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CARDIOVASCULAR ANESTHESIA

Cardiopulmonary Dysfunction During Minimally Invasive Thoraco-Lumboendoscopic Spine Surgery

B. Vollmar, MD^*, A. Olinger, MD, U. Hildebrandt, MD, and M. D. Menger, MD^*

*Institute for Clinical & Experimental Surgery and Departments of Trauma Surgery and General Surgery, University of Saarland, Homburg/Saar, Germany

Address correspondence and reprint requests to Brigitte Vollmar, MD, The Center of Blood Research, Harvard Medical School, 200 Longwood Ave., Boston, MA 02115. Address e-mail to vollmar @cbr.med.harvard.edu.

The endoscopic retroperitoneal approach to thoraco-lumbar anterior spine fusion is associated with CO₂ insufflation into the thoracic space. We studied the cardiopulmonary effects of this CO₂ thoraco-retroperitoneal insufflation compared with the conventional open surgical procedure using thoraco-phreno-lumbotomy in 12 pigs under balanced anesthesia, paralysis, and mechanical ventilation. During open surgery of the thoraco-lumbar spine, animals exhibited unchanged systemic and pulmonary hemodynamics, as well as ventilation and oxygenation variables. Animals retroperitoneally insufflated with CO₂ (12 mm Hg) exhibited a significant increase of PaCO₂ and a moderate decrease of PaO₂, SaO₂, and pH, with insignificant changes of central venous filling pressures and systemic hemodynamics. Endoscopic phrenotomy with thoracic CO₂ insufflation instantaneously and drastically affected hemodynamic status and pulmonary gas exchange with marked hypoxia, hypercapnia, systemic hypotension, tachycardia, and pulmonary hypertension within minutes. An increase of minute ventilation, inspiratory oxygen fraction, and positive end-expiratory pressure promptly reversed these cardiopulmonary effects. CO₂ evacuation allowed the animals to completely recover and regain almost baseline cardiopulmonary status, except for a reduced arterial blood pressure. Appropriate monitoring and immediate CO₂ desufflation may be beneficial in cases of therapy-resistent hemodynamic, oxygenation, and ventilation difficulties.

Implications: For endoscopic thoraco-lumbar spine fusion, CO₂ thoraco-retroperitoneum–induced cardiopulmonary dysfunction must be of concern, especially in patients with cardiopulmonary compromise. Appropriate monitoring and immediate CO₂ desufflation may be beneficial in cases of therapy-resistant hemodynamic, oxygenation, and ventilation difficulties.