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Labetalol in regulation of CO2-pneumoperitoneum induced arterial hypertension during laparoscopic cholecystectomy

Intraabdominal pressure (IAP)(15 mmHg) during CO2-pneumoperitoneum causes sympathetic and neuroendocrine cardiac activation and increases systemic vascular resistance with consequently elevation of right- and left heart filling pressure (1, 2). The increase in MAP during CO2-pneumoperitoneum depends on elevated plasma vasopresin, rennin and aldosteron concentration (3). The influence of CO2-pneumoperitoneum in patients with preexisting arterial hypertension (AH) is still of interest. Aim was to determine the elevation of the arterial blood pressure in ASA II and III patient with preexisting AH during CO2-pneumoperitoneum and tested labetalol in its control during the laparoscopic surgery (LC). The Ethics Committee approved the protocol and 516 patients were included in the prospective, randomized, study during one-year period. In Group A, the increase of MAP was evaluated in 108 LC patients (78 without and 30 with AH). The data were compared with 108 patients (72 without and 36 with AH) during opened cholecystectomy. Group B consisted of 300 LC patient with AH. This group was divided into five subgroups of 60 patients each (30 ASA II and 30 ASA III) in which the efficiency of five drags with antihypertensive effects was observed. All patients were premedicated (midazolam 7.5 mg orally). Anesthesia was induced with midazolam (0.15 mg/kg), narcuron (0.1 mg/kg) and fentanyl (0.003 mg/kg). Patients were intubated and mechanically ventilated to maintenance end-tidal CO2 under 45 mmHg. The patient position in 15 degree of reverse Trendelenburg positioning was constant. Ten minutes after insufflation of CO2, fentany (0.005 μ g/kg/min), halotan (0.5-0.8 V%), droperidol (0.1 mg/kg), urapidil (0.5 mg/kg) or labetalol (0.15 mg/kg) was applied. Invasive measurements of MAP were performed prior and after CO2 insufflation, and in 10 min intervals. Statistical analysis was performed by non-parametric tests of ANOVA (Friedman, Kruskal-Wallis and Wilcoxon-Mann-Whitney test). MAP increased for 10% in normotensive but for significantly 18% in hypertensive patients 10 min after CO2 insufflation (P<0.05). Larger doses of anesthetics (halotan) and analgesics (fentanyl, droperidol) were sufficient to control perioperative hypertension in normotensive patients and in hypertonics with mild AH. Labetalol and urapidil were equally effective in the regulation of AH in ASA III hypertonics. Reactive tachicardia was noted with urapidil application and required adequate hydration of patients. Except in chronic lung diseases and with preserved myocardial function, labetalol (alpha- and non-selective beta-adrenergic blocker) proves to be a better choice in the control of AH during LC with CO2 pneumoperitoneum in ASA III patient with arterial hypertension. References 1 Larsen JF, Svendsen FM, Pedersen V. Randomized clinical trial of the effect of pneumoperitoneum on cardiac function and haemodynamics during laparoscopic cholecystectomy. Br J Surg 2004 ; 91(7):848-54. 2 Anderson L, Lindberg G, Bringman S, et al. Pneumoperitoneum versus abdominal wall lift: effects on central haemodynamics and intrathoracic pressure during laparoscopic cholecystectomy. Acta Anaesthesiol Scand 2003 ; 47(7):838-46. 3 Hirvonen EA, Nuutinen LS, Vuolteenaho O. Hormonal responses and cardiac filling pressures in head-up or head-down position and pneumoperitoneum in patients undergoing operative laparoscopy. Br J Anaesth 1997 ; 78:128-33.

labetalol; pneumoperitoneum; laparoscopic cholecystectomy

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