European Journal of Cardiovascular Medicine

Laparoscopy is an endoscopic visualization of the peritonial cavity by creating pneumoperitoneum which distends the abdomen from its contents. (l)

pneumoperitoneum is a small opening created by the use of needle to &ansverse the abdominal wall and distend the cavity. (2) Laparoscopy became a familiar method for the diagnosis and freatment of intra-abdominal surgeries and gynecological procedures, so it requires gas to insumate the abdomen for the correct visualization and manipulation. (3)

Advantages of laparoscopic surgeries

• Small incisions
• Less pain
• Post operative ileus
• 
  Short hospital stay

Gases used to create pneumoperitoneum CO2, Helium, Argon, Nitrogen, N20, and room Air (6) Compared to other gases CO2 is the ideal gas for insufflation because which has good properties. They are readily available, highly lipid soluble, nontoxic combustible  prime requirement of the laparoscopy is to create pneumoperitoneum using a gas which should be color less and excreted by lungs CO2 is most commonly used because it reduces the risk of complication of venous air embolism However , CO2 has disadvantages like tachycardia and sudden hypertension which results in myocardial O2 demand due to high insufflation may readily absorbs from peritoneal cavity in hypercarbia and respiratory acidosis that may lead to cardiovascular collapse.(9) So measuring of PAC02 is mandatory for all laparoscopic surgeries.EtCO2 is the best reflector of alveolar CO2 (PACO2). End carbon dioxide (Etc02) refers to the graphical measurement of CO2 partial pressure during end of expiration. Normal values of EtCO2 is 35-45 mmhg . Continuous analysis of End tidal carbon dioxide is known as Capnography. Capnography works on the principal of (11) infrared light absorption of CO2 in the mixture of gases.

PHASE 1: INSPIRATORY BASELINE

PHASE 2: EXPIRATORY UPSTROKE

               PHASE 3: ALVEOLAR PLATEAU              2

PHASE 4: INSPIRATORY DOWNSTROKE

sudden drop in Et CO2 indicates malposition of endotracheal tube severe hypotension, cardiac arrest, massive pulmonary embolism, disconnection or disruption of samplings. Gradual drop in Etc02 reflects decrease in paC02that occur when there is an imbalance between minute ventilation and metabolic rate commonly in general anesthesia at a fixed volume. (12)

Et CO2 is the most commonly used and non — invasive substitute for paC02 in evaluating the adequacy of ventilation. Especially patient with pulmonary disease where significant increase in paC02 and pH. Hence ABG is frequently required in patient with cardiopulmonary disorders undergoing laparoscopic surgeries However, paC02 findings from ABG is not reliable always feasible in ASA - I and

ASA —Il patients Etc02 is found reliable. So monitoring etc02 and hemodyanamic is

(13)

necessary during laparoscopic surgery.

AIMS AND OBJECTIVES

The aim of the study is to compare the End tidal carbon dioxide (Etc02) values before creating pneumoperitoneum, immediately after pneumoperitoneum and 10 minutes after pneumoperitoneum in patients undergoing laparoscopic surgeries in the department of Anesthesiology and Critical Care at Chettinad Hospital and Research

Institute, Kodambakkam, Kanchipuram District — 603103, Tamil Nadu.

REVIEW OF LITERATURE

The study conducted by Damini S Makwana injune 2014 compared Etc02 values in patients undergoing laparoscopic surgeries during general anaesthesia and founded the Etc02 and Pac02 significantly higher than pre insufflation values out within physiological range. It also found that in normal healthy patients, Etc02 correlate well with Pac02.

The study conducted by Asif Umar in 2012 evaluated the haemodynamic changes during different abdominal procedures in for patients undergoing laparoscopic cholecystectomy. He found that Etc02 increase immediately after insufflation and raise in Etc02 continued with the increasing period c02 insufflation till exsufflation.

Jean L Georis et all studied in 1993 about hemodyanamic changes in laparoscopic cholecystectomy and found that there is an increase in Etc02 values following the insufflation of c02.

The study conducted by Abdul Hakeem in 2016 evaluated the effects of c02 pneumoperitoneum on arterial partial pressure of c02 pH , end tidal carbon dioxide (Etc02) and bicarbonate in patients during laparoscopic cholecystectomy and he found that this study emphasized that paC02 level could be controlled by increasing respiratory rate rather than increasing tidal volume , due to proven benefits of low lung protective ventilation during c02 pneumoperitoneum within the limits of permissive hypercapnia .

Rahul. S. Jadhav et all conducted the study in 2017 evaluated the end tidal carbon dioxide (Etc02) level during laparoscopic surgery and he found that it was not possible to establish a correlation between the amount of c02 insufflate and pEtc02 levels because of leak around the laparoscope.

