haemodynamic changes in minimal invasive surgery in paediatric patients.docx

8/9/2019 HAEMODYNAMIC CHANGES IN MINIMAL INVASIVE SURGERY IN PAEDIATRIC PATIENTS.docx

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DEPARTMENT OF ANAESTHESIOLOGY CHHATRAPATI SHAHUJI MAHARAJ MEDICAL UNIVERSITY,

(UPGRADED KING GEORGE MEDICAL UNIVERSITY)LUCKNOW. (INDIA)

August, 2011

Certifcate

This is to certify that the Research work entitled “HAEMODYNAMIC CHANGES IN

MINIMAL INVASIVE SURGERY IN PAEDIATRIC PATIENTS”

has been under taken by the

candidate “Dr Yogesh verma” in this department.

It is further certified that the candidate has fulfilled the pre-requisites

necessary for the submission of the thesis.

Chief Supervisor:

(DR ANITA MALIK)

MD, DA

Professor

Department of Anaesthesiology,CSMMU, Lucknow. U.P.

Co Supervisors:

(DR RAJNI KAPOOR ) ( DRRAJNI GUPTA)

MD MD

Professor Associate Professor


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Department of Anaesthesiology, Department of Anaesthesiology

CSMMU, Lucknow. U.P CSMMU, Lucknow. U.P

(DR REETU VERMA) MD Lecturer

Department of Anaesthesiology

CSMMU, Lucknow, U.P

(DR JYOTSNA AGARWAL)MD

Professor

Department of Anaesthesiology

CSMMU, Lucknow, U.P

( DR ASHISH WAKHLU) MS, MCh Professor,

Department of Paeiatric surgery,

CSMMU, Lucknow, U.P


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DEPARTMENT OF ANAESTHESIOLOGY

Chhatrapati Shahu!i Mahara! Meical Uni"ersity

Lucknow

Cert!"#te August, #$%%

&his is to certify that the research work entitle,

“HAEMODYNAMIC CHANGES IN MINIMAL INVASIVE

SURGERY IN PAEDIATRIC PATIENTS has 'een carrie out 'y the caniate Dr. ogesh )erma, in the epartment.

&his is further certifie that the caniate has also fulfille all the

pre*re+uisites necessary for the su'mission of this thesis.

F!"#$"%&% $'% "&!&'%&% *+

P"!-. /. !g"$

M.D, D.A

Professor an eaDepartment of Anaesthesiology

Chhatrapati Shahu!i Mahara! Meical Uni"ersity

Lucknow


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A"$%&'e*e+

e%t


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&his thesis arose in part out of the stuy that has 'een one since - came to the

Department f Anaesthesiology, CSM Meical Uni"ersity. /y that time, - ha"e worke

with a great num'er of people whose contri'ution in assorte ways to this stuy an the

making of the thesis eser"e special mention. -t is a pleasure to con"ey my gratitue to

them all in my hum'le acknowlegment.

-n the first place - woul like to recor my gratitue to D". /$sh" !g"$ MD,

DA professor an hea, Department of anaesthesiology, CSM Meical Uni"ersity for her

a"ice an guiance from the "ery early stage of this stuy as well as gi"ing me

e0traorinary e0periences throughout the work. A'o"e all an the most neee, she

pro"ie me unflinching encouragement an support in "arious ways. - am ine'te to

her more than she knows.

At the very outset, words are inadequate to express my deepgratitude to my chie guide and supervisor, Dr. A%t# M#$ DA, MD

,Proessor in department o anaesthesiology, Chhatrapati Shahui

Mahara Medical !niversity,"uc#now, without whose inspiring guidance,

unstinted cooperation and exceptional attitude this thesis could not

have seen light o day$ % consider it my privilege to wor# under his

supervision$

1ors are inae+uate to e0press the epth of my gratitue for my respecte co*

guie D". R$3' K$4!!" ,MD, Professor, Department of Anaesthesiology, Chhatrapati

Shahu!i Mahara! Meical Uni"ersity, lucknow for his co*operation, constructi"e

suggestions, encouragement right from the 'eginning, affection an masterly guiance

helpe me to complete this work.


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- am e0tremely grateful to my respecte co*guie D". /+!ts'$ Ag$"#$5. MD,

professor, Department of Anaesthesiology, CSMMU for her a"ice, super"ision, an

crucial contri'ution, which mae her a 'ack'one of this stuy an so to this thesis. er

in"ol"ement with her originality has triggere an nourishe my intellectual maturity thatwill 'enefit from, for a long time to come.

At the "ery outset, wors are inae+uate to e0press my eep gratitue to my

respecte co*guie Dr. R#% G-t#, MD, Associate Proessor, Department of

Anaesthesiology, Chhatrapati Shahu!i Mahara! Meical Uni"ersity, lucknow, without

whose inspiring guiance, unstinte co*operation an e0ceptional attitue this thesis

woul not ha"e seen the light of the ay. - consier pri"ilege to work uner his

super"ision. e has always inspire me to work honestly .

- con"ey my heartful gratitue an my profoun sense of regar to my respecte

co*guie Dr. Reet- Ver+#, MD, "ecturer, Department of Anaesthesiology,

Chhatrapati Shahu!i Mahara! Meical Uni"ersity, lucknow, uner whom - ha"e pri"ilege

opportunity work. 1ithout whose "alua'le guiance, constant encouragement an

inispensi'le suggestions it woul ha"e 'een impossi'le for me to accomplish this work.

- woul like to acknowlege with e0treme gratitue the intellectual an moral

support e0tene to me 'y respecte co*guie Pr&/. A0101 W#$1-, MS, MCh,

Professor Department o Paediatric surgery, Chhatrapati Shahu!i Mahara!

Meical Uni"ersity,Lucknow. er personal interest, constant encouragement an

constructi"e suggestions helpe me to complete this work in the present form.

% am also than#ul to seniors, colleagues and uniors or their

continuous co&operation and encouragement.

1here woul - 'e without my family2 My parents eser"e special mention for

their insepara'le support an prayers. My 3ather, M" 6.D.6&"$, an my mother M"s

Mu7t$ 6&"$ sincerely raise me with care an gentle lo"e. M"s A"h$'$ 6&"$, M"s

K$8t$ 6&"$, an Mss M!h' , thanks for 'eing my supporti"e an caring sisters.


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an % am than#ul my 'etter half D". A"h$'$ for her lo"e , care an support in my

life.

Parents are the first teachers, teachers are the secon parents4 with these wors -

hum'ly acknowlege the affectionate an caring attitue of my teachers throughout my

work, an all praises to almighty GOD who enlightene me to carry out this stuy

successfully.

- woul also like to thank M" 6$"u' an M" T$"u' of Arun Photostate for pro"iing

the statistical analysis an ha"e one real goo !o' in presenting this work on paper.

3inally, - woul like to thank e"ery'oy who was important to the successful

reali5ation of thesis, as well as e0pressing my apology that - coul not mention personally one 'y one.

&'ogesh (erma


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C&%te%t0

%)*+D!C*%)A%M - *./ S*!D'+/(%/0 - "%*/+A*!+/Material and Methods1servationsDiscussion

Conclusion2i1liographyS!MMA+' 3/)C"S/D S/PA+A*/"'4


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I%tr&-"t&%

%n recent years, there has 1een a considera1le improvement in

laparoscopic surgical techniques and equipments and this has led to an

increasing num1er o diagnostic and surgical procedures 1eing done

laparoscopically not only in adults 1ut also in paediatric patients$ 0ith


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increasing experience in paediatric laparoscopic procedures, and

advances in miniaturised instrumentation, laparoscopy5s place in the

modern paediatric surgical armamentarium has fnally 1ecome

accepted$ *he many 1enefts reported ater laparoscopy, which include smaller

incisions, reduced surgical stress and 6uid shits that may accompany

it, lesser postoperative pain, earlier oral inta#e, quic#er mo1ili7ation,

aster discharge, 1etter cosmetic e8ect, reduced postoperative

respiratory and wound complications, shortened postoperative

convalescence, explain its success and the e8orts to encourage its use$

"aparoscopic procedures may also 1e cost&e8ective due to the shorter

length o hospital stay although the initial equipment cost may 1e

higher$

0ith the success o laparoscopy, the demands and applica1ility o this

technique in children has a rising trend$ As a result, the num1er o

children requiring services o paediatric anaesthesiologists or

laparoscopic procedures is increasing day 1y day$ *he

pneumoperitoneum required or laparoscopy induce physiologic

changes that complicate anaesthetic management$ 9nowledge o the

pathophysiologic consequences o increased intra&a1dominal pressure

is important or the anaesthesiologist$

Physiological changes during laparoscopic surgery are mainly related

to the increased intraa1dominal pressure 3%AP4 associated with C:

