25. Fluid Management and Renal Function During a Laparoscopic Case Done Under CO 2 Pneumoperitoneum
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1 25. Fluid Management and Renal Function During a Laparoscopic Case Done Under CO 2 Pneumoperitoneum Gamal Mostafa, M.D. Frederick L. Greene, M.D. Minimally invasive surgery aims to attenuate the stress of surgical trauma while achieving the desired therapeutic effect. The pneumoperitoneum and the patient s position required for laparoscopy induce pathophysiologic changes that complicate intraoperative and anesthetic management. In addition, the long operative time of some laparoscopic procedures and the difficulty in evaluating the volume of blood loss are factors that make laparoscopic surgery a potentially high-risk procedure. Carbon dioxide is currently the most commonly used gas for creating pneumoperitoneum. Insufflation of CO 2 into the peritoneal cavity is known to have certain cardiorespiratory and hemodynamic consequences. These changes affect intraoperative renal function and are also closely related to intravascular volume status and intravenous fluid therapy during the procedure. Although the hemodynamic, renal, and fluid management aspects of laparoscopic surgery might not be of obvious concern in a young, healthy individual who is undergoing a brief laparoscopic procedure, this is certainly not the case when a long, complicated procedure is performed on a high-risk patient. An understanding of the physiologic changes of carboperitoneum is essential for formulation of an appropriate intraoperative management plan, which may entail invasive perioperative monitoring to optimize hemodynamic performance. Under optimal conditions, pneumoperitoneum can be tolerated by patients with limited physiologic reserve who can, therefore, benefit from minimally invasive surgery. Because more complicated laparoscopic surgery is now being performed and the application for these procedures is extending to older and perhaps sicker patients who are medically compromised, clear understanding of the physiologic changes in different body systems caused by pneumoperitoneum is essential for both the surgeon and the anesthesiologist. A. The Intraperitoneal Pressure The normal mean intraabdominal pressure is zero (equal to atmospheric pressure) or less. Peritoneal insufflation during laparoscopic procedures is one of several important clinical conditions causing elevation of intraabdominal pres-
2 282 G Mostafa and F L Greene sure. Pathophysiologically, this is defined as compartment syndrome, a condition in which increased pressure in a confined anatomic space can adversely affect the circulation and function of the tissues therein. Deleterious consequences of elevated intraabdominal pressure appear gradually in a graded response that is related to the level of pressure. Operative laparoscopy is usually performed with a constant pneumoperitoneum at mmhg pressure. B. Renal response to CO 2 Pneumoperitoneum The main effect of increased intraabdominal pressure associated with CO 2 pneumoperitoneum on renal physiology is decreased renal blood flow and glomerular filtration rate. The decrease in renal blood flow mainly affects the renal cortex. The superficial cortical arteries are particularly sensitive to increased sympathetic activity because of their rich innervation and high blood flow rate compared with other regions of the kidney. Insufflation of the abdomen to 15mmHg pressure has been shown to cause 60% reduction in renal cortical perfusion. This decrease in renal cortical blood flow translates clinically into a 50% reduction in urine output. Oliguria is a universally observed phenomenon during laparoscopic pneumoperitoneum. It can be profound and is always greater than observed with the same procedure performed through a laparotomy. An increase of intraabdominal pressure to 40mmHg induces complete anuria. After evacuation of the pneumoperitoneum, renal cortical perfusion returns to normal almost immediately. Oliguria, on the other hand, remains for almost an hour after the procedure. C. Mechanisms of Carboperitoneum-Induced Oliguria Peritoneal insufflation triggers two important mechanisms that lead to reduction in urine output; one is pressure mediated and the other is hormonal (Figures 25.1, 25.2). 1. The direct compressive effect of pneumoperitoneum on the renal parenchyma and the renal vein causes decreased renal cortical perfusion and subsequent oliguria. 2. The hormonally mediated reduction in urine output occurs, in part, because of the stimulatory action of pneumoperitoneum on the peritoneal stretch receptors leading to antidiuretic hormone and aldosterone release. 3. Also important is the documented activation of the renin-aldosterone mechanism observed with pneumoperitoneum (see Figure 25.2). This not only causes oliguria but also leads to renal vasoconstriction, further decrease in renal perfusion, and perpetuation of the cycle. 4. The compressive effect of pneumoperitoneum on the renal parenchyma and renal vein is immediately and completely reversed on deflation of the abdomen with return of renal blood flow to baseline.
3 25. Fluid Management and Renal Function 283 Figure Mechanism of oliguria in laparoscopic cases. The role of decreased cardiac output is questionable. IAP, intraabdominal pressure; CO, cardiac output; ADH, antidiuretic hormone. Figure The intrinsic hormonally mediated renal mechanism for oliguria in laparoscopic procedures. VC, vasoconstriction; GFR, glomerular filtration rate.
