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The tidal volume challenge improves the reliability of dynamic preload indices during robot-assisted laparoscopic surgery in the Trendelenburg position with lung-protective ventilation.

ABSTRACT: BACKGROUND:The reliability of pulse pressure variation (PPV) and stroke volume variation (SVV) is controversial under pneumoperitoneum. In addition, the usefulness of these indices is being called into question with the increasing adoption of lung-protective ventilation using low tidal volume (VT) in surgical patients. A recent study indicated that changes in PPV or SVV obtained by transiently increasing VT (VT challenge) accurately predicted fluid responsiveness even in critically ill patients receiving low VT. We evaluated whether the changes in PPV and SVV induced by a VT challenge predicted fluid responsiveness during pneumoperitoneum. METHODS:We performed an interventional prospective study in patients undergoing robot-assisted laparoscopic surgery in the Trendelenburg position under lung-protective ventilation. PPV, SVV, and the stroke volume index (SVI) were measured at a VT of 6?mL/kg and 3?min after increasing the VT to 8?mL/kg. The VT was reduced to 6?mL/kg, and measurements were performed before and 5?min after volume expansion (infusing 6% hydroxyethyl starch 6?ml/kg over 10?min). Fluid responsiveness was defined as ?15% increase in the SVI. RESULTS:Twenty-four of the 38 patients enrolled in the study were responders. In the receiver operating characteristic curve analysis, an increase in PPV?>?1% after the VT challenge showed excellent predictive capability for fluid responsiveness, with an area under the curve (AUC) of 0.95 [95% confidence interval (CI), 0.83-0.99, P ?2% after the VT challenge predicted fluid responsiveness, but showed only fair predictive capability, with an AUC of 0.76 (95% CI, 0.60-0.89, P

SUBMITTER: Jun JH

PROVIDER: S-EPMC6686427 | biostudies-literature | 2019 Aug

REPOSITORIES: biostudies-literature

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The tidal volume challenge improves the reliability of dynamic preload indices during robot-assisted laparoscopic surgery in the Trendelenburg position with lung-protective ventilation.

Jun Joo-Hyun JH Chung Rack Kyung RK Baik Hee Jung HJ Chung Mi Hwa MH Hyeon Joon-Sang JS Lee Young-Goo YG Park Sung-Ho SH

BMC anesthesiology 20190807 1

<h4>Background</h4>The reliability of pulse pressure variation (PPV) and stroke volume variation (SVV) is controversial under pneumoperitoneum. In addition, the usefulness of these indices is being called into question with the increasing adoption of lung-protective ventilation using low tidal volume (V<sub>T</sub>) in surgical patients. A recent study indicated that changes in PPV or SVV obtained by transiently increasing V<sub>T</sub> (V<sub>T</sub> challenge) accurately predicted fluid respon ...[more]