insu;ation o the a1domen, the patient5s postural modifcations 3head&

up or head&down4 and C: a1sorption and its general e8ects$

%ncreases in %AP a8ect 1oth ventilation and circulation$ %ncreased %AP

induces a mechanical compression o the diaphragm that reduces

pulmonary compliance, vital capacity, unctional residual capacity


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3-+C4 and total lung volume$ Pneumoperitoneum in children has a

maor impact on cardiac volumes and unction, mainly through the

e8ect on ventricular load conditions$

Although experimental and clinical data regarding the cardiorespiratory

e8ect o laparoscopic surgery with invasive and non invasive

monitoring in adult have 1een esta1lished, literature on

cardiorespiratory changes in children is limited$ *he present study was

conducted to assess the hemodynamic changes during minimal

invasive surgeries in pediatric patients$


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Re2e' &/

Lter#t-re


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Minimally invasive surgery use indirect visualisation,

instrumentation and aims to minimise the trauma o any interventional

process 1ut still achieve a satisactory therapeutic result$ "aparoscopy

is the most widely studied minimally invasive procedure$

%n #g

neonate$ Since then innumera1le paediatric laparoscopic procedures

have 1een perormed with development o 1etter technology,equipment and resources$ 2ut these procedures are 1ecoming more

and more challenging to the anaesthesiologist especially when dealing

with the younger paediatric age group$

&he intra* a'ominal pressure le"el is a ma!or eterminant of cariorespiratory

changes uring laparoscopy. &he cario"ascular response to an increase in intra*

a'ominal pressure in"ol"es changes in preloa, systemic "ascular resistance an

myocarial contractility.A ecrease in cariac output (C6 may occur as a result of

ecrease "enous return an an increase in systemic "ascular resistance (S)76. &he

reuction in preloa is epenent on the egree of increase in a'ominal pressure. -n

aults, with minor increases in -AP (8%9mmg6, there is an increase in "enous return an

cariac output resulting from the isplacement of 'loo from the splanchnic "enous

circulation. 1ith intra*a'ominal pressure of a'o"e #$mmg, preloa ecreases while

systemic "ascular resistance increases. &hese factors lea to a ecrease in cariac output.

&he mean arterial pressure usually remains unchange or e"en increases 'ecause of the

increase in systemic "ascular resistance. -n the paeiatric patient similar changes in the

cario"ascular status ha"e 'een seen at much lower -AP.


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S-&9 &t $5(1::;) in their retrospecti"e stuy showe that intraoperati"ely high

:tC# in ;o significant impro"ement in

postoperati"e analgesia was foun. -t was therefore recommene to pay special attention

to intraoperati"e anaesthetic an surgical management of chilren unergoing

laparoscopic surgery, particularly new'orns an infants

T&3#0 #% "&e#*-e0 (4556) ound minimal cardiovascular

changes in paediatric patients during laparoscopy in their study$ An

increase in 1lood pressure was seen which pro1a1ly resulted rom an

increase in systemic vascular resistance related to the increased %AP

and the increased PaC:$ %n a retrospective paediatric study, it was

ound that arterial pressure increased only when %AP was higher than

?mm.g.

H0%*1 et # (4556). concluded that the changes to /tC:during laparoscopy did not in6uence the hemodynamic sta1ility in their

study$ *he younger children gave a aster reaction time o /tC:

change ater C: insu;ation than do the older children which may 1e

related to the variation o physiological exhi1ition at di8erent state o

development$ Children enrolled were o age rom


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muscle relaxation$ *he intraa1dominal pressure exerted 1y C: was


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changes li#e head down tilt induced a mean decrease o ?E days weighing :$HI #g, end&tidal

car1on dioxide was monitored$ %ntra&a1dominal pressure was not

permitted to rise a1ove


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were o1tained E min ater intu1ation, min ater car1on

dioxide insu8ation, E min ater desu;ation and ater extu1ation$ *he

p., Pa:, Sa: and Sp: decreased, and PaC: increased 1y

insu;ation o car1on dioxide intraperitoneally, and improved ollowingde6ation$ *he changes in 1ase excess and 1icar1onate were minimal,

statistically and clinically insignicant$ *he changes in p. and Pa:

during the study were statistically signifcant$ *he increase in PaC: at

> min ater pneumoperitoneum was statistically signifcant when

compared with values o1tained E min ater intu1ation$ An inant with

primary 1iliary atresia 3P2A4 and prior 1ronchopneumonia showed

persistent hypercapnia ollowing desu;ation$ Another inant with P2A

had an Sp: o =:F when awa#e 1ut 1etter Sp: values during

laparoscopy$ Sp: decrease 3lowest=F4 was o1served in an inant

with pyloric stenosis when intra&a1dominal pressure 3%AP4 rose to


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S#$$# #% "&e#*-e0 (;


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R&'%e= #% Ar*e 3:4 reported the anaesthetic

management and outcomes o their frst E< laparoscopic

undoplications$ *hey reviewed case records o the E patients 3one

redo4 with median age ? years 3E months to : years4$ Median durationo anaesthesia was 4 min$ During the procedure, the heart

rate and 1lood pressure increased 1y more than :F over 1aseline in

&


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minutes ater de6ation in the peritoneal cavity$ %ntra&a1dominal

pressure never exceeded ?mm.g$ %ntrasurgical measurements o the

parameters always remained within physiological range or each age

group$ .eart rate was constantly within normal ranges withoutundergoing statistically signifcant modifcations during the di8erent

moments o the surgical procedures$ Systolic 1lood pressure and

Diastolic 1lood pressure, always remaining within physiological

parameters age&related to the patient, tended towards a statistically

signifcant rise during the whole pneumoperitoneum time$ *he mean

value o arterial oxygen saturation was completely steady during the

whole treatment$ /nd&tidal C: showed a statistically signifcant rise

during pneumoperitoneum compared with the post&induction and pre&

insulation parameters, E minutes ater desu;ation$ .owever,

normocar1ia was maintained during the whole laparoscopic procedure$

/ven i 1ody temperature remained within physiological ranges, it

decreased progressively throughout the whole laparoscopic procedure$

Pneumoperitoneum was associated with increases in let ventricular

end&diastolic volume, let ventricular end&systolic volume and let

ventricular end&systolic meridional wall stress$ 2eore, during and ater

intra&a1dominal insu;ation, systolic unction indexes, let ventricular

ractional shortening and eection raction, underwent slight,

insignifcant changes$ *he /D( was recognised as a good indicator o

preload the increase is mostly due to a drainage e8ect on the

splanchnic circulation, with an increase in venous return to the right

heart$

*he overall cardiovascular changes associated with laparoscopic

surgery depend upon the intra&a1dominal pressure attained, the

amount o C: a1sor1ed, the patients intravascular volume status,


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the ventilatory technique, surgical conditions, and the anaesthetic

agents used$ Patient positioning, hypercar1ia, and the use o positive

pressure ventilation can urther compromise the cardiovascular

unction$ (agally mediated re6ex 1radycardia or even asystole canoccur during insu;ation, especially in inants and small children$ *he

a1sorption o car1ondioxide rom the peritoneal cavity leads to an

increase in the end tidal C: 3/tC:4 during laparoscopic surgery

which requently requires an increase in the minute ventilation in

children to compensate or the hypercar1ia$

H-ette+#%% et # (;


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PAP was recorded ater C: insu;ation in the extraperitoneal group$

!se o the let lateral position resulted in a signifcant increase in

/tC: 3>H$< I >$? vs B I >$G, p N $B4 ater C: insu;ation

compared to the right decu1itus lateral position$ *ransperitonealsurgery was perormed in >: 1oys and < girl with a mean age o >$G I

B$< years or cryptorchidism 3>:4 and attempted pyeloplasty 3


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concentration to within F, average end tidal car1on dioxide concentration increased F,average dynamic compliance decreased BGF : saturation ell in B pediatric patients operated on

1y laparoscopic undoplication$ Patients were divided into two groups

namely, group A and group 2$ roup A included years4,scheduled or laparoscopic

undoplication or gastro&oesophageal re6ux$ )oninvasive thoracic

electrical 1ioimpedance cardiac index 3C%4, stro#e volume index 3S(%4,

heart rate 3.+4, mean arterial pressure 3MAP4 and pea# inspiratory

pressure 3P%P4 were recorded, together with /tC: and PaC: at fve


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time points@ 1eore insu;ation, :, >E and H min ater start o C:

insu;ation and H I E mm.g and PaC: increased rom >< I B to >= I E mm.g $ C%

increased rom :$>= I $G? to :$=: I $=B lQminR


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1eore insu;ation, , ?, = minutes ater creating PP and ater

desu;ation$ *he %AP was maintained at


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showed varying and oten statistically signifcant respiratory and

hemodynamic changes with laparoscopy$

A1+e et # 3:=4 studied e8ect o pneumoperitoneum during

laparoscopic surgery in patients 1elow Eyears o age$ *hey concludedthat patients were sta1le other than expected 6uctuation during

intu1ation and reversal and #nowledge o pathophysiological changes

is essential to saely guide these children through potentially

deleterious intraoperative changes$

H=&?J% 8=&%4 et # (;


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A+ O/ T1e St-=


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*o study the haemodynamic changes 3He#rt R#te,S=0t&" 8&& Pre00-re, D#0t&" 8&& Pre00-re,

#% Me#% Arter# Pre00-re4 in minimal invasive

surgery in paediatric patients$


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M#ter# #%

Met1&0


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After getting appro"al from ethical committee of Chhatrapati Shahu!i Mahara!

