Philip Lebowitz1, Adam Yedlin2, A Ari Hakimi3, Christopher Bryan-Brown4, Mahesan Richards5, Reza Ghavamian6. 1. Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA. Electronic address: plebowit@montefiore.org. 2. Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA. Electronic address: adam.yedlin@gmail.com. 3. Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA. Electronic address: arihakimi@gmail.com. 4. Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA. Electronic address: cwildonbb@aol.com. 5. Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA. Electronic address: mrichard@montefiore.org. 6. Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA. Electronic address: rghavami@montefiore.org.
Abstract
STUDY OBJECTIVE: Robotic-assisted laparoscopic prostatectomy requires patients to be secured in a steep Trendelenburg position for several hours. Added to the CO2 pneumoperitoneum that is created, this positioning invariably restricts diaphragmatic and chest wall excursion, which can adversely affect respiratory gas exchange. This study sought to measure the extent of respiratory gas change during this procedure. DESIGN: Retrospective, institutional review board approved. SETTING: Operating room. PATIENTS: N = 186 males, American Society of Anesthesiologists 2-3, with prostatic carcinoma undergoing robotic-assisted laparoscopic radical prostatectomy. INTERVENTIONS: Arterial blood gases and noninvasive respiratory measurements were recorded for those patients (n = 32) in whom a radial arterial catheter had been inserted intraoperatively, specifically timed to different phases of the procedure: supine lithotomy, steep Trendelenburg, and return to supine. Ventilatory parameters were standardized. MEASUREMENTS: Systemic blood pressure, heart rate, respiratory rate, Pao2, Paco2, oxygen saturation as measured by pulse oximetry, and end-tidal carbon dioxide pressure. MAIN RESULTS: Although no patients developed perioperative respiratory complications, the Pao2 invariably fell (395 vs 316 mm Hg; P = .001) while the patients were in steep Trendelenburg, and the Paco2-end-tidal carbon dioxide pressure rose (10.0 vs 13.4 mm Hg; P < .0001). Upon return to supine, patients' respiratory measurements promptly returned to within 15% of baseline. Subgroup analysis for high-BMI vs low-BMI patients as well as for patients with pulmonary disease and/or a smoking history showed similar individual effects and only small, although significant, respiratory gas exchange aberrations. CONCLUSIONS: Positioning patients with a CO2 pneumoperitoneum in steep Trendelenburg for several hours imposes restriction of diaphragmatic and chest wall movement sufficient for respiratory gas exchange to be adversely affected. Return of function to within 15% of baseline occurred within minutes after return to supine and release of the CO2 pneumoperitoneum. No patients during the study period developed pulmonary complications that required alteration in their level of care.
STUDY OBJECTIVE: Robotic-assisted laparoscopic prostatectomy requires patients to be secured in a steep Trendelenburg position for several hours. Added to the CO2 pneumoperitoneum that is created, this positioning invariably restricts diaphragmatic and chest wall excursion, which can adversely affect respiratory gas exchange. This study sought to measure the extent of respiratory gas change during this procedure. DESIGN: Retrospective, institutional review board approved. SETTING: Operating room. PATIENTS: N = 186 males, American Society of Anesthesiologists 2-3, with prostatic carcinoma undergoing robotic-assisted laparoscopic radical prostatectomy. INTERVENTIONS: Arterial blood gases and noninvasive respiratory measurements were recorded for those patients (n = 32) in whom a radial arterial catheter had been inserted intraoperatively, specifically timed to different phases of the procedure: supine lithotomy, steep Trendelenburg, and return to supine. Ventilatory parameters were standardized. MEASUREMENTS: Systemic blood pressure, heart rate, respiratory rate, Pao2, Paco2, oxygen saturation as measured by pulse oximetry, and end-tidal carbon dioxide pressure. MAIN RESULTS: Although no patients developed perioperative respiratory complications, the Pao2 invariably fell (395 vs 316 mm Hg; P = .001) while the patients were in steep Trendelenburg, and the Paco2-end-tidal carbon dioxide pressure rose (10.0 vs 13.4 mm Hg; P < .0001). Upon return to supine, patients' respiratory measurements promptly returned to within 15% of baseline. Subgroup analysis for high-BMI vs low-BMI patients as well as for patients with pulmonary disease and/or a smoking history showed similar individual effects and only small, although significant, respiratory gas exchange aberrations. CONCLUSIONS: Positioning patients with a CO2 pneumoperitoneum in steep Trendelenburg for several hours imposes restriction of diaphragmatic and chest wall movement sufficient for respiratory gas exchange to be adversely affected. Return of function to within 15% of baseline occurred within minutes after return to supine and release of the CO2 pneumoperitoneum. No patients during the study period developed pulmonary complications that required alteration in their level of care.
Authors: Rafael Rocha Tourinho-Barbosa; Marcos Tobias-Machado; Adalberto Castro-Alfaro; Gabriel Ogaya-Pinies; Xavier Cathelineau; Rafael Sanchez-Salas Journal: Arab J Urol Date: 2017-12-14