PMID: 31390982

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Project description:BackgroundProne position is frequently used in patients with acute respiratory distress syndrome (ARDS), especially during the Coronavirus disease 2019 pandemic. Our study investigated the ability of pulse pressure variation (PPV) and its changes during a tidal volume challenge (TVC) to assess preload responsiveness in ARDS patients under prone position.MethodsThis was a prospective study conducted in a 25-bed intensive care unit at a university hospital. We included patients with ARDS under prone position, ventilated with 6 mL/kg tidal volume and monitored by a transpulmonary thermodilution device. We measured PPV and its changes during a TVC (ΔPPV TVC6-8) after increasing the tidal volume from 6 to 8 mL/kg for one minute. Changes in cardiac index (CI) during a Trendelenburg maneuver (ΔCITREND) and during end-expiratory occlusion (EEO) at 8 mL/kg tidal volume (ΔCI EEO8) were recorded. Preload responsiveness was defined by both ΔCITREND ≥ 8% and ΔCI EEO8 ≥ 5%. Preload unresponsiveness was defined by both ΔCITREND < 8% and ΔCI EEO8 < 5%.ResultsEighty-four sets of measurements were analyzed in 58 patients. Before prone positioning, the ratio of partial pressure of arterial oxygen to fraction of inspired oxygen was 104 ± 27 mmHg. At the inclusion time, patients were under prone position for 11 (2-14) hours. Norepinephrine was administered in 83% of cases with a dose of 0.25 (0.15-0.42) µg/kg/min. The positive end-expiratory pressure was 14 (11-16) cmH2O. The driving pressure was 12 (10-17) cmH2O, and the respiratory system compliance was 32 (22-40) mL/cmH2O. Preload responsiveness was detected in 42 cases. An absolute change in PPV ≥ 3.5% during a TVC assessed preload responsiveness with an area under the receiver operating characteristics (AUROC) curve of 0.94 ± 0.03 (sensitivity: 98%, specificity: 86%) better than that of baseline PPV (0.85 ± 0.05; p = 0.047). In the 56 cases where baseline PPV was inconclusive (≥ 4% and < 11%), ΔPPV TVC6-8 ≥ 3.5% still enabled to reliably assess preload responsiveness (AUROC: 0.91 ± 0.05, sensitivity: 97%, specificity: 81%; p < 0.01 vs. baseline PPV).ConclusionIn patients with ARDS under low tidal volume ventilation during prone position, the changes in PPV during a TVC can reliably assess preload responsiveness without the need for cardiac output measurements.Trial registrationClinicalTrials.gov (NCT04457739). Registered 30 June 2020 -Retrospectively registered, https://clinicaltrials.gov/ct2/show/record/NCT04457739.

Project description:BACKGROUND:The aim of this study was to investigate the effect of the steep Trendelenburg position (STP) with pneumoperitoneum on whole-blood viscosity (WBV) in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). The study also analyzed the associations of clinical patient-specific and time-dependent variables with WBV and recorded postoperative outcomes. METHODS:Fifty-eight adult male patients (ASA physical status of I or II) undergoing elective RALP were prospectively analyzed in this study. WBV was intraoperatively measured three times: at the beginning of surgery in the supine position without pneumoperitoneum; after 30?min in the STP with pneumoperitoneum; and at the end of surgery in the supine position without pneumoperitoneum. The WBV at a high shear rate (300?s-?1) was recorded as systolic blood viscosity (SBV) and that at a low shear rate (5?s-?1) was recorded as diastolic blood viscosity (DBV). Systolic blood hyperviscosity was defined as >?13.0?cP at 300?s-?1 and diastolic blood hyperviscosity was defined as >?4.1?cP at 5?s-?1. RESULTS:The WBV and incidences of systolic and diastolic blood hyperviscosity significantly increased from the supine position without pneumoperitoneum to the STP with pneumoperitoneum. When RALP was performed in the STP with pneumoperitoneum, 12 patients (27.3%) who had normal SBV at the beginning of surgery and 11 patients (26.8%) who had normal DBV at the beginning of surgery developed new systolic and diastolic blood hyperviscosity, respectively. The degree of increase in WBV after positioning with the STP and pneumoperitoneum was higher in the patients with hyperviscosity than in those without hyperviscosity at the beginning of surgery. Higher preoperative body mass index (BMI) and hematocrit level were associated with the development of both systolic and diastolic blood hyperviscosity in the STP with pneumoperitoneum. All patients were postoperatively discharged without fatal complications. CONCLUSIONS:Changes in surgical position may influence WBV, and higher preoperative BMI and hematocrit level are independent factors associated with the risk of hyperviscosity during RALP in the STP with pneumoperitoneum. TRIAL REGISTRATION:Clinical Research Information Service, Republic of Korea, approval number: KCT0003295 on October 25, 2018.

