PERIOPERATIVE METABOLISM IN PATIENTS WITH ACUTE CALCULUS CHOLECYSTITIS AND METHODS OF ITS CORRECTION

Abstract

It is important to study changes in metabolism in patients with acute calculus cholecystitis (ACC) during laparoscopic cholecystectomy  and to find ways to correct them. The aim of the study. To study the perioperative metabolism in ACC patients and evaluate the possibilities of its correction. Materials and methods. The study was prospective, not randomized. 129 patients with ACC, aged 36-84 years (54 men, 75 women), who underwent laparoscopic cholecystectomy, were studied. Preoperative risk ASA II-IV. General anesthesia with the use of the inhaled anesthetic sevoflurane and the narcotic analgesic fentanyl in low-flow mechanical ventilation. Perioperative intensive care was conducted in accordance with the International Standards for the Safe Anesthesiology Practice WFSA (World Federation of Societies of Anesthesiologists, 2010). In group I (n = 61) a retrospective energy audit was performed according to the protocols of anesthesia of medical histories and calculations of indirect calorimetry with the determination of current the Metabolic Rate (MR) and Basal Metabolic Rate (BMR). In group II (n = 68), operational monitoring was supplemented by the use of indirect calorimetry to determine MR, BMR, Target Metabolic Rate (TMR)  and the degree of Metabolic Disorders (MD) (MD = 100 × (TMR-MR)/TMR  %), and intensive care is supplemented by additional infusion therapy and glucocorticoids, taking into account the dynamics of metabolic changes. Results. The initial parameters of metabolism, in both groups, were without disturbance, and MR significantly exceeded BMR (in group I - by 30,5%, in group II - by 28,8%) and had the following values: in group I - 749±12 cal×min-1×m-2, in group II - 756±13 cal×min-1×m-2. In both groups, at the stage of the reverse position of Trendelenburg, the imposition of pneumoperitoneum and the beginning of the operation, significant metabolic disorders were observed with MR reduction to the basal level. Slow recovery of MR was observed in patients of group I, the value of which at the time of awakening remained 7,6% below baseline (p <0,05). In patients of group II, on the background of enhanced infusion therapy and glucocorticoids, the recovery of MR was more intense and, by the time of awakening, its value exceeded the corresponding value of group I by 10,4% (p <0,05). At the same time, the MD and TMR were low and did not differ from the initial values. Patients in group II, compared with group I, woke up faster and were transferred to the ward, and nausea and vomiting were 2,7 times less common: 7,35% in group II and 19,7% in group I (p <0,05). At 6 and 12 hours after awakening, the sensation of pain on the VAS scale in group II was lower than in group I, respectively, by 24,3% and 34,4% (p <0,05). Conclusions. Perioperative energy monitoring makes it safer to perform laparoscopic cholecystectomy in patients with ACC. Additional determination of the target metabolism and the degree of metabolic disorders allows you to more effectively build perioperative intensive care.