Meical Uni"ersity (U.P.6 the present prospecti"e stuy entitle B&he haemoynamic

changes in minimal in"asi"e surgery in paeiatric patients was conucte in

C.S.M.M.U. Lucknow .As minimal in"asi"e surgery has recently 'een starte in

paeiatric patients ,the patients inclue in the stuy were neonate to %# year of age

( ASA -,-- 6 unergoing minimal in"asi"e surgery amitte to paeiatric surgery

epartment of C.SM.M.U. uner general anaesthesia. Patients of raise intracranial

tension an hypo"olumia were e0clue from the stuy.

A thorough preanaesthetic check up of the patient was one @ hours 'efore thesurgery an proper consent was taken.

After premeication with intra"enous atropine($.$%*$.$#mgEkg6,fentanyl (%*#

mcgEkg6the patients were inuce with thiopentone (*? mgEkg6 an enotracheal

intu'ation was performe with succinylcholine (%*#mgEkg6. Loaing ose of atracurium

($.9Ekg6 an maintenance of $.%*$.#mgEkg was one with $# an >#. >asogastric tu'e

was passe. /ilateral auscultation of chest was one after any change of patientFs

position. At the en of surgery myoneural 'lockae was re"erse with neostigmine

($.$*$.$@mgEkg6 an atropine($.$# mgEkg6 an patients were e0tu'ate .

.

M&%t&r%* &/ t1e #te%t

• Systolic 2$P

• Diastolic 2$P

• Mean Arterial Pressure

• .eart +ate


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• Pulse xymetry

• /tco:

• C: %nsu;ation Pressure

• Continuous /C Monitoring

T+e er&0 /&r +&%t&r%*

2eore induction 31aseline4, ater induction, 1eore insu;ations,

every E min ater insu;ation till > minutes, every


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6n(nso'ser"atioof . >o

GG

Σ=

;. St#%#r De2#t&%@ %t is denoted 1y the ree# letter σ$ % a

sample is more than > then$

n

X X #6( −Σ

=σ

0hen sample in less than > then$

%

6( #

−

−Σ

= n

X X

σ

>. P#re t te0t@ *o compare the change in a parameter at two

di8erent time intervals paired VtV test was used$

where:

#2 is the mean di8erence, i$e$ the sum o the di8erences o all

the data points 3set < point < & set : point :, $$$4 divided 1y the

num1er opairs

SD is the standard deviation o the di8erences 1etween all the

pairs

N is the num1er o pairs$

B$ A%#=00 &/ V#r#%"e@ A%#=00 &/ V#r#%"e 3A)(A4@ *he

A)(A test was used to compare the within group and 1etween

group variances amongst the study groups i.e. the three di8erent

sealers$ Analysis o variance o these three sealers at a particular


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time interval revealed the di8erences amongst them$ A)(A

provided W-V ratio, where a higher V-V value depicted a higher

inter&group di8erence$

@ - NsDifferenceHroupwithinof Sumof Mean

sDifferenceHroup/etweenof Sumof Mean

Dere%"e0

S-+

&/

S-#r

e0 /

Me#%

S-#re F

2etween

roups A )< UNAO)< UO'

0ithin roups 2 ): 'N2O):

6$ P&0t?H&" Te0t0 (T-$e=?HSD)

M NtreatmentO

group

mean

n N

num1er per

treatmentO

group


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:$ Select two means and note the relevant varia1les 3Means, Mean

Square 0ithin, and num1er per conditionOgroup4

>$ Calculate *u#eys test or each mean comparison

B$ Chec# to see i *u#eys score is statistically signifcant with

*u#eys pro1a1ilityOcritical value ta1le ta#ing into account

appropriate d within and num1er o treatments$

. Le2e &/ 0*%!"#%"e@ VpV is level o signifcance

p T $E )ot signifcant

p J$E Signifcant

p J$< .ighly signifcant

p J$< (ery highly signifcant


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Re0-t0

*he present study was carried out to study the haemodynamic

changes in minimal invasive surgery in pediatric patients$ -or this

purpose a total o E> patients were enrolled in the study$


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T#3e 4De+&*r#1" D0tr3-t&% (%6>)

S$)o$

Characteristic Statistic


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S.N&.

C1#r#"ter0t" N&. &/ "#0e0 Per"e%t#*e


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T#3e ;3@ Ge%er'0e D0tr3-t&% &/ 0-3e"t0

S.N&.

Ge%er N&. &/ "#0e0 Per"e%t#*e


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0eight wise distri1ution o patients has 1een shown in *a1le >

1elow@

T#3e >@ We*1t D0tr3-t&% ($*)

N M%+-+ M#+-+ Me#% St. De2#t&%

E> :$G :H$


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*he mean oxygen saturation was =G$?I


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A*e'0e C&+#r0&% &/ 8#0e%e #r#+eter0

T#3e 6@ 8#0e%e P#r#+eter0 % ere%t #*e *r&-0

S) Parameterroup A

!pto < 'ear

3nN:E4

roup 2

T< 'ear 3nN:G4Signifcance o

di8erence

Mean SD Mean SD t p

< HR 143.48 9.92 118.79 9.93 8.059 DBP 59.68 3.65 67.00 5.41 1.606 0.114

B MAP 71.05 6.61 78.67 5.74 2.818 0.007

E SPO2 98.76 1.54 98.43 1.67 0.537 0.593

? EtCO2 29.40 3.71 30.79 3.15 2.325 0.024

Mean heart rate was signifcantly higher in roup A as compared

to roup 2$ -or rest o the parameters, roup 2 has higher mean value

as compared to roup A, however, the di8erence 1etween two groups

was o1served to 1e signifcant statistically or all the varia1les except

oxygen saturation$ Mean oxygen saturation was higher in roup A as

compared to roup 2 1ut the di8erence was not signifcant statistically$

A0 3#0e%e #r#+eter0 01&'e # 'e 2#r#3t=

3et'ee% t'& *r&-0, t '#0 %&t /e#03e t& 0t-= t1e #*e'0e

ere%"e0 % 1e+&=%#+" 2#r#3e0 #t ere%t t+e

%ter2#0 % t1e #30e%"e &/ # +#t"1e r&!e #t 3#0e%e '1"1

0 #% e00e%t# /&r # "r&00&2er 0t-=. He%"e % 0-30e-e%t

re0-t0 1e+&=%#+" "1#%*e0 1#2e 3ee% 0"-00e "&e"t2e=

/&r # #*e *r&-0 t&*et1er.

