Humidified Carbon Dioxide Insufflation Research Articles

Is there a role for warm humidified carbon dioxide insufflation in open abdominal surgery?

Is there a role for warm humidified carbon dioxide insufflation in open abdominal surgery?

A phase I, nonrandomized controlled trial demonstrating the novel technique of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy utilizing warm humidified carbon dioxide insufflation

The aim of this work was to report on the safety and feasibility of warm humidified CO2 (WHCO2 ) insufflation during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Ten consecutive patients with histologically confirmed peritoneal cancer were enrolled in this phase I pilot nonrandomized controlled trial. They were alternately assigned to CRS and HIPEC with WHCO2 versus standard procedure. WHCO2 was delivered at 10L/min, a pressure of 4.5bar, 37ºC and 98% relative humidity during CRS using the HumiGardTM system. HIPEC was performed with an open abdomen using the Coliseum technique at 42ºC for 60min. All patients were admitted to the intensive care unit and commenced on total parenteral nutrition postoperatively. Surface and core temperatures were measured every 30min using an infrared camera and nasopharyngeal probe, respectively. Clinicopathological, intra- and postoperative details were collated between groups, and median surface and core temperatures were statistically compared. Surface and core temperatures were generally higher in the WHCO2 group. Core temperature at 120 and 180min was significantly higher in the WHCO2 versus the non-WHCO2 group (p=0.028 and 0.008, respectively). There was a significant linear relationship between core and surface temperature at 30, 60, 90, 120, 150 and 180min (p=0.033, 0.004, 0.007, 0.021, 0.009 and 0.006, respectively). The peritoneal cancer index was lower but the estimated blood loss was higher in the non-WHCO2 than the WHCO2 group. WHCO2 in CRS and HIPEC appears to be safe and feasible. An appropriately powered phase II trial will be required to determine if WHCO2 is associated with improved intra- and postoperative outcomes.

Fetoscopic Insufflation modeled in EXTEND: Warm Humidified Carbon Dioxide Insufflation is Safer for the Fetus

Fetoscopic Insufflation modeled in EXTEND: Warm Humidified Carbon Dioxide Insufflation is Safer for the Fetus

Randomized clinical trial of the effect of intraoperative humidified carbon dioxide insufflation in open laparotomy for colorectal resection.

BackgroundAnimal studies have shown that peritoneal injury can be minimized by insufflating the abdominal cavity with warm humidified carbon dioxide gas.MethodsA single‐blind RCT was performed at a tertiary colorectal unit. Inclusion criteria were patient aged 18 years and over undergoing open elective surgery. The intervention group received warmed (37°C), humidified (98 per cent relative humidity) carbon dioxide (WHCO2 group). Multiple markers of peritoneal inflammation and oxidative damage were used to compare groups, including cytokines and chemokines, apoptosis, the 3‐chlorotyrosine/native tyrosine ratio, and light microscopy on peritoneal biopsies at the start (T0) and end (Tend) of the operation. Postoperative clinical outcomes were compared between the groups.ResultsOf 40 patients enrolled, 20 in the WHCO2 group and 19 in the control group were available for analysis. A significant log(Tend/T0) difference between control and WHCO2 groups was documented for interleukin (IL) 2 (5·3 versus 2·8 respectively; P = 0·028) and IL‐4 (3·5 versus 2·0; P = 0·041), whereas apoptosis assays documented no significant change in caspase activity, and similar apoptosis rates were documented along the peritoneal edge in both groups. The 3‐chlorotyrosine/tyrosine ratio had increased at Tend by 1·1‐fold in the WHCO2 group and by 3·1‐fold in the control group. Under light microscopy, peritoneum was visible in 11 of 19 samples from the control group and in 19 of 20 samples from the WHCO2 group (P = 0·006). The only difference in clinical outcomes between intervention and control groups was the number of days to passage of flatus (2·5 versus 5·0 days respectively; P = 0·008).ConclusionThe use of warmed, humidified carbon dioxide appears to reduce some markers related to peritoneal oxidative damage during laparotomy. No difference was observed in clinical outcomes, but the study was underpowered for analysis of surgical results. Registration number: NCT02975947 ( http://www.clinicaltrials.gov/).