4 284 G Mostafa and F L Greene 5. Persistence of oliguria after completion of a laparoscopic procedure is hormonally mediated due to high levels of antidiuretic hormone and aldosterone. 6. It is important to remember that pneumoperitoneum-induced oliguria is completely independent of the effect of increased intraabdominal pressure on the cardiac output and is mainly a local renal effect of pneumoperitoneum. 7. In addition, neither bilateral ureteral compression nor decrease in renal artery pressure has a role in the mechanism of oliguria associated with laparoscopy. D. Clinical Significance of Oliguria The decreased renal perfusion and the resultant drop in the urine output during and for some time after a laparoscopic procedure should be considered by the surgeon and the anesthesiologist. 1. If possible, the lowest insufflation pressure should be used during gaseous laparoscopy to minimize the potential for significant hemodynamic renal alterations. 2. This is even more prudent when performing a laparoscopic procedure on a patient with borderline renal function. In these instances, it is also important to avoid the concomitant use of any potentially nephrotoxic medication or anesthetic agent as this may have an additive effect on the already compromised renal function. 3. Pulmonary edema from excessive intraoperative fluid administration is a main concern with pneumoperitoneum-induced oliguria. This complication occurs due to vigorous attempts to reverse the oliguria. It is important to remember that the decreased urine output, in this instance, is independent of the cardiac output and cannot be corrected by administering fluids in a futile attempt to achieve a predetermined bias of what intraoperative urine output should be. This will only lead to pulmonary edema. E. Volume-Dependent Response to CO 2 Pneumoperitoneum The response of cardiac output to pneumoperitoneum is dependent on two major variables: the increase in intraabdominal pressure and the baseline intravascular volume status of the patient (Figure 25.3). When the intravascular volume is low, increased intraabdominal pressure compresses the inferior vena cava (IVC) and impedes right ventricular filling, causing a decrease in cardiac output. On the other hand, with high intravascular volume, venous return is aided by the pneumoperitoneum, and cardiac output is increased.
5 25. Fluid Management and Renal Function 285 Figure The distinctive influence of volume status on the effect of pneumoperitoneum on cardiac output. IAP, intraabdominal pressure; IVC, inferior vena cava; CO, cardiac output. F. Principles of Intraoperative Fluid Management in Uncomplicated Laparoscopic Surgery 1. Urine output is not an accurate reflection of the intravascular volume status during laparoscopy, as oliguria is the norm. Therefore, intravenous fluid administration during an uncomplicated laparoscopic procedure should not be guided by urine output. 2. Excessive fluid loss that normally takes place in open abdominal surgery is avoided during laparoscopy. Because of this, the need for supplemental fluid is usually eliminated. Intraoperative fluid administration should not exceed a maintenance rate (110 ml/hr for a 70-kg adult) in an uncomplicated procedure on a healthy individual. 3. The appropriate volume of fluid required intraoperatively is given as balanced salt solution. The additional use of colloids or albumin solutions is unnecessary and is potentially harmful. 4. It is important to remember that oliguria will last for about an hour after completion of the procedure due to the hormonal effects of pneumoperitoneum.
6 286 G Mostafa and F L Greene 5 It is important to remember that patients who have undergone a mechanical bowel preparation are almost always hypovolemic at the start of the case. Ideally, these patients should be given one or several liters of I.V. fluids prior to anesthetic induction in an effort to restore them to the euvolemic state. G. Laparoscopy in the Compromised and Critically Ill Patient Certain clinical situations make fluid management during a laparoscopic procedure more complicated. This is essentially because, in these situations, the physiologic response to pneumoperitoneum cannot be considered isolated as it is compounded by coexisting factors that can lead to harmful consequences even with a mild elevation of intraabdominal pressure. 1. Patients with hemorrhagic shock and hypovolemia have aggravated hemodynamic and renal consequences of pneumoperitoneum. This is particularly pertinent in the acutely injured patient in whom diagnostic laparoscopy may be used. If the volume status of the patient is not corrected before the procedure, diagnostic laparoscopy may amplify the hemodynamic instability. 2. Critically ill patients may require diagnostic laparoscopy for the diagnosis of sepsis. It is important to consider that these patients are frequently hypovolemic and are receiving mechanical ventilation with high positive end-expiratory pressure (PEEP). These two factors can compound the effect of pneumoperitoneum leading to acute circulatory compromise if adequate intravenous fluids are not administered. 3. The high-risk cardiac patient requires accurate fluid management. Invasive monitoring with a pulmonary artery catheter and intraoperative assessment of mixed venous saturation are useful in evaluating and correcting intraoperative events of decreased tissue perfusion as indicated by decrease in mixed venous saturation. Volume loading can be used to reverse these events. 4. Prophylactic volume expansion, in euvolic patients, is recommended in instances when the anticipated period of pneumoperitoneum is longer than 4 hours. This practice has been shown to have a protective effect on renal hemodynamics. This concern can be important in certain procedures such as laparoscopic donor nephrectomy. H. Selected References Andrus CH, Wittgen CM, Naunheim KS. Anesthetic and physiological changes during laparoscopy and thoracoscopy: the surgeon s view. Semin Laparosc Surg 1994;1:
7 25. Fluid Management and Renal Function 287 Chiu AW, Chang LS, Birkett DH, Babayan RK. The impact of pneumoperitoneum, pneumoretroperitoneum, and gasless laparoscopy on the systemic and renal hemodynamics. J Am Coll Surg 1995;181: Doty JM, Saggi BH, Sugerman HJ, et al. Effect of increased renal venous pressure on renal function. J Trauma 1999;47: Harman PK, Kron IL, McLachlan HD, Freedlender AE, Nolan SP. Elevated intra-abdominal pressure and the renal function. Ann Surg 1982;196: London ET, Ho HS, Neuhaus AMC, Wolfe BM, Rudich SM, Perez RV. Effect of intravascular volume expansion on renal function during prolonged CO 2 pneumoperitoneum. Ann Surg 2000;231: Safran DB, Orlando R. Physiologic effects of pneumoperitoneum. Am J Surg 1994; 167: Safran D, Sgambati S, Orlando R. Laparoscopy in high-risk cardiac patients. Surg Gynecol Obstet 1993;176: Schein M, Wittmann DH, Aprahamian CC, Condon RE. The abdominal compartment syndrome: the physiological and clinical consequences of elevated intra-abdominal pressure. J Am Coll Surg 1995;180:
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