STUDY OF CHANGE IN HEMODYNAMIC VARIA8LES


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T#3e @ C1#%*e % He#rt R#te #t ere%t t+e %ter2#0

Correspo!"# $%&'es

%t (%se&"e

At !"))eret t"*e

"ter$%&s

+t+ +p+

,o. Me% SD ,o. Me% SD

B%se&"e 53 130.4 15.9 - - A 53 130.4 15.9 53 149.5 14.8 /16.536


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At all time intervals except


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T#3e @ C1#%*e % S8P #t ere%t t+e %ter2#0

Correspo!"# $%&'es

%t (%se&"e

At !"))eret t"*e

"ter$%&s

+t+ +p+


B%se&"e 53 95.8 10.2 - -

A 53 95.8 10.2 53 130.8 8.4 /25.583


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At all time intervals the mean S2P was signifcantly higher as

compared to 1aseline 3pJ$E4$


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T#3e 7@ C1#%*e % D8P #t ere%t t+e %ter2#0

Correspo!"# $%&'es

%t (%se&"e

At !"))eret t"*e

"ter$%&s

+t+ +p+


B%se&"e 53 63.5 5.9 - -

A 53 63.5 5.9 53 77.8 5.8 /14.356


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At all time intervals the mean D2P was signifcantly higher as



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T#3e 5@ C1#%*e % MAP #t ere%t t+e %ter2#0

Correspo!"# $%&'es

%t (%se&"e

At !"))eret t"*e

"ter$%&s

+t+ +p+


B%se&"e 53 75.1 7.2 - -

A 53 75.1 7.2 53 95.3 5.5 /19.354


49/124

At all time intervals the mean MAP was signifcantly higher as

compared to 1aseline 3pJ$E4 except at


50/124

T#3e 4


51/124

At all time intervals, mean oxygen saturation was higher as

compared to corresponding 1aseline values$ *he change rom 1aseline

was signifcant at all time intervals except at


52/124

T#3e 44@ C1#%*e % E% t# CO; #t ere%t t+e%ter2#0

Correspo!"# $%&'es

%t (%se&"e

At !"))eret t"*e

"ter$%&s

+t+ +p+

,o. Me% SD ,o. Me% SDB%se&"e 53 30.1 3.5 - -

A 53 30.1 3.5 53 34.2 3.8 /7.409


53/124

At all ollow up intervals the mean /nd tidal C: levels were

signifcantly higher as compared to 1aseline$$

TYPE OF SURGERY


54/124

T#3e 4;@ C&+#r0&% &/ He#rt R#te % #3&+%# L##r&0"&"0-r*er= #% T1&r#"" ##r&0"&" 0-r*er= t=e0 #t ere%t

t+e %ter2#0

a1dominal"aparoscopy *horacic laparoscpy

+t+ +p+


B%se&"e 39 131.77 15.71 14 126.71 16.26 1.024 0.311

A 39 149.67 14.87 14 149.14 15.05 0.113 0.911

s')) 39 154.64 13.83 14 154.14 16.54 0.110 0.913

5* 39 151.28 16.11 14 147.93 13.59 0.694 0.491

10* 39 150.67 14.91 14 147.57 14.10 0.675 0.503

15* 39 151.72 14.93 14 148.00 15.97 0.785 0.436

20* 39 151.18 13.52 14 146.79 16.01 0.993 0.325

25* 39 151.44 12.91 14 145.79 15.63 1.328 0.190

30* 39 149.33 14.98 14 142.93 17.30 1.318 0.193

40* 39 150.74 14.09 14 145.14 14.99 1.255 0.215

50* 39 151.44 14.86 14 146.21 13.49 1.154 0.254

60* 38 152.03 13.34 14 144.29 14.97 1.796 0.079

70* 36 151.25 14.12 14 144.21 14.71 1.564 0.124

80* 34 151.74 13.35 14 145.36 15.62 1.432 0.159

90* 32 152.88 13.89 14 146.21 15.42 1.448 0.155

100* 27 152.48 13.29 14 146.29 15.00 1.355 0.183

110* 23 149.96 12.47 12 148.58 16.18 0.279 0.782

120* 19 149.63 11.18 9 144.44 18.87 0.916 0.368

130* 15 147.07 13.20 6 143.67 18.14 0.480 0.637

140* 10 141.80 15.81 1 144.00 . /0.133 0.897

150* 8 144.88 9.73 1 147.00 . /0.206 0.843

160* 6 144.50 11.78 1 139.00 . 0.432 0.683

170* 2 146.00 11.31 1 143.00 . 0.217 0.864

180* 2 144.00 7.07 1 143.00 . 0.115 0.927

At !es') 39 141.36 14.56 14 139.29 14.98 0.454 0.652

5* !es') 39 137.46 14.93 14 135.14 13.70 0.509 0.613

10* !es') 39 135.31 15.24 14 132.50 15.20 0.592 0.557

15* !es') 39 132.97 14.12 14 131.93 14.51 0.236 0.814


55/124

Student VtV&test

)o di8erence 1etween two types o surgery was o1served at any

time interval$


56/124

T#3e 4>@ C&+#r0&% &/ S8P R#te % #3&+%# L##r&0"&"0-r*er= #% T1&r#"" ##r&0"&" 0-r*er= t=e0 #t ere%t

t+e %ter2#0

a1dominal"aparoscopy *horacic laparoscpy

+t+ +p+


B%se&"e 39 95.59 10.67 14 96.43 9.10 /0.262 0.795

A 39 128.97 8.13 14 135.86 7.21 /2.794 0.007

s')) 39 139.92 8.70 14 147.64 8.90 /2.831 0.007

5* 39 133.74 7.38 14 140.36 9.04 /2.709 0.009

10* 39 131.15 5.85 14 135.50 8.02 /2.156 0.036

15* 39 130.28 6.41 14 134.00 6.77 /1.835 0.072

20* 39 129.90 6.08 14 131.57 6.89 /0.853 0.398

25* 39 129.13 6.50 14 129.64 5.72 /0.262 0.794

30* 39 129.08 7.63 14 129.07 4.34 0.003 0.998

40* 39 128.95 7.32 14 128.57 8.67 0.158 0.875

50* 39 127.54 5.72 14 129.00 7.53 /0.753 0.455

60* 38 128.47 4.74 14 129.86 4.96 /0.922 0.361

70* 36 127.31 7.69 14 128.64 4.11 /0.615 0.541

80* 34 127.29 7.53 14 128.50 5.40 /0.543 0.590

90* 32 127.34 7.13 14 129.86 7.25 /1.094 0.280

100* 27 127.30 5.09 14 129.71 5.53 /1.401 0.169

110* 23 127.09 4.75 12 128.00 4.86 /0.536 0.596

120* 19 127.63 4.92 9 128.56 3.81 /0.495 0.625

130* 15 127.40 4.88 6 126.17 5.88 0.495 0.627

140* 10 127.60 4.40 1 127.00 . 0.130 0.899

150* 8 129.50 3.30 1 128.00 . 0.429 0.681

160* 6 129.83 1.72 1 129.00 . 0.448 0.673

170* 2 127.50 0.71 1 132.00 . /5.196 0.121

180* 2 129.00 4.24 1 127.00 . 0.385 0.766

At !es') 39 115.77 6.73 14 114.57 5.76 0.592 0.557

5* !es') 39 111.10 6.00 14 111.86 7.89 /0.371 0.713

10* !es') 39 109.03 6.74 14 107.00 6.32 0.980 0.332

15* !es') 39 107.44 7.06 14 106.57 5.89 0.409 0.684


57/124

Student VtV&test


time interval$


58/124

T#3e 4B@ C&+#r0&% &/ D8P R#te % #3&+%# L##r&0"&"0-r*er= #% T1&r#0" ##r&0"" 0-r*er= t=e0 #t ere%t

t+e %ter2#0

a1dominal"aparoscopy *horasic laparoscpy

+t+ +p+


B%se&"e 39 63.67 5.97 14 63.21 5.95 0.243 0.809

A 39 78.44 5.72 14 76.21 5.83 1.240 0.221

s')) 39 81.95 5.60 14 79.21 5.74 1.558 0.125

5* 39 79.64 4.97 14 79.07 5.28 0.362 0.719

10* 39 79.21 4.21 14 78.14 4.96 0.773 0.443

15* 39 78.79 4.48 14 76.21 3.49 1.947 0.057

20* 39 77.92 3.30 14 77.00 4.93 0.783 0.437

25* 39 78.26 3.65 14 76.93 4.97 1.057 0.295

30* 39 78.18 4.22 14 76.00 3.78 1.700 0.095

40* 39 78.82 4.03 14 76.79 3.40 1.685 0.098

50* 39 77.21 3.42 14 77.00 4.24 0.181 0.857

60* 38 77.87 3.68 14 77.57 4.16 0.249 0.804

70* 36 77.92 4.77 14 79.00 5.82 /0.678 0.501

80* 34 78.32 6.37 14 77.79 3.53 0.296 0.768

90* 32 77.59 6.53 14 80.21 16.35 /0.783 0.438

100* 27 78.07 5.47 14 77.43 4.54 0.379 0.707

110* 23 77.83 2.35 12 75.50 4.68 1.971 0.057

120* 19 76.58 3.01 9 77.00 3.50 /0.329 0.745

130* 15 76.60 2.75 6 74.33 3.93 1.512 0.147

140* 10 76.70 2.16 1 76.00 . 0.309 0.765

150* 8 77.88 4.39 1 78.00 . /0.027 0.979

160* 6 78.33 2.88 1 75.00 . 1.073 0.332

170* 2 77.00 5.66 1 77.00 .


