Laparoscopy / Q000009:adverse effects*; D011028:Pneumoperitoneum, Artificial; D011135:Polysaccharides, Bacterial; D012772:Shock, Septic / Q000503:physiopathology*; D013552:Swine
D000959:Antihypertensive Agents; D002317:Cardiovascular Agents; D011135:Polysaccharides, Bacterial; D011464:Epoprostenol; D007213:Indomethacin