haemodynamic changes in minimal invasive surgery in paediatric patients.docx
TRANSCRIPT
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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+
,o. Me% SD ,o. Me% SD
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+
,o. Me% SD ,o. Me% SD
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
compared to 1aseline 3pJ$E4$
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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+
,o. Me% SD ,o. Me% SD
B%se&"e 53 75.1 7.2 - -
A 53 75.1 7.2 53 95.3 5.5 /19.354
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At all time intervals the mean MAP was signifcantly higher as
compared to 1aseline 3pJ$E4 except at
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T#3e 4
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At all time intervals, mean oxygen saturation was higher as
compared to corresponding 1aseline values$ *he change rom 1aseline
was signifcant at all time intervals except at
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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
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At all ollow up intervals the mean /nd tidal C: levels were
signifcantly higher as compared to 1aseline$$
TYPE OF SURGERY
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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+
,o. Me% SD ,o. Me% SD
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
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Student VtV&test
)o di8erence 1etween two types o surgery was o1served at any
time interval$
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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+
,o. Me% SD ,o. Me% SD
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
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Student VtV&test
)o di8erence 1etween two types o surgery was o1served at any
time interval$
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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+
,o. Me% SD ,o. Me% SD
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 .
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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
a1dominal"aparoscopy *horasic laparoscpy
+t+ +p+
,o. Me% SD ,o. Me% SD
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
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)o di8erence 1etween two types o surgery was o1served at any
time interval$
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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
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%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$
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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
a1dominal"aparoscopy *horasic laparoscpy
+t+ +p+
,o. Me% SD ,o. Me% SD
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
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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$
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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
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)o signifcant di8erence was o1served at any time interval$
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T#3e 45@ C&+#r0&% &/ S8P % 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# $ 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
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)o signifcant di8erence was o1served at any time interval$
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T#3e ;
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)o signifcant di8erence was o1served at any time interval$
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T#3e ;4@ C&+#r0&% &/ MAP % 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# $ p1 B%se&"e 15 77.1 8.1 9 74.3 8.3 5 74.8 3.5 24 74.1 6.9 0.553 0.649
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
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)o signifcant di8erence was o1served at any time interval$
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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
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*he mean oxygen saturation among patients with lateral position
as compared to other positions was signifcantly lower at all time
intervals except
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T#3e ;>@ C&+#r0&% &/ E% t# CO; % 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# $ p1 B%se&"e 15 31.0 3.7 9 31.4 2.7 5 28.2 3.6 24 29.5 3.4 1.580 0.206
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
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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$
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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+
,o. Me% SD ,o. Me% SD
B%se&"e 25 143.5 9.9
A 25 143.5 9.9 25 161.1 10.6 /9.502
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At all time intervals the mean heart rate was signifcantly higher
as compared to 1aseline 3pJ$E4 except at
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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+
,o. Me% SD ,o. Me% SD
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
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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 ;@ C1#%*e % D8P #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 25 59.7 3.6
A 25 59.7 3.6 25 76.5 6.7 /11.426
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At all time intervals the mean D2P was signifcantly higher as
compared to 1aseline 3pJ$E4$
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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+
,o. Me% SD ,o. Me% SD
B%se&"e 25 71.1 6.6 - -
A 25 71.1 6.6 25 93.2 6.0 /12.981
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At all time intervals the mean MAP was signifcantly higher as
compared to 1aseline 3pJ$E4$
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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
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At all time intervals, mean oxygen saturation was higher as
compared to corresponding 1aseline values$ At
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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
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/xcept at
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AGEWISE A3&2e 4 Ye#r
T#3e >
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At all time intervals the mean heart rate was signifcantly higher
as compared to 1aseline 3pJ$E4$
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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+
,o. Me% SD ,o. Me% SD
B%se&"e 28 103.2 7.3
A 28 103.2 7.3 28 133.6 6.8 /17.029
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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 >;@ C1#%*e % D8P #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 28 67.0 5.4 28 - -
A 28 67.0 5.4 28 79.0 4.6 /9.858
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At all time intervals the mean D2P was signifcantly higher as
compared to 1aseline 3pJ$E4$
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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+
,o. Me% SD ,o. Me% SD
B%se&"e 28 78.7 5.7
A 28 78.7 5.7 28 97.2 4.3 /15.390
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At all time intervals the mean MAP was signifcantly higher as
compared to 1aseline 3pJ$E4 except at
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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
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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
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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
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At all time intervals the mean value was signifcantly higher as
compared to 1aseline$
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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$
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.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
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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 ?
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with 1ase line3pJ$E4$ Ater
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0hen we compared heart rate according to position o
surgery 3"ateral, +everse *rendelen1erg, Supine, *rendelen1erg4,
changes were not statistically signifcant 3ta1le
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3range
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o .g and ater insu;ations, it increased to IH$< 3BG$=
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R&'%e= #% Ar*e 3:4 ound in their study that 1lood
pressure increased 1y more than :F over 1aseline$
8#r&%"% et # (;
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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>
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8#r&%"% et # (;
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min it increased to =?$:IE$G 3>E$>F4, =B$HIB$G
3>>$$GIE$< 3>
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n comparing mean ifference of MAP at ifferent time inter"als of insufflation an
esufflation from 'aseline in our stuy, there was a clinically an statistically significant
increase in MAP 3pJ$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 >:$$BI>$: 3$?F4 ,>:$>I>$ 3=$G?F4, and
>$ 3H$=>F4 mm o .g respectively$ 0hile in age group $GI>$: mm o .g and ater
insu;ations, it increased to B>$>I >$> 3B$EGF4 mm o .g and ater
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Emin, min it increased to BE$
3BE$$: 3BB$
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inants and children$ *he /*C: increased rom >:I >$< to a maximum
o >EI B$G mm.g 3PJ$
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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&%
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*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>$B, male and emale ratio BE@G and mean weight 3in #g4 o
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signifcant statistically$ 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$
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83&*r#1=
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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