59/124


60/124

T#3e 46@ C&+#r0&% &/ MAP % #3&+%# L##r&0"&"0-r*er= #% T1&r#0" ##r&0"" 0-r*er= t=e0 #t ere%t

t+e %ter2#0


+t+ +p+


B%se&"e 39 75.15 7.58 14 74.86 6.31 0.131 0.896

A 39 95.16 5.61 14 95.76 5.39 /0.346 0.731

s')) 39 100.16 6.64 14 100.98 6.24 /0.399 0.691

5* 39 96.62 5.80 14 99.50 4.40 /1.691 0.097

10* 39 96.19 4.39 14 97.26 5.18 /0.748 0.458

15* 39 95.64 5.05 14 95.48 3.71 0.112 0.912

20* 39 95.02 3.88 14 95.19 5.27 /0.130 0.897

25* 39 95.04 4.44 14 94.50 4.44 0.393 0.696

30* 39 94.54 5.70 14 93.69 3.12 0.527 0.600

40* 39 95.53 4.28 14 94.05 4.16 1.119 0.268

50* 39 93.85 3.77 14 94.33 3.94 /0.403 0.689

60* 38 94.54 3.69 14 95.00 3.52 /0.408 0.685

70* 36 94.38 5.19 14 95.55 4.60 /0.736 0.465

80* 34 94.37 6.57 14 94.69 3.30 /0.172 0.864

90* 32 93.73 6.60 14 91.79 5.19 0.976 0.335

100* 27 93.81 5.35 14 93.21 5.09 0.346 0.731110* 23 93.36 3.85 12 93.00 4.02 0.260 0.796

120* 19 93.21 3.84 9 94.19 3.15 /0.661 0.514

130* 15 92.44 4.16 6 91.61 4.05 0.418 0.681

140* 10 92.63 4.04 1 93.00 . /0.086 0.933

150* 7 87.38 5.21 1 94.67 . /1.309 0.239

160* 6 89.67 3.44 1 93.00 . /0.896 0.411

170* 2 90.50 6.36 1 95.33 . /0.620 0.647

180* 2 94.00 0.00 1 90.33 . . .

At !es') 39 86.26 5.75 14 84.50 2.90 1.090 0.281

5* !es') 39 85.18 5.12 14 85.57 3.18 /0.267 0.790

10*!es') 39 83.26 5.04 14 82.71 3.00 0.378 0.707

15*!es') 39 82.46 4.09 14 82.36 4.65 0.079 0.937

Student VtV&test


61/124


time interval$


62/124

T#3e 4@ C&+#r0&% &/ O=*e% S#t-r#t&% % #3&+%#L##r&0"&" 0-r*er= #% T1&r#0" ##r&0"" 0-r*er= t=e0

#t ere%t t+e %ter2#0

%p%rosop" or%osto* +t+ +p+

,o. Me% SD ,o. Me% SDB%se&"e 39 99.26 0.72 14 96.71 1.90 7.157


63/124

%n laparoscopic surgery group the mean value was higher as

compared to thoracoscopic surgery group upto minutes and the

di8erence was signifcant statistically too$ *hereater, till desu;ation

the value in laparoscopic group was lower as compared to

thoracoscopic group 1ut the di8erence was not signifcant statistically$


64/124

T#3e 4@ C&+#r0&% &/ E% t# CO; "&%"e%tr#t&%#3&+%# L##r&0"&" 0-r*er= #% T1&r#0" ##r&0""

0-r*er= t=e0 #t ere%t t+e %ter2#0


+t+ +p+


B%se&"e 39 29.85 3.80 14 30.93 2.20 /1.003 0.321

A 39 33.92 4.28 14 35.14 2.07 /1.021 0.312

s')) 39 40.54 4.20 14 42.93 4.68 /1.773 0.082

5* 39 42.77 4.06 14 46.79 2.55 /3.457 0.001

10* 39 42.95 4.36 14 46.57 3.25 /2.829 0.007

15* 39 42.28 3.59 14 46.79 2.94 /4.206


65/124

At all time intervals the mean value was higher in thoracoscopic

group as compared to laparoscopic group 1ut the di8erence was

signifcant only 1etween Emin to min intervals and rom E min

ater desu;ation till the end$


66/124

POSITION

T#3e 47@ C&+#r0&% &/ He#rt R#te % Dere%t &0t&%0

SN Parameter Lateral (n=15) ReverseTrendelenberg

(n=9)

Supine (n=5) Trendlenberg(n=24)

AN!A

n "ean S# n "ean S# n "ean S# n "ean S# $ p

1 B%se&"e 15 128.1 20.8 9 133.7 13.2 5 132.0 14.7 24 130.3 14.1 0.236 0.871

2 A 15 148.5 15.9 9 151.6 14.2 5 152.0 16.2 24 148.9 14.8 0.134 0.939

3 s')) 15 154.5 19.0 9 154.4 10.7 5 161.0 13.5 24 153.2 13.0 0.388 0.762

4 5* 15 146.7 18.8 9 154.2 13.6 5 156.4 16.9 24 150.0 13.6 0.712 0.550

5 10* 15 146.8 19.9 9 150.2 12.3 5 155.2 14.7 24 150.5 11.8 0.443 0.723

6 15* 15 147.3 20.8 9 153.3 12.3 5 153.0 15.8 24 151.5 12.2 0.392 0.759

7 20* 15 146.6 18.6 9 153.1 12.5 5 152.0 15.7 24 150.6 11.6 0.463 0.710

8 25* 15 146.6 18.0 9 153.0 13.6 5 150.8 12.2 24 150.7 11.4 0.460 0.712

9 30* 15 144.2 19.6 9 154.3 14.4 5 149.4 10.1 24 146.9 14.4 0.813 0.493

10 40* 15 147.2 14.6 9 155.1 16.0 5 147.2 10.6 24 148.8 14.6 0.626 0.601

11 50* 15 147.7 17.3 9 154.1 11.2 4 150.8 13.7 24 149.6 13.4 0.987 0.406

12 60* 15 145.3 20.7 9 152.2 12.0 5 157.0 11.3 24 150.8 11.0 0.380 0.768

13 70* 15 147.7 17.3 9 154.1 11.2 4 150.8 13.7 24 149.6 13.4 0.880 0.459

14 80* 15 144.8 18.0 9 154.4 11.7 4 150.5 13.8 22 150.0 13.0 0.954 0.423

15 90* 15 146.5 16.7 9 152.4 12.1 3 141.3 1.5 21 152.4 13.7 0.314 0.815

16 100* 15 148.0 17.2 8 152.5 9.3 3 149.3 5.8 20 152.6 15.3 0.360 0.782

17 110* 14 148.9 17.4 7 155.4 13.0 3 148.7 16.7 17 149.8 11.5 0.849 0.478

18 120* 11 149.1 16.9 5 156.0 11.6 2 138.0 4.2 17 149.2 12.3 1.172 0.341

19 130* 8 144.4 20.2 5 157.0 10.8 2 139.0 0.0 13 148.1 10.3 0.423 0.739

20 140* 5 143.8 20.3 4 153.5 11.9 1 141.0 . 11 144.9 13.3 0.544 0.600

21 150* 0 . . 2 152.5 17.7 1 139.0 . 8 139.8 15.5 0.181 0.838

22 160* 0 . . 1 143.0 . 1 140.0 . 7 146.1 10.2 1.067 0.425

At !es') 15 142.0 18.6 9 144.0 10.9 5 141.4 19.0 2 4 138.8 12.4 0.327 0.806

5* !es') 15 135.8 18.0 9 139.7 11.7 5 138.0 18.8 24 136.2 12.9 0.157 0.925

10*!es') 15 132.9 19.2 9 137.6 13.6 5 133.4 14.9 24 134.7 13.6 0.177 0.911

15*!es') 15 132.9 19.3 9 133.9 11.7 5 131.2 11.5 24 132.5 12.2 0.041 0.989


67/124

)o signifcant di8erence was o1served at any time interval$


68/124

T#3e 45@ C&+#r0&% &/ S8P % Dere%t &0t&%0


(n=9)


AN!A

n "ean S# n "ean S# n "ean S# n "ean S# $ p1 B%se&"e 15 99.6 12.8 9 94.0 11.3 5 97.2 6.4 24 93.8 8.3 1.124 0.348

