A 56 year old African American man with a past medical history of HIV, TB (treated), and very severe stage IV COPD (FEV1 25%) with a thirty pack years smoking history presented for an outpatient bilateral hernia repair. The patient had been an active smoker since he was 16 year old. He currently takes Tudorza daily and albuterol inhaler as needed. This regimen controls his symptoms well as an outpatient. He does have persistent hypercapnia with an ABG of PH 7.34, PCO2 49, PO2 67, and a normal bicarbonate of 26.
The patient underwent bilateral laparoscopic hernia repair with mesh placement. During the procedure he received fentanyl, propofol, succinylcholine, rocuronium for intubation and induction. Peritoneal space was insufflated with 12 mmHg CO2 pressure. In this procedure, he was found to have bilateral inguinal hernias, and a right femoral hernia. He was under general anesthesia for two hours and eighteen minutes. Repair of his hernia was done without any complications. In the PACU the patient became confused and somnolent.
Because of his altered mental status an ABG was checked and he was found to have an acute respiratory acidosis with a PH of 7.25 and pCO2 of 80 mmHg. He was started on BiPAP as well as Albuterol 2.5 mg neb once and Ipratropium-Albuterol nebulizers. The following day he was more oriented, and a repeat ABG showed a pH of 7.36 and pCO2 of 60 mmHg. He was discharged home on budesonide and formoterol nebulizers.
Laparoscopy is a commonly used minimally invasive surgical technique that utilizes CO2 to create a pneumoperitoneum which allows the surgeon to easily visualize structures and perform surgery. Laparoscopy has improved outcomes, and decreased length of hospital stay as compared to open procedures for most patients. While laparoscopy is a useful surgical technique, it may not be ideal for all patients. Carbon dioxide in its gaseous state diffuses into the circulation extremely quickly during the process of creating a pneumoperitoneum. For most patients the rapid absorption of CO2 from the pneumoperitoneum created during laparoscopy can be offset by adjusting the ventilator. This is not always possible for patients with severe COPD. Several studies have shown patients with mild (stage I) to moderate (stage II) COPD develop significant hypercapnia during laparoscopic procedures without any changes in the rate of complication or prolonged hospital stay after the procedure. However, no studies have been conducted in patient with severe (stage IV) COPD.
Two approaches may be used to combat the accumulation of excess CO2 in patients with severe COPD. As discussed in the case presented, postoperative treatment of hypercapnic respiratory failure via BiPAP was utilized to stabilize the patient. The second, and more proactive approach to this issue is the use of alternative surgical and anesthetic techniques in patients with severe COPD to prevent the development of postoperative hypercarpnea. These alternative techniques include the use of open instead of laparoscopic procedures with the aid of local blocks. With the use of these alternative surgical and anesthetic methods patients may be managed in a way that aims to prevent the development of postoperative hypercapnic respiratory failure.
Although the use of laparoscopy has become common place, it may not be the ideal surgical approach in all patients as presented here. We write this to bring awareness to the use of alternative techniques which may be used to more optimally manage patients with severe pulmonary pathology.