Project description:BackgroundLaparoscopic surgery has become a standard of care for many gynecological surgeries due to its lower morbidity, pain and cost compared to open techniques. Unfortunately, the use of carbon dioxide (CO2) to insufflate the abdomen is the main contributor to post-operative shoulder pain.MethodsWe aim to assess the effect of postoperative Trendelenburg position on shoulder pain after gynecological laparoscopic procedures. We hypothesize that maintaining the patient in Trendelenburg for 24 h postoperatively will significantly decrease postoperative shoulder pain and analgesic consumption. After obtaining written informed consent, 108 patients were prospectively randomized into two groups. In the control group, patients underwent standard gynecologic laparoscopic procedures; then after passive deflation of the pneumoperitoneum at the end of the surgery, the patients were placed in supine head up position in the post anesthesia care unit (PACU) and received our institution's common postoperative care. Patients in the intervention group were subjected to the same maneuver but were positioned in a Trendelenburg position (20 °) once fully awake and cooperative in the PACU and retained this position for the first 24 h. Numerical rating scale (NRS) was used to assess shoulder pain and nausea upon patient arrival to the PACU, at 4, 6, 12 (primary outcome) and 24 h postoperatively. Time to first rescue pain medication, total rescue pain medications and overall satisfaction with pain control were recorded. 101 patients were included in the final data analysis.ResultsBoth groups were comparable in terms of baseline characteristics. NRS pain scores were significantly lower in the intervention group at 12 h compared to the control group (0 [0-1] versus 5 [1-4], p < 0.001), furthermore improvement in postoperative shoulder pain between time of arrival to PACU (time zero) and 12 h postoperatively was significantly higher in patients allocated to the experimental group compared to the control group. Pain scores were significantly lower in patients allocated to the experimental group versus the control group (0 [0-1] versus 5 [1-4], p < 0.001).ConclusionIn conclusion, Trendelenburg position is an easy non-pharmacologic intervention that is beneficial in reducing postoperative shoulder pain following gynecologic laparoscopic surgery.Trial registrationRetrospectively registered at Clinicaltrials.gov, registration number NCT04129385, date of registration: June 28, 2019.

Project description:Intraperitoneal insufflation of carbon dioxide may affect the sympathetic activity that leads to changes in ventricular repolarization. This in turn can result in changes of heart rate-corrected QT (QTc) interval and Tpeak-Tend (Tp-e) interval. Dexmedetomidine is a highly selective ?2-receptor agonist and has potential antiarrhythmic properties. This prospective, randomized, double-blinded, controlled study evaluated the effects of dexmedetomidine administration on QTc and Tp-e intervals during robot-assisted laparoscopic prostatectomy with steep Trendelenburg position.Fifty patients scheduled for robot-assisted laparoscopic prostatectomy randomly received either a continuous infusion of dexmedetomidine at a rate of 0.3??g/kg/hour, from anesthetic induction until the end of the Trendelenburg position (dexmedetomidine group; n?=?25), or the same volume of normal saline (control group; n?=?25). Anesthesia was maintained with sevoflurane and remifentanil. The primary and secondary goals were to evaluate the effect of dexmedetomidine on the QTc and Tp-e interval changes. Mean arterial pressure, heart rate, end-tidal CO2, and end-tidal sevoflurane concentrations were assessed as well.Forty-seven patients (94%) completed the study. Dexmedetomidine significantly attenuated QTc interval prolongation and reduced the Tp-e interval, even though the baseline values of the QTc and Tp-e intervals were similar between the 2 groups (PGroup?×?Time?=?0.001 and 0.014, respectively). Twenty-two patients (96%) in the control group and 13 (54%) in the dexmedetomidine group had QTc interval prolongation of >20?ms from the baseline value during surgery (P?=?0.001). The maximum QTc interval prolongation from the baseline value during surgery was 46?±?21?ms in the control group and 24?±?21?ms in the dexmedetomidine group (mean?±?SD, P?=?0.001). Mean arterial pressure and heart rate were comparable between the groups.Continuous infusion of dexmedetomidine at a rate of 0.3??g/kg/hour significantly attenuated the QTc interval prolongation induced by CO2 pneumoperitoneum with steep Trendelenburg position. Furthermore, dexmedetomidine reduced the Tp-e interval. Thus, dexmedetomidine administration may be effective for patients who are susceptible to the development of ventricular arrhythmia during robot-assisted laparoscopic prostatectomy.

Dataset Information

The tidal volume challenge improves the reliability of dynamic preload indices during robot-assisted laparoscopic surgery in the Trendelenburg position with lung-protective ventilation.

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The tidal volume challenge improves the reliability of dynamic preload indices during robot-assisted laparoscopic surgery in the Trendelenburg position with lung-protective ventilation.

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