2 A 15 134.9 7.5 9 126.0 12.4 5 132.4 5.1 24 129.7 6.8 2.614 0.062

3 s')) 15 144.5 12.9 9 139.2 10.7 5 142.4 5.7 24 141.3 6.5 0.671 0.574

4 5* 15 138.1 12.1 9 132.8 8.8 5 137.4 6.3 24 134.5 4.9 1.042 0.382

5 10* 15 133.3 8.8 9 133.0 8.7 5 131.4 4.6 24 131.6 4.7 0.238 0.870

6 15* 15 132.5 9.2 9 131.4 5.5 5 130.0 7.2 24 130.7 5.2 0.270 0.847

7 20* 15 129.7 8.9 9 131.7 6.7 5 130.4 4.9 24 130.2 4.5 0.175 0.913

8 25* 15 128.3 8.7 9 130.7 8.0 5 129.8 4.0 24 129.2 3.9 0.263 0.852

9 30* 15 127.8 9.7 9 132.0 7.4 5 127.8 4.2 24 129.0 4.8 0.763 0.521

10 40* 15 129.5 9.7 9 132.9 7.5 5 127.4 4.0 24 127.2 6.5 1.344 0.271

11 50* 15 129.2 5.7 9 131.1 4.4 4 129.0 3.2 24 127.8 4.4 0.845 0.476

12 60* 15 127.9 8.8 9 130.4 6.4 5 129.2 3.9 24 126.8 4.3 1.126 0.348

13 70* 15 129.2 5.7 9 131.1 4.4 4 129.0 3.2 24 127.8 4.4 0.426 0.735

14 80* 15 128.1 9.6 9 129.4 6.8 4 125.3 3.9 22 127.1 5.1 0.608 0.614

15 90* 15 127.5 9.8 9 130.3 8.2 3 128.0 2.6 21 126.6 3.8 0.663 0.580

16 100* 15 129.3 10.2 8 130.1 7.6 3 127.7 2.1 20 126.5 4.3 0.025 0.994

17 110* 14 128.4 6.9 7 128.0 7.6 3 127.7 3.2 17 128.0 2.9 0.424 0.73718 120* 11 128.1 5.1 5 128.4 6.2 2 129.0 2.8 17 126.5 4.4 0.591 0.627

19 130* 8 128.9 3.9 5 129.6 6.7 2 126.5 2.1 13 126.9 4.4 0.757 0.533

20 140* 5 125.6 6.4 4 129.8 5.3 1 131.0 . 11 126.4 4.5 0.992 0.412

21 150* 0 . . 2 131.0 1.4 1 129.0 . 8 126.5 4.4 0.126 0.884

22 160* 0 . . 1 129.0 . 1 131.0 . 7 129.1 3.5 1.506 0.325

At !es') 15 115.0 7.0 9 113.9 5.9 5 118.6 7.3 24 115.7 6.3 0.591 0.624

5* !es') 15 111.6 8.4 9 108.4 6.6 5 115.8 5.9 24 111.3 4.8 1.431 0.245

10*!es') 15 107.8 7.7 9 106.3 7.5 5 109.2 3.3 24 109.6 6.2 0.594 0.622

15*!es') 15 108.0 7.7 9 105.6 6.3 5 107.8 8.8 24 107.2 6.1 0.252 0.860


69/124



70/124

T#3e ;


71/124



72/124

T#3e ;4@ C&+#r0&% &/ MAP % Dere%t &0t&%0


(n=9)


AN!A


2 A 15 96.0 5.6 9 94.7 7.3 5 96.4 2.5 24 94.9 5.4 0.212 0.888

3 s')) 15 100.0 6.9 9 100.0 8.7 5 96.5 6.0 24 101.5 5.4 0.861 0.468

4 5* 15 98.5 6.6 9 98.2 5.6 5 94.4 5.5 24 97.0 4.9 0.787 0.507

5 10* 15 97.2 5.0 9 97.5 6.0 5 97.0 3.1 24 95.5 4.1 0.622 0.604

6 15* 15 95.2 5.5 9 96.7 5.1 5 93.4 7.1 24 95.9 3.5 0.591 0.624

7 20* 15 94.9 5.4 9 96.1 4.2 5 94.1 6.3 24 95.0 3.0 0.274 0.844

8 25* 15 94.0 5.6 9 96.9 5.9 5 94.6 3.0 24 94.8 3.0 0.818 0.490

9 30* 15 93.4 6.1 9 96.7 4.5 5 90.1 8.7 24 94.9 3.1 2.155 0.105

10 40* 15 95.0 4.9 9 97.2 5.1 5 94.6 2.3 24 94.5 3.8 0.871 0.463

11 50* 15 95.0 4.1 9 96.7 2.3 4 93.4 4.4 24 93.9 3.4 2.230 0.096

12 60* 15 94.0 4.8 9 96.0 3.8 5 96.0 4.3 24 92.8 2.5 1.541 0.216

13 70* 15 95.0 4.1 9 96.7 2.3 4 93.4 4.4 24 93.9 3.4 0.962 0.419

14 80* 15 96.1 7.6 9 95.3 4.6 4 95.3 2.0 22 93.4 2.9 0.545 0.654

15 90* 15 94.7 8.5 9 96.3 4.8 3 95.3 4.6 21 93.4 3.7 0.302 0.824

16 100* 15 92.0 9.6 8 94.6 4.5 3 93.6 6.6 20 93.3 3.0 0.157 0.924

17 110* 14 92.8 5.1 7 94.3 4.0 3 94.1 9.2 17 93.9 5.4 0.712 0.55218 120* 11 93.2 4.1 5 95.1 2.9 2 90.5 9.2 17 93.0 3.4 0.292 0.831

19 130* 8 94.3 3.4 5 94.1 4.1 2 93.2 3.1 13 92.9 3.9 0.457 0.716

20 140* 5 91.6 4.5 4 94.1 2.2 1 94.3 . 11 91.6 4.5 0.898 0.445

21 150* 0 . . 2 95.3 0.0 1 95.0 . 8 91.7 4.1 0.016 0.902

22 160* 0 . . 0 . . 1 89.0 . 7 88.2 5.9 5.325 0.075

At !es') 15 84.9 4.4 9 84.8 2.5 5 86.4 4.6 24 86.6 6.4 0.489 0.691

5* !es') 15 85.6 5.7 9 82.9 2.9 5 87.4 2.9 24 85.5 4.6 1.195 0.321

10*!es') 15 83.8 4.2 9 81.1 4.6 5 86.6 9.2 24 82.7 3.2 1.803 0.159

15*!es') 15 84.0 5.8 9 80.9 3.9 5 82.4 3.6 24 82.0 3.1 1.184 0.326


73/124



74/124

T#3e ;;@ C&+#r0&% &/ O=*e% S#t-r#t&% %Dere%t &0t&%0

SN Parameter Lateral (n=15) Reverse

Trendelenberg

(n=9)

Supine (n=5) Trendlenberg

(n=24)

AN!A

n "ean S# n "ean S# n "ean S# n "ean S# $ p

1B%se&"e 15 97.0 2.1 9 99.2 0.7 5 99.4 0.5 24 99.2 0.8 10.764


75/124

*he mean oxygen saturation among patients with lateral position

as compared to other positions was signifcantly lower at all time

intervals except


76/124

T#3e ;>@ C&+#r0&% &/ E% t# CO; % Dere%t &0t&%0


(n=9)


