Transesophageal Echocardiographic Assessment of Hemodynamic Changes during Laparoscopic Surgeries at High Altitude

Ab s t r Ac t Introduction: Anesthesia at high altitudes is challenging due to vast variations in physiology, which are further complicated by the positioning and pneumoperitoneum during laparoscopic surgeries. These changes can be better understood and managed with the help of echocardiography. Here, we demonstrate the effect of laparoscopy on hemodynamics with the help of transesophageal echocardiography (TEE) at high altitudes in three patients. Materials and methods: Three ASA I patients (patient 1, laparoscopic cholecystectomy; patient 2, laparoscopic vaginal hysterectomy; patient 3, laparoscopic hernioplasty with mesh repair) who underwent laparoscopic surgeries at an altitude of 3,500 m were studied. Various parameters were measured by TEE which included left ventricle ejection fraction (EF), left ventricular outflow tract (LVOT) velocity time integral (VTI), cardiac output (CO), E/A, E/eI, tricuspid annular plane systolic excursion (TAPSE), and pulmonary artery acceleration time (PAAT). The mean arterial pressure (MAP), heart rate, SpO2, and end-tidal carbon dioxide were also measured. These parameters were recorded at 10-time points: before induction of anesthesia (T1), before insufflation (T2), after positioning (T3), 5 mm Hg pneumoperitoneum (T4), 10 mm Hg pneumoperitoneum (T5), 14 mm Hg pneumoperitoneum (T6), 10 minutes after 14 mm Hg pneumoperitoneum (T7), 20 minutes after 14 mm Hg pneumoperitoneum (T8), 30 minutes after 14 mm Hg pneumoperitoneum (T9), and 5 minutes after desufflation (T10). Results: We observed a decrease in MAP, LVOT VTI, and CO after pneumoperitoneum when associated with reverse RT position and an increase in MAP, LVOT VTI, and CO when associated with Trendelenburg position. The right ventricular systolic function measured by TAPSE, left ventricular EF, and LV diastolic function remained the same throughout the procedure in all the three patients. Pulmonary artery acceleration time gradually decreased after pneumoperitoneum in all the three patients but stayed in a normal range throughout the procedure. The results of our study are consistent with the previous studies performed at sea level. Conclusion: The present study showed that laparoscopic surgeries may be safely performed in healthy individuals at high altitudes. However, the study was limited by small sample size and done only in healthy subjects.