This document summarizes a presentation on using oral clonidine premedication to attenuate hemodynamic variations caused by pneumoperitoneum during laparoscopic surgery. It describes how pneumoperitoneum can cause increases in blood pressure, heart rate, and acidosis due to hypercarbia. A study was conducted comparing 50 patients given 150 μg of oral clonidine 90 minutes before surgery to 50 patients given a placebo. Clonidine was found to provide hemodynamic stability and reduce postoperative pain, nausea, vomiting and shivering compared to the placebo. The conclusion is that clonidine protects against the stress response to pneumoperitoneum and provides stable hemodynamics during laparoscopic procedures.

1. Presentation by Dr S.N.Bhagirath
Professor Hemalatha
Professor and HoD –Dr P.N.Vishwanathan

2. Overview
 Laparoscopic surgeries-increasingly used in varied fields of
surgery.
 Prerequisites for laparoscopic surgery- working cavity,
positional changes
 Working cavity (pneumoperitoneum and its associated side effects)
– hemodynamic effects in terms of SBP, DBP, MAP
 Clonidine oral premedication-
1. Attenuation of these hemodynamic variations
2. Extended post operative analgesia
3. Reduced nausea, vomiting and shivering

3. Pneumoperitoneum
Increased IAP
>15 mm of Hg
Increased
absorption of
CO2
Decreased
exsufflation of
CO2
Hypercarbia
50 – 70 mm of Hg
Acidosis
Trendelenburg’s
position

4. • decreased cardiac
contractility
• sensitization of
myocardium to
arrythmogenic effects of
catecholamines
• systemic vasodilatation
• centrally mediated
sympathetic stimulation
•Decreased CO
•Decreased SV
•Decreased pH
•Increased HR
•Increased BP
•Increased CVP
•Increased Epinephrine
•Increased
Nor Epinephrine
Hypercarbia, Acidosis
Clonidine

5. Patients, material & methods
100 Adult ASA physical status I & II (aged 18 years – 50 years)
Group C (Clonidine) Group P (Placebo)
• 50 patients
• Tab. Clonidine 150 μg as
premedication -90 mins before
• 50 patients
• Tab. Ranitidine 150 mg as
premedication -90 mins before
• Obese patients, patients on antihypertensives and patients with
severe CVS abnormalities excluded from either group
• SBP, DBP, MAP, HR, SpO2, EtCO2, ECG were recorded prior
to induction, before pnp, 3, 15 and 30 mins after pnp, 5 mins
after release of CO2 and 5 mins after extubation.

6. Anaesthesia
 Monitors- SpO2, HR (pulseox), NBP, ECG, EtCO2
 Induction-Thiopentone 5 mg Kg-1
 Muscle relaxant for intubation-Suxamethonium 1.5 mg Kg-1
 Maintained with 33 % O2 in N2O + 0.4 % Halothane
 Relaxant-Vecuronium bromide 0.1 mg Kg-1
 Analgesia-Fentanyl Citrate 1.5 μg Kg-1
 EtCO2 maintained between 35-45 mm of Hg
 Table position-reverse trendelenburg position
 SBP, DBP, MAP, EtCO2, SpO2, ECG were recorded
 Reversal with Neostigmine – 0.05 mg Kg-1 and
Glycopyrrolate 0.01 mg Kg-1
 Degree of pain & sedation assessed with VAS & sedation score.

7. Observations
 Changes in pulse pressure in two groups

8. Observations
 Changes in systolic pressure in two groups

9. Observations
 Changes in mean arterial pressure in two groups

10. Observations
 Changes in diastolic blood pressure in two groups

11. Observations
 VAS Score

12. Discussion
 Hemodynamic changes assoc with pnp-first seen in 1947
 Other drugs tried at attenuating hemodynamic response
1. Esmolol 2. Labetalol 3. Nifedipine
 Aho et al: 4.5μg/kg of Clonidine-decreased MAP
 Joris et al: 8μg/kg of Clonidine-decreased catecholamine levels
 Malek et al: 150μg of Clonidine-hemodynamic stability-pnp
 Sung et al: 150μg of Clonidine-hemodynamic stability-pnp
 Yu et al: 150μg of Clonidine-hemodynamic stability-pnp
 Ishizaki et al: Safe IAP in laparoscopic surgery (<14 mm of Hg)

13. Clonidine
 Imidazoline derivative
 Centrally acting selective
partial α-2 agonist
α-2
Clonidine
Creates a false perception
of high circulating levels
of catecholamines
Reduced
signal to
adrenals
Decreased secretion
of catecholamines
•Decreased HR
• Decreased
blood pressure

14. Conclusion
 Clonidine provides stable hemodynamics during pnp.
 Protects against stress response due to pneumoperitoneum
 Reduced post operative pain.
 Reduced nausea, vomiting and shivering.

15. References
 Booker WM, French DM, Molano PA. Further studies on the acute effects of intra
abdominal pressure. Am J Physiol 1947; 149: 292-8.
 Aho M, Scheinin M, Lehtinen AM, et al. Intramuscularly administered
dexmedetomidine attenuates haemodynamic and stress responses to
gynaecologic laparoscopy. Anesth Analg 1992; 75: 932-9.
 Joris J.L., J.D. Cliche, J.L.M. Canivet, N.J. Jacquet, J.J.Y. Legros and M.L. Lamy.
Hemodynamic Changes Induced by Laparoscopy and Their Endocrine Correlates:
Effects of Clonidine. JACC Vol. 32, No. 5 November 1, 1998:1389-96
 Malek KJ, Knor J, Kurzova A, Lopourova M. Adverse haemodynamic changes
during laparoscopic cholecystectomy and their possible suppression with clonidine
premedication. Comparison with intravenous and intramuscular premedication.
Rozhl Chir 1999; 78: 286-91.
 Ishizaki Y, Bandae Y, Shimomura K, Abe H, Ohtomo Y, Idezuki Y. Safe intra
abdominal pressure of carbon dioxide pneumoperitoneum during laparoscopic
surgery. Surgery 1993; 114: 549-54.

16. Warm thanks to one and all..
Wish you all a happy year ahead..