AN!A


2 A 15 35.5 2.6 9 33.1 3.6 5 29.6 5.2 24 34.9 3.6 4.024 0.012

3 s')) 15 42.6 4.8 9 39.1 4.6 5 41.8 3.5 24 40.9 4.2 1.256 0.300

4 5* 15 46.3 3.3 9 41.0 6.1 5 43.0 2.9 24 43.5 3.1 3.838 0.015

5 10* 15 46.3 3.4 9 39.8 6.2 5 42.8 3.2 24 44.2 3.2 5.333 0.003

6 15* 15 46.3 3.4 9 40.6 5.2 5 42.2 4.1 24 43.0 2.6 5.775 0.002

7 20* 15 46.1 3.3 9 43.4 2.8 5 41.4 2.5 24 42.7 3.4 4.426 0.008

8 25* 15 45.7 2.7 9 42.8 2.9 5 40.6 2.4 24 43.3 2.5 5.720 0.002

9 30* 15 46.6 4.6 9 42.3 3.8 5 40.8 3.8 24 42.5 3.2 5.013 0.004

10 40* 15 45.6 3.1 9 41.9 4.0 5 41.4 4.6 24 42.5 3.9 3.034 0.038

11 50* 15 45.2 2.4 9 42.4 2.3 4 42.0 4.1 24 43.3 3.7 5.524 0.002

12 60* 15 46.1 3.2 9 42.9 3.2 5 41.6 3.4 24 42.5 2.7 2.054 0.119

13 70* 15 45.2 2.4 9 42.4 2.3 4 42.0 4.1 24 43.3 3.7 1.680 0.184

14 80* 15 45.1 3.7 9 43.2 2.9 4 43.0 4.7 22 42.6 3.1 5.189 0.004

15 90* 15 46.1 2.4 9 43.1 2.7 3 41.3 6.0 21 42.8 2.5 4.739 0.006

16 100* 15 46.1 2.1 8 43.0 3.6 3 42.7 4.0 20 42.7 2.8 4.091 0.013

17 110* 14 45.6 2.6 7 43.1 3.4 3 40.7 2.3 17 42.4 3.0 5.405 0.00418 120* 11 45.9 1.6 5 41.8 2.9 2 45.0 0.0 17 43.1 2.4 5.229 0.006

19 130* 8 45.9 1.7 5 42.4 2.9 2 39.0 0.0 13 42.6 2.9 1.883 0.171

20 140* 5 46.0 1.0 4 42.0 3.2 1 43.0 . 11 42.4 3.5 0.071 0.932

21 150* 0 . . 2 42.5 0.7 1 43.0 . 8 41.3 6.0 0.011 0.989

22 160* 0 . . 1 41.0 . 1 42.0 . 7 41.0 6.5 0.175 0.846

At !es') 15 35.7 3.2 9 36.1 2.2 5 30.8 4.3 24 34.4 4.1 2.774 0.051

5* !es') 15 35.0 2.0 9 34.6 2.1 5 32.6 3.7 24 33.8 3.6 1.005 0.398

10*!es') 15 34.4 2.4 9 34.9 2.5 5 30.4 3.8 24 32.5 3.5 3.347 0.026

15*!es') 15 33.5 1.9 9 32.9 1.5 5 29.4 3.4 24 31.4 2.2 5.723 0.002


77/124

Mean /nd tidal C: was maximum in "ateral group and minimum

in reverse trendelen1erg and supine groups$ *he di8erences among

groups were signifcant statistically at all time intervals upto

minutes except 1aseline, at insu;ation, ? min and H min and at

desu;ation and E min ater desu;ation$


78/124

AGEWISE Ut& 4 Ye#r

T#3e ;B@ C1#%*e % He#rt R#te #t ere%t t+e %ter2#0

Correspo!"# $%&'es%t (%se&"e

At !"))eret t"*e"ter$%&s

+t+ +p+


B%se&"e 25 143.5 9.9

A 25 143.5 9.9 25 161.1 10.6 /9.502


79/124

At all time intervals the mean heart rate was signifcantly higher

as compared to 1aseline 3pJ$E4 except at


80/124

T#3e ;6@ C1#%*e % S8P #t ere%t t+e %ter2#0

Correspo!"# $%&'es

%t (%se&"e

At !"))eret t"*e

"ter$%&s

+t+ +p+


B%se&"e 25 87.5 5.4 25 127.7 9.0 - -

A 25 87.5 5.4 25 127.7 9.0 /25.559


81/124




82/124

T#3e ;@ C1#%*e % D8P #t ere%t t+e %ter2#0

Correspo!"# $%&'es

%t (%se&"e

At !"))eret t"*e

"ter$%&s

+t+ +p+


B%se&"e 25 59.7 3.6

A 25 59.7 3.6 25 76.5 6.7 /11.426


83/124




84/124

T#3e ;@ C1#%*e % MAP #t ere%t t+e %ter2#0

Correspo!"# $%&'es

%t (%se&"e

At !"))eret t"*e

"ter$%&s

+t+ +p+


B%se&"e 25 71.1 6.6 - -

A 25 71.1 6.6 25 93.2 6.0 /12.981


85/124




86/124

T#3e ;7@ C1#%*e % O=*e% S#t-r#t&% #t ere%t t+e%ter2#0

Correspo!"# $%&'es

%t (%se&"e

At !"))eret t"*e

"ter$%&s

+t+ +p+

,o. Me% SD ,o. Me% SDB%se&"e 25 98.8 1.5 - -

A 25 98.8 1.5 25 99.3 1.2 /2.177 0.040

s')) 25 98.8 1.5 25 99.4 1.1 /2.683 0.013

5* 25 98.8 1.5 25 99.1 1.3 /1.518 0.142

10* 25 98.8 1.5 25 99.2 1.2 /2.193 0.038

15* 25 98.8 1.5 25 99.4 1.2 /2.777 0.010

20* 25 98.8 1.5 25 99.2 1.3 /2.138 0.043

25* 25 98.8 1.5 25 99.4 0.8 /2.698 0.01330* 25 98.8 1.5 25 99.2 1.3 /1.792 0.086

40* 25 98.8 1.5 25 99.4 0.9 /2.874 0.008

50* 25 98.8 1.5 25 99.1 1.4 /1.445 0.161

60* 25 98.8 1.5 25 99.2 1.1 /1.953 0.063

70* 25 98.8 1.5 25 99.3 1.1 /2.397 0.025

80* 24 98.7 1.5 24 99.3 1.2 /2.696 0.013

90* 24 98.7 1.5 24 99.3 1.1 /3.021 0.006

100* 20 98.7 1.7 20 99.0 1.2 /1.234 0.232110* 16 98.8 1.3 16 99.3 1.2 /1.581 0.135

120* 13 98.8 1.5 13 99.1 1.3 /1.171 0.264

130* 9 98.7 1.6 9 99.2 1.3 /1.250 0.247

140* 3 99.7 0.6 3 100.0 0.0 /1.000 0.423

150* 2 100.0 0.0 2 100.0 0.0


87/124


compared to corresponding 1aseline values$ At


88/124

T#3e ;5@ C1#%*e % E% t# CO; #t ere%t t+e%ter2#0

Correspo!"# $%&'es

%t (%se&"e

At !"))eret t"*e

"ter$%&s

+t+ +p+

,o. Me% SD ,o. Me% SDB%se&"e 25 29.4 3.7 - -

A 25 29.4 3.7 25 33.0 4.3 /4.727


89/124

/xcept at


90/124

AGEWISE A3&2e 4 Ye#r

T#3e >


91/124

At all time intervals the mean heart rate was signifcantly higher

as compared to 1aseline 3pJ$E4$


92/124

T#3e >4@ C1#%*e % S8P #t ere%t t+e %ter2#0

Correspo!"# $%&'es

%t (%se&"e

At !"))eret t"*e

"ter$%&s

+t+ +p+


B%se&"e 28 103.2 7.3

A 28 103.2 7.3 28 133.6 6.8 /17.029


93/124




94/124

T#3e >;@ C1#%*e % D8P #t ere%t t+e %ter2#0

Correspo!"# $%&'es

%t (%se&"e

At !"))eret t"*e

"ter$%&s

+t+ +p+


B%se&"e 28 67.0 5.4 28 - -

A 28 67.0 5.4 28 79.0 4.6 /9.858


95/124




96/124

T#3e >>@ C1#%*e % MAP #t ere%t t+e %ter2#0

Correspo!"# $%&'es

%t (%se&"e

At !"))eret t"*e

"ter$%&s

+t+ +p+


B%se&"e 28 78.7 5.7

A 28 78.7 5.7 28 97.2 4.3 /15.390


97/124


compared to 1aseline 3pJ$E4 except at


98/124

T#3e >B@ C1#%*e % O=*e% S#t-r#t&% #t ere%tt+e %ter2#0

Correspo!"# $%&'es

%t (%se&"e

At !"))eret t"*e

"ter$%&s

+t+ +p+

,o. Me% SD ,o. Me% SDB%se&"e 28 98.4 1.7 - -

A 28 98.4 1.7 28 99.1 1.2 /3.195 0.004

s')) 28 98.4 1.7 28 99.1 1.2 /3.022 0.005

5* 28 98.4 1.7 28 98.9 1.5 /2.372 0.025

10* 28 98.4 1.7 28 98.8 1.4 /1.737 0.094

15* 28 98.4 1.7 28 98.9 1.2 /2.469 0.020

20* 28 98.4 1.7 28 98.8 1.4 /1.473 0.152

25* 28 98.4 1.7 28 98.8 1.4 /1.383 0.178

30* 28 98.4 1.7 28 98.8 1.4 /1.627 0.115

40* 28 98.4 1.7 28 99.0 1.3 /2.400 0.024

50* 28 98.4 1.7 28 98.9 1.5 /2.121 0.043

60* 27 98.4 1.7 27 99.0 1.4 /2.367 0.026

70* 25 98.3 1.7 25 98.8 1.5 /1.953 0.063

80* 24 98.3 1.7 24 98.9 1.5 /2.532 0.019

90* 22 98.1 1.8 22 98.8 1.6 /2.732 0.012

100* 21 98.0 1.7 21 98.7 1.5 /2.280 0.034

110* 19 98.2 1.7 19 98.7 1.5 /1.874 0.077120* 15 98.2 1.7 15 99.1 1.5 /2.982 0.010