After obtaining approval from the institutional ethical committee (proposal no : 330/1HEC/lO-17) dated on 23.10.2017 and written informed consent was obtained from the patients undergoing laparoscopic surgeries in the department of Anesthesioloy and Critical Care at Chettinad Hospital and Research Institute, Kelambakkam , Kanchipuram district was included in the study after meeting the inclusion criteria.

INCLUSION CRITERIA:

• Age 18 to 65 years of both sexes.
• ASA grade I and Il.
• Patient scheduled for elective and emergency laparoscopic surgeries

EXCLUSION CRITERIA:

• History of cardiovascular disorder.
• History of neurological disorder.
• Pregnant patients.
• Patient not willing to take part in the study

STUDY DESIGN:

Prospective clinical study

SAMPLE SIZE:

The sample size was calculated as 113 participants at a-error 0.005 and 80% based on the study done by Damini S Makwana et al on January to June 2014.

FORMULA:

 1.96 n = exp (I-p) /m2 n = required sample size t = confidence level at 95 % (standard value of 1.96) p = estimated prevalence in % m = margin of error at 5% = 0.05

METHODOLOGY

A thorough preanesthetic check-up, including detailed history, general and systemic examination and review of routine investigations, was conducted a day before surgery. After ensuring nil per oral status of at least 6 h preoperatively, all patients was premedicated with Tab diazepam smg and Tab ranitidine 150 mg the night before surgery.

After shifting the patients to operation theater, preinduction vital parameters, such as

Heart Rate (HR), Systolic Blood Pressure (SBP), Diastolyic Blood Pressure (DBP)

Mean Arterial Blood Pressure (MBP) Respiratory Rate (RR), Temperature, and Sp02 was recorded. An intravenous access was achieved and all patients received Inj midazolam Img and Inj glycopyrolate 0.2mg intravenously (i.v). After preoxygenation with 100% 02 for 3 min, anesthesia will be induced with propofol(lO%) 2mg/kg i.v till the abolition of eyelash reflex. Endotracheal intubation with an adequate-sized, cuffed endotracheal tube was facilitated by neuromuscular blocker Atracurium 0.5mg/kg i.v..

Patient was intubated with appropriate size Endotracheal tube (ETD using Macintosh blade 3size / 4 size, after intubation Etc02 values was noted and anesthesia is maintained with 02 + Air + Isoflurane. Before and after the creation of pneumoperitoneum with c02 of 12— 14 liters, Etc02 values was noted.

At the end of the surgery the residual neuromuscular blockade reversed with inj. Neostigmine -0.05mg / kg iv and inj . Glycopyrrolate -0.5 mg iv. Post operatively patient was given 02 with face mask and vital parameters such as Heart Rate (HR), Systolic Blood Pressure (SBP), Diastolyic Blood Pressure (DBP), Mean Arterial Blood Pressure (MBP) , Respiratory Rate( RR) , Temperature, and Sp02 was monitored

GRAPH - 1: Comparison of End tidal carbon dioxide (EtCO2) before pneumoperitoneum, immediately after pneumoperitoneum and 10 minutes after pneumoperitoneum values in ASA — 1 and ASA Il patients undergoing undergoing Laproscopic

GRAPH - 2: Comparison End tidal carbon dioxide (EtCO2) before pneumopentoneum , Immediately after pneumoperitoneum and 10 nunutes after pneumopentoneum values in Bronchial Asthma patients and other ASA — Il patients.

In this study, study population consisted of 1 13 patients with American Society of Anesthesiology (ASA) grade I and Il.

Analysis of EtCO2 in three stages such as before pneumoperitoneum, immediately after pneumoperitoneum and 10 minutes after pneumoperitoneum during laparoscopic surgeries shows increase in EtCO2 values seen at the stage of immediately after pneumoperitoneum.

This rise in EtCO2 after insufflation of CO2 was explained on the basis of absorption of CO2 as a result of higher CO2 tension gradient between the pneumoperitoneum and the blood perfusing the peritoneum.

In this study, study population consisted of 113 patients with American Society of Anesthesiology (ASA) grade I and Il.

It was found from the present study that EtCO2 value increase after the pneumoperitoneum due to insufflation of CO2 and it slightly decreased after 10 minutes of pneumoperitoneum and it continues till the end of the surgery. Finally, EtCO2 level reached its baseline after few minutes of exsufflation of CO2.

This study highlights that, the EtCO2 value of ASA I and ASA Il (other than bronchial asthma) patients was slightly increased immediately after pneumoperitoneum when compare EtCO2 values of before pneumoperitoneum and 10 mins after pneumoperitoneum

In ASA Il bronchial asthma patients, the EtCO2 value was increased significantly immediately after pneumoperitoneum when compare to other ASA Il patients.

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