Clinical effects of warmed humidified carbon dioxide insufflation in infants undergoing major laparoscopic surgery

Purpose:Some studies have reported that warmed humidified carbon dioxide (CO2) insufflation in adult laparoscopic surgery could reduce pain and improve the core body temperature (CBT). However, similar studies are lacking in infants. Thus, this study aimed to investigate the clinical effects of warmed, humidified CO2 insufflation in pediatric patients undergoing major laparoscopic surgeries.Methods:From January 2015 to December 2017, infants who underwent major laparoscopic surgeries in Ningbo Women and Children's Hospital were randomized to Group A (standard CO2 insufflation) or Group B (warmed humidified CO2 insufflation, 35°C, 95% relative humidity). Change in CBT at the end of surgery was the primary outcome. Secondary outcomes included surgery time, intraoperative blood loss, oxygen saturation (SO2), and Face, Legs, Activity, Cry and Consolability (FLACC) scale. These variables were compared between the 2 groups.Results:Sixty-three infants (38 females, 25 males) were included; 30 patients were in Group A and 33 in Group B. The diseases treated with the laparoscopic approach included congenital megacolon, congenital diaphragmatic hernia, and intestinal malrotation. No deaths were noted. CBT was significantly higher in Group B at the end of surgery (P = .021). The occurrence of postoperative shivering (P = .02), hypothermia (P = .032), bowel movement (P = .044), and hospital stay (P = .038) was significantly different between the 2 groups; Group B had less shivering and hypothermia occurrence after surgery. Moreover, Group B demonstrated a more rapid postoperative recovery of bowel movement and shortened hospital stay than Group A. There was no statistical difference in operative time (P = .162), intraoperative blood loss (P = .541), SO2 (P = .59), and FLACC scale (P = .65) between the 2 groups.Conclusion:The use of warmed humidified CO2 insufflation in infants undergoing major laparoscopic surgery was helpful for maintaining normothermia and was associated with several positive postoperative outcomes, including less shivering and hypothermia, faster recovery of bowel movement, and shortened hospital stay.

Increased visceral tissue perfusion with heated, humidified carbon dioxide insufflation during open abdominal surgery in a rodent model.

Tissue perfusion during surgery is important in reducing surgical site infections and promoting healing. This study aimed to determine if insufflation of the open abdomen with heated, humidified (HH) carbon dioxide (CO2) increased visceral tissue perfusion and core body temperature during open abdominal surgery in a rodent model. Using two different rodent models of open abdominal surgery, visceral perfusion and core temperature were measured. Visceral perfusion was investigated using a repeated measures crossover experiment with rodents receiving the same sequence of two alternating treatments: exposure to ambient air (no insufflation) and insufflation with HH CO2. Core body temperature was measured using an independent experimental design with three treatment groups: ambient air, HH CO2 and cold, dry (CD) CO2. Visceral perfusion was measured by laser speckle contrast analysis (LASCA) and core body temperature was measured with a rectal thermometer. Insufflation with HH CO2 into a rodent open abdominal cavity significantly increased visceral tissue perfusion (2.4 perfusion units (PU)/min (95% CI 1.23–3.58); p<0.0001) compared with ambient air, which significantly reduced visceral blood flow (-5.20 PU/min (95% CI -6.83- -3.58); p<0.0001). Insufflation of HH CO2 into the open abdominal cavity significantly increased core body temperature (+1.15 ± 0.14°C) compared with open cavities exposed to ambient air (-0.65 ± 0.52°C; p = 0.037), or cavities insufflated with CD CO2 (-0.73 ± 0.33°C; p = 0.006). Abdominal visceral temperatures also increased with HH CO2 insufflation compared with ambient air or CD CO2, as shown by infrared thermography. This study reports for the first time the use of LASCA to measure visceral perfusion in open abdominal surgery and shows that insufflation of open abdominal cavities with HH CO2 significantly increases visceral tissue perfusion and core body temperature.

Changes in the coelomic microclimate during carbon dioxide laparoscopy: morphological and functional implications.

