Effects of positive end-expiratory pressure on intraocular pressure and optic nerve sheath diameter in robot-assisted laparoscopic radical prostatectomy

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Abstract

Background:

There has been no study of the effect of post end-expiratory pressure (PEEP) on intraocular or intracranial pressure during pneumoperitoneum with steep Trendelenburg positioning. We investigated the effects of 5 cmH ₂O of PEEP on intraocular pressure and optic nerve sheath diameter as a surrogate for intracranial pressure in robot-assisted laparoscopic radical prostatectomy.

Methods:

Fifty patients scheduled for robot-assisted laparoscopic radical prostatectomy were divided into a zero-PEEP (ZEEP) group and a 5 cmH ₂O of PEEP (PEEP) group. Intraocular pressure, optic nerve sheath diameter, and respiratory and hemodynamic parameters were measured before induction (T0), 10 minutes after induction of general anesthesia in the supine position before CO ₂ insufflation (T1), 5 minutes (T2), and 30 minutes (T3) after steep Trendelenburg positioning with pneumoperitoneum, after desufflation of pneumoperitoneum in the supine position (T4), and after 30 minutes in the recovery room postoperatively (T5).

Results:

There was no significant difference in intraocular pressure or optic nerve sheath diameter between the groups during the study. The partial pressure of arterial oxygen and dynamic lung compliance at T1, T2, T3, and T4 were significantly higher in the PEEP than in the ZEEP group. There was no difference in mean arterial pressure or heart rate between groups at any time.

Conclusion:

Applying 5 cmH ₂O of PEEP did not increase intraocular pressure or optic nerve sheath diameter during pneumoperitoneum with steep Trendelenburg positioning in robot-assisted laparoscopic radical prostatectomy. These results suggest that low PEEP can be safely applied during surgery with pneumoperitoneum and steep Trendelenburg positioning in patients without preexisting eye disease and brain pathology.

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Most cited references 32

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Protective mechanical ventilation during general anesthesia for open abdominal surgery improves postoperative pulmonary function.

Gianlorenzo Dionigi, Paolo Severgnini, Alice Frigerio … (2013)

The impact of intraoperative ventilation on postoperative pulmonary complications is not defined. The authors aimed at determining the effectiveness of protective mechanical ventilation during open abdominal surgery on a modified Clinical Pulmonary Infection Score as primary outcome and postoperative pulmonary function. Prospective randomized, open-label, clinical trial performed in 56 patients scheduled to undergo elective open abdominal surgery lasting more than 2 h. Patients were assigned by envelopes to mechanical ventilation with tidal volume of 9 ml/kg ideal body weight and zero-positive end-expiratory pressure (standard ventilation strategy) or tidal volumes of 7 ml/kg ideal body weight, 10 cm H2O positive end-expiratory pressure, and recruitment maneuvers (protective ventilation strategy). Modified Clinical Pulmonary Infection Score, gas exchange, and pulmonary functional tests were measured preoperatively, as well as at days 1, 3, and 5 after surgery. Patients ventilated protectively showed better pulmonary functional tests up to day 5, fewer alterations on chest x-ray up to day 3 and higher arterial oxygenation in air at days 1, 3, and 5 (mmHg; mean ± SD): 77.1 ± 13.0 versus 64.9 ± 11.3 (P = 0.0006), 80.5 ± 10.1 versus 69.7 ± 9.3 (P = 0.0002), and 82.1 ± 10.7 versus 78.5 ± 21.7 (P = 0.44) respectively. The modified Clinical Pulmonary Infection Score was lower in the protective ventilation strategy at days 1 and 3. The percentage of patients in hospital at day 28 after surgery was not different between groups (7 vs. 15% respectively, P = 0.42). A protective ventilation strategy during abdominal surgery lasting more than 2 h improved respiratory function and reduced the modified Clinical Pulmonary Infection Score without affecting length of hospital stay.

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The effects of steep trendelenburg positioning on intraocular pressure during robotic radical prostatectomy.

Andrew Roth, Hamdy Awad, Soledad Fernandez … (2009)

Intraocular pressure (IOP) increases in steep Trendelenburg positioning, but the magnitude of the increase has not been quantified. In addition, the factors contributing to this increase have not been studied in robot-assisted prostatectomy cases. In this study, we sought to quantify the changes in IOP and examine perioperative factors responsible for these changes while patients are in the steep Trendelenburg position during robotic prostatectomy. In this prospective study, we measured IOP using a Tono-pen XL in 33 patients undergoing robot-assisted prostatectomy. The IOP was measured before anesthesia while supine and awake (baseline T1), anesthetized and supine (T2), anesthetized after insufflation of the abdomen with carbon dioxide (CO(2)) (T3), anesthetized in steep Trendelenburg (T4), anesthetized in steep Trendelenburg at the end of the procedure (T5), anesthetized supine before awakening (T6), and 1 hr after awakening in the supine position (T7). On average, IOP was 13.3 +/- 0.58 (mean +/- SE) mm Hg higher at the end of the period of steep Trendelenburg position (T5) compared with supine position T1 (P < 0.0001). The least square estimates for each time point in mm Hg were as follows: T1 = 15.7, T2 = 10.7, T3 = 14.6, T4 = 25.2, T5 = 29.0, T6 = 22.2, T7 = 17.0. Using univariate mixed effects models for the T1-T5 time periods, peak airway pressure, mean arterial blood pressure, ETco(2), and time were significant predictors of the IOP increase, whereas age, body mass index, blood loss, volume of IV fluid administered, mean airway pressure, and desflurane concentration were not predictive. In T4-T5, which involved no significant positional or perioperative interventions, we performed a multivariate analysis to evaluate predictors of IOP increases. Surgical duration (in minutes) and ETco(2) were the only significant variables predicting changes in IOP during stable and prolonged Trendelenburg positioning. On average, IOP increased 0.21 mm Hg per mm Hg increase in ETco(2) after adjusting for time. An increase of 0.05 mm Hg in IOP per minute of surgery on average was observed during this period in the Trendelenburg position after adjusting for ETco(2). IOP reached peak levels at the end of steep Trendelenburg position (T5), on average 13 mm Hg higher than the preanesthesia induction (T1) value. Surgical duration and ETco(2) were the only significant predictors of IOP increase in the Trendelenburg position (T4-T5).