130* 12 98.5 1.7 12 99.3 0.9 /2.138 0.056

140* 8 99.3 0.7 8 99.9 0.35 /2.376 0.049

150* 7 99.1 0.7 7 99.9 0.4 /3.873 0.008

160* 6 99.2 0.8 6 99.8 0.4 /2.000 0.102

170* 3 99.3 0.6 3 100.0 0.0 /2.000 0.184

180* 3 99.3 0.6 3 100.0 0.0 /2.000 0.184

At !es') 28 98.4 1.7 28 98.4 3.0 0.162 0.873

5* !es') 28 98.4 1.7 28 98.8 1.0 /1.616 0.118

10* !es') 28 98.4 1.7 28 99.0 1.3 /3.074 0.005

15* !es') 28 98.4 1.7 28 99.1 1.2 /3.104 0.004

3Paired t&test4


99/124


compared to corresponding 1aseline values$ *he change rom 1aseline

was signifcant at all time intervals except at


100/124

T#3e >6@ C1#%*e % E% t# CO; #t ere%t t+e%ter2#0

Correspo!"# $%&'es

%t (%se&"e

At !"))eret t"*e

"ter$%&s

+t+ +p+

,o. Me% SD ,o. Me% SDB%se&"e 28 30.8 3.2 - -

A 28 30.8 3.2 28 35.4 3.0 /5.685


101/124

At all time intervals the mean value was signifcantly higher as

compared to 1aseline$


102/124

Discussion

Physiological changes during laparoscopic surgery in paediatric

patients are related to the changes associated with the increased intra

a1dominal pressure3%AP4 due to the insu;ation o the a1domen 1y

C:, the patient5s postural modifcations 3head&up or head&down4 and

the C: a1sorption$ Smaller distance 1etween capillaries and

peritoneum and greater a1sorptive area o peritoneum in relation to

1ody weight leads to signifcant vascular a1sorption in children$


103/124

.ypercar1ia has direct e8ects on the myocardium and secondary

e8ects mediated via the autonomic nervous system$ *he

cardiovascular physiology in children and especially inants is

signifcantly di8erent rom that o adults$ *he 1lood pressure andsystemic vascular resistance are lower in children and the heart rate,

oxygen consumption and cardiac output are relatively higher$

*he %AP 3intra&a1dominal pressure4, the maor actor responsi1le

or the cardiovascular e8ects, involves changes in myocardial

contractility and systemic vascular resistance 3S(+4$ A decreased

venous return and increased S(+ will decrease cardiac output 3C4$ %n

adults with minor increases in %AP o less than


104/124

undergoing a spectrum o :B ifferent surgical proceures 'eing performe

laparoscopically an thoracoscopically. %ntra a1dominal pressure was #ept

1etween ?&$B, male and emale ratio BE@G and mean weight (in kg6 of

to G mm o .g$ Mean mean arterial

pressure 3MAP4 ranged rom ?


105/124

with 1ase line3pJ$E4$ Ater


106/124

0hen we compared heart rate according to position o

surgery 3"ateral, +everse *rendelen1erg, Supine, *rendelen1erg4,

changes were not statistically signifcant 3ta1le


107/124

3range


108/124

o .g and ater insu;ations, it increased to IH$< 3BG$=


109/124

R&'%e= #% Ar*e 3:4 ound in their study that 1lood

pressure increased 1y more than :F over 1aseline$

8#r&%"% et # (;


110/124

line3pJ$E4$ At all time intervals the mean D2P was signifcantly

higher as compared to 1aseline 3pJ$E4 3ta1le G4$

n comparing D2P 1etween age group o &:F4, HH$HIB$H3>


111/124

8#r&%"% et # (;


112/124

min it increased to =?$:IE$G 3>E$>F4, =B$HIB$G

3>>$$GIE$< 3>


113/124

n comparing mean ifference of MAP at ifferent time inter"als of insufflation an

esufflation from 'aseline in our stuy, there was a clinically an statistically significant

increase in MAP 3pJ$E4 from 'aseline. &his was in accorance with stuy one 'y

De 1aal et al (#$$;6.

/nd tidal C:

%n our study at 1aseline the endtidal C: 3/tC:4 o patients varied

rom :B to B mm o .g with a mean value o >$$E mm o .g$

Ater insu;ation all the patients had signifcant increase o /tC: with

mean value o B$GIB$B, B>$=IB$B, and

B>$EIB$: mm o .g respectively3ta1le B$:I>$, >>$>I>$> and >:$$BI>$: 3$?F4 ,>:$>I>$ 3=$G?F4, and

>$ 3H$=>F4 mm o .g respectively$ 0hile in age group $GI>$: mm o .g and ater

insu;ations, it increased to B>$>I >$> 3B$EGF4 mm o .g and ater


114/124

Emin, min it increased to BE$

3BE$$: 3BB$


115/124

inants and children$ *he /*C: increased rom >:I >$< to a maximum

o >EI B$G mm.g 3PJ$


116/124

A clinically an statistically significant increase in heart rate, systolic 'loo

pressure, iastolic 'loo pressure, mean arterial pressure, an en tial car'on io0ie

(/tC:6 from preoperati"e ('aseline6 "alue was o'ser"e in the paeiatric patients in

our stuy uring the perio of laparoscopy. *hese haemodynamic and cardiorespiratory changes serve as a

reminder o the care and planning needed in perorming these

procedures, especially in sic# and smaller children in ensuring a sae

and event&ree course or the small pediatric patient$

C&%"-0&%


117/124

*he present prospective study entitled W*he haemodynamic

changes in minimal invasive surgery in paediatric patients$X was

conducted in E> paediatric patients o ASA %and %% o mean age 3yrs$4

>$:?I>$B, male and emale ratio BE@G and mean weight 3in #g4 o


118/124


119/124

signifcant statistically$ According to position o surgery mean /tC:

was maximum in "ateral group and minimum in reverse trendelen1erg

and supine groups$ *he di8erences among groups were signifcant$

?& *he oxygen saturation range varied rom =B to $$EF with a range rom :B to BF $

3rom the a'o"e stuy we conclue that there were clinically an statistically

significant increase in heart rate, systolic 'loo pressure, iastolic 'loo pressure, mean

arterial pressure, an en tial car'on io0ie (/tC:6 from preoperati"e ('aseline6

"alue in the paeiatric patients uring the perio of laparoscopy.

Physiological changes uring laparoscopic surgery in paeiatric patients are

relate to the changes associate with the increase intra a'ominal pressure(-AP6 ue to

the insufflation of the a'omen 'y C#, the patientFs postural moifications (hea*up or

hea*own6 an the C# a'sorption. Smaller istance 'etween capillaries an

peritoneum an greater a'sorpti"e area of peritoneum in relation to 'oy weight leas to

significant "ascular a'sorption in chilren. ypercar'ia has irect effects on the

myocarium an seconary effects meiate "ia the autonomic ner"ous system.

*hese hemodynamic and cardiorespiratory changes serve as a

reminder o the care and planning needed in perorming these

procedures, especially in sic# and smaller children in ensuring a sae

and event&ree course or the small pediatric patient$


120/124

83&*r#1=


121/124


122/124

H4 Dave S, 0alid A$ -arhat$ Physiological e8ects o pediatric

urological laproscopic surgery$ %ndian Zournal o !rology

:?::@B>B&=G4 De 0all //, 9al#man CZ$ .emodynamic changes during low

pressure car1ondioxide pneumoperitoneum in young children$

Paediatr anaesth :>@


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:B4 *o1ias ZD$, Anaesthesia or minimally invasive surgery in

children$ 2est Pract +es Clin Anaesthesiol$ :: Mar

haemodynamic changes in minimal invasive surgery in paediatric patients.docx

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