In this article the adverse effects of laparoscopic CO2 pneumoperitoneum and coelomic climate change, and their potential prevention by warmed, humidified carbon dioxide insufflation are reviewed. The use of pressurized cold, dry carbon dioxide (C02) pneumoperitoneum causes a number of local effects on the peritoneal mesothelium, as well as systemic effects. These can be observed at a macroscopic, microscopic, cellular and metabolic level. Local effects include evaporative cooling, oxidative stress, desiccation of mesothelium, disruption of mesothelial cell junctions and glycocalyx, diminished scavenging of reactive oxygen species, decreased peritoneal blood flow, peritoneal acidosis, peritoneal hypoxia or necrosis, exposure of the basal lamina and extracellular matrix, lymphocyte infiltration, and generation of peritoneal cytokines such as IL-1, IL-6, IL-8 and TNFα. Such damage is increased by high CO2 insufflation pressures and gas velocities and prolonged laparoscopic procedures. The resulting disruption of the glycocalyx, mesothelial cell barrier and exposure of the extracellular matrix creates a cascade of immunological and pro-inflammatory events and favours tumour cell implantation. Systemic effects include cardiopulmonary and respiratory changes, hypothermia and acidosis. Such coelomic climate change can be prevented by the use of lower insufflation pressures and preconditioned warm humidified CO2. By achieving a more physiological temperature, pressure and humidity, the coelomic microenvironment can be better preserved during pneumoperitoneum. This has the potential clinical benefits of maintaining isothermia and perfusion, reducing postoperative pain, preventing adhesions and inhibiting cancer cell implantation in laparoscopic surgery.

Changes in the coelomic microclimate during carbon dioxide laparoscopy: morphological and functional implications

AbstractIn this article the adverse effects of laparoscopic CO2pneumoperitoneum and coelomic climate change, and their potential prevention by warmed, humidified carbon dioxide insufflation are reviewed. The use of pressurized cold, dry carbon dioxide (C02) pneumoperitoneum causes a number of local effects on the peritoneal mesothelium, as well as systemic effects. These can be observed at a macroscopic, microscopic, cellular and metabolic level. Local effects include evaporative cooling, oxidative stress, desiccation of mesothelium, disruption of mesothelial cell junctions and glycocalyx, diminished scavenging of reactive oxygen species, decreased peritoneal blood flow, peritoneal acidosis, peritoneal hypoxia or necrosis, exposure of the basal lamina and extracellular matrix, lymphocyte infiltration, and generation of peritoneal cytokines such as IL-1, IL-6, IL-8 and TNFα. Such damage is increased by high CO2insufflation pressures and gas velocities and prolonged laparoscopic procedures. The resulting disruption of the glycocalyx, mesothelial cell barrier and exposure of the extracellular matrix creates a cascade of immunological and pro-inflammatory events and favours tumour cell implantation. Systemic effects include cardiopulmonary and respiratory changes, hypothermia and acidosis. Such coelomic climate change can be prevented by the use of lower insufflation pressures and preconditioned warm humidified CO2. By achieving a more physiological temperature, pressure and humidity, the coelomic microenvironment can be better preserved during pneumoperitoneum. This has the potential clinical benefits of maintaining isothermia and perfusion, reducing postoperative pain, preventing adhesions and inhibiting cancer cell implantation in laparoscopic surgery.

Beneficial Effects of Humidified, Warmed Carbon Dioxide Insufflation During Laparoscopic Bariatric Surgery: A Randomized Clinical Trial. What if Sample Size Calculation Made Difference?

Sir: We read with interest the article published by Dr. Savel and colleagues [1]. While the authors are to be commended for their aim to conduct a prospective, randomized double-blind trial about the effect of warm and humidified carbon dioxide insufflation on postoperative pain and morphine requirements, there seems to be some issues with the study design. In particular, even though this trial appears to be adequately designed and analyzed, it does not seem to be adequately powered. In fact, in order for a particular finding to be claimed as significant (or not), the study should be adequately powered. The authors state their primary endpoints were visual analogic pain scores (VAS) and morphine requirements. They refer to an older article [2] but, unfortunately, seem to have failed sample size calculation. Nowhere in this reference article is the variability (SD) in morphine requirement at 24 h 10 mg. Considering a more reasonable variability (SD) of 30 mg and considering a clinically significant difference of 10 mg, a total of 193 patients per group would have been required (considering the “standard” α error of 0.05 and a power of 0.8) in this study. As for VAS, the authors did not perform any sample size calculation, and therefore, it is almost impossible to perform a pre-study sample size calculation. However, assuming a mean VAS value of 2.5±1.8 at 24 h [3] and considering a reduction of 1.8 clinically significant, more than 30 patients per group would have been required. It is also possible to perform a post hoc sample size calculation or power analysis on the statistical tests they have used from their data. In particular, considering a mean VAS value of 3.8±1.7 in the control group (Table 2), and a difference of 1.3, their test had a power of only 0.52 to detect such difference (considering an α error of 0.05). Appropriate sample size calculation and power is mandatory to draw adequate conclusions. In this case, the authors state no differences in opioid requirements and postoperative pain exists between the 2 groups. Are we sure it is really so? We hope our observations are useful to other authors planning surgical trials. “Editor’s Note: “Dr. Savel was invited to respond to this Letter-to-the Editor and declined.”