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Effects of PEEP on the intracranial system of patients with head injury and subarachnoid hemorrhage: the role of respiratory system compliance.

Rodolfo Proietti, Giorgio Conti, Francesco Della Corte … (2005)

Positive end-expiratory pressure (PEEP) can be effective in improving oxygenation, but it may worsen or induce intracranial hypertension. The authors hypothesized that the intracranial effects of PEEP could be related to the changes in respiratory system compliance (Crs). A prospective study investigated 21 comatose patients with severe head injury or subarachnoid hemorrhage receiving intracranial pressure (ICP) monitoring who required mechanical ventilation and PEEP. The 13 patients with normal Crs were analyzed as group A and the 8 patients with low Crs as group B. During the study, 0, 5, 8, and 12 cm H2O of PEEP were applied in a random sequence. Jugular pressure, central venous pressure (CVP), cerebral perfusion pressure (CPP), intracranial pressure (ICP), cerebral compliance, mean velocity of the middle cerebral arteries, and jugular oxygen saturation were evaluated simultaneously. In the group A patients, the PEEP increase from 0 to 12 cm H2O significantly increased CVP (from 10.6 +/- 3.3 to 13.8 +/- 3.3 mm Hg; p < 0.001) and jugular pressure (from 16.6 +/- 3.1 to 18.8 +/- 3.2 mm Hg; p < 0.001), but reduced mean arterial pressure (from 96.3 +/- 6.7 to 91.3 +/- 6.5 mm Hg; p < 0.01), CPP (from 82.2 +/- 6.9 to 77.0 +/- 6.2 mm Hg; p < 0.01), and mean velocity of the middle cerebral arteries (from 73.1 +/- 27.9 to 67.4 +/- 27.1 cm/sec; F = 7.15; p < 0.001). No significant variation in these parameters was observed in group B patients. After the PEEP increase, ICP and cerebral compliance did not change in either group. Although jugular oxygen saturation decreased slightly, it in no case dropped below 50%. In patients with low Crs, PEEP has no significant effect on cerebral and systemic hemodynamics. Monitoring of Crs may be useful for avoiding deleterious effects of PEEP on the intracranial system of patients with normal Crs.

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Author and article information

Journal

Journal ID (nlm-ta): Medicine (Baltimore)

Journal ID (iso-abbrev): Medicine (Baltimore)

Journal ID (publisher-id): MEDI

Title: Medicine

Publisher: Wolters Kluwer Health

ISSN (Print): 0025-7974

ISSN (Electronic): 1536-5964

Publication date Collection: June 2019

Publication date (Electronic): 05 April 2019

Volume: 98

Issue: 14

Electronic Location Identifier: e15051

Affiliations

[a ]Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital

[b ]Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute

[c ]Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.

Author notes

[∗ ]Correspondence: Dong Woo Han, Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Republic of Korea (e-mail: hanesth@ 123456yuhs.ac ).

Article

Publisher ID: MD-D-18-07946 Accession ID: 15051

DOI: 10.1097/MD.0000000000015051

PMC ID: 6455825

PubMed ID: 30946349

SO-VID: d901049b-d3c3-4501-9f07-41a36ae1a4d9

License:

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc/4.0

History

Date received : 28 October 2018

Date revision received : 6 February 2019

Date accepted : 5 March 2019

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Keywords: intracranial hypertension,intraocular pressure,post end-expiratory pressure,robotic prostatectomy

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Keywords: intracranial hypertension, intraocular pressure, post end-expiratory pressure, robotic prostatectomy

Effects of positive end-expiratory pressure on intraocular pressure and optic nerve sheath diameter in robot-assisted laparoscopic radical prostatectomy : A randomized, clinical trial

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Background:

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Results:

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Karger: Ophthalmology

Most cited references 32

Protective mechanical ventilation during general anesthesia for open abdominal surgery improves postoperative pulmonary function.

The effects of steep trendelenburg positioning on intraocular pressure during robotic radical prostatectomy.

Effects of PEEP on the intracranial system of patients with head injury and subarachnoid hemorrhage: the role of respiratory system compliance.

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