The Effect of Heated Humidified Carbon Dioxide on Postoperative Pain, Core Temperature, and Recovery Times in Patients Having Laparoscopic Surgery: A Randomized Controlled Trial

Study Objective To determine whether use of heated humidified carbon dioxide as insufflation gas during gynecologic laparoscopy reduced postoperative pain and hypothermia. Design A randomized controlled trial (Canadian Task Force classification 1). Setting A tertiary referral hospital. Patients Sixty women scheduled for gynecologic laparoscopy between 30 and 90 minutes’ duration. Interventions Operative laparoscopic management of endometriosis, adhesions, or adnexal pathology. Measurements and Main Results Sixty patients were randomized into either receiving heated humidified carbon dioxide (study group) or standard cold dry gas (control group). Intraoperative and postoperative core temperature, total analgesic use, postoperative nausea, and recovery room time were recorded. Postoperative pain intensity was assessed using visual analog scale. Statistical analysis was performed using software. No significant difference was revealed between groups with regard to postoperative pain, analgesic requirements, recovery room time, or postoperative nausea. The control group had less postoperative hypothermia, suggesting that external warming blankets may be more effective than heated humidified gas at maintaining intraoperative normothermia. Conclusion The use of heated humidified carbon dioxide insufflation for short-duration gynecologic laparoscopy up to 90 minutes’ duration was not associated with any significant benefit with regard to postoperative pain, hypothermia, or time of recovery room stay.

Prospective, case‐matched study of heated and humidified carbon dioxide insufflation in laparoscopic colorectal surgery

Laparoscopic colorectal surgery is often prolonged and may cause hypothermia. It is uncertain if heated and humidified carbon dioxide (CO(2)) in laparoscopic colorectal surgery is beneficial. This is a prospective case-matched study on the use of heated and humidified CO(2) in patients undergoing laparoscopic colorectal surgery. Twenty consecutive patients undergoing laparoscopic colorectal surgery with heated (36 degrees C) and humidified (95%) CO(2) were compared with 20 consecutive patients using standard CO(2) (30.2 degrees C). All procedures were performed by a single surgeon in an institution. The changes in core temperature during surgery, visual quality of images and the short-term clinical outcome were documented. The core temperature fell during surgery in both groups. Although the fall of core temperature was more in the control group, it was not statistically significant (P > 0.05). The passage of flatus was more delayed in heated and humidified group (P = 0.004), but it did not affect the hospital discharge. All the other parameters, including the quality of visual images and the postoperative pain, were similar in both groups. Despite better temperature maintenance (nonsignificant), pneumoperitoneum using heated and humidified CO(2) gas did not appear to have any clinical benefits in laparoscopic colorectal surgery.

A randomized controlled trial to determine the effects of humidified carbon dioxide insufflation during thoracoscopy.

The humidification of gas insufflated during laparoscopy can reduce the degree of postoperative hypothermia and may result in less peritoneal reaction and less postoperative pain. The present study was designed to determine whether the beneficial effects of humidified gas insufflation also applied to thoracoscopy. Six pigs were each studied on three separate occasions with insufflation into the right thoracic cavity of either humidified gas, standard dry gas, or with no insufflation (control procedure). Core body temperature was recorded every 15 min, and biopsies of the parietal pleura were taken at the end of each study for electron microscopy. Humidification of insufflated gas significantly minimized the fall in core temperature during the procedure. Electron microscopy showed that dry gas insufflation resulted in greater structural injury to the pleura than humidified gas insufflation. The potential benefits of humidifying insufflation gas during thoracoscopy warrant its evaluation in the clinical setting.