Effects of pneumoperitoneum and Trendelenburg position on intracranial pressure assessed using different non-invasive methods.

BACKGROUND The laparoscopic approach is becoming increasingly frequent for many different surgical procedures. However, the combination of pneumoperitoneum and Trendelenburg positioning associated with this approach may increase the patient's risk for elevated intracranial pressure (ICP). Given that the gold standard for the measurement of ICP is invasive, little is known about the effect of these common procedures on ICP. METHODS We prospectively studied 40 patients without any history of cerebral disease who were undergoing laparoscopic procedures. Three different methods were used for non-invasive estimation of ICP: ultrasonography of the optic nerve sheath diameter (ONSD); transcranial Doppler-based (TCD) pulsatility index (ICPPI); and a method based on the diastolic component of the TCD cerebral blood flow velocity (ICPFVd). The ONSD and TCD were measured immediately after induction of general anaesthesia, after pneumoperitoneum insufflation, after Trendelenburg positioning, and again at the end of the procedure. RESULTS The ONSD, ICPFVd, and ICPPI increased significantly after the combination of pneumoperitoneum insufflation and Trendelenburg positioning. The ICPFVd showed an area under the curve of 0.80 [95% confidence interval (CI) 0.70-0.90] to distinguish the stage associated with the application of pneumoperitoneum and Trendelenburg position; ONSD and ICPPI showed an area under the curve of 0.75 (95% CI 0.65-0.86) and 0.70 (95% CI 0.58-0.81), respectively. CONCLUSIONS The concomitance of pneumoperitoneum and the Trendelenburg position can increase ICP as estimated with non-invasive methods. In high-risk patients undergoing laparoscopic procedures, non-invasive ICP monitoring through a combination of ONSD ultrasonography and TCD-derived ICPFVd could be a valid option to assess the risk of increased ICP.

[1]  R. Moretti,et al.  Ultrasonography of the optic nerve in neurocritically ill patients , 2011, Acta anaesthesiologica Scandinavica.

[2]  E. Ryding,et al.  Transcranial Doppler sonography pulsatility index (PI) reflects intracranial pressure (ICP). , 2004, Surgical neurology.

[3]  B. Matta,et al.  Intraoperative non invasive intracranial pressure monitoring during pneumoperitoneum: a case report and a review of the published cases and case report series , 2016, Journal of Clinical Monitoring and Computing.

[4]  W. Schwenk,et al.  The European Association for Endoscopic Surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery , 2002, Surgical Endoscopy.

[5]  D. H. King,et al.  Arterial assessment by Doppler-shift ultrasound. , 1974, Proceedings of the Royal Society of Medicine.

[6]  V. Noble,et al.  Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure. , 2007, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[7]  J. Pickard,et al.  Transcranial Doppler Pulsatility Index: What it is and What it Isn’t , 2012, Neurocritical Care.

[8]  H. Hansen,et al.  Fundamentals of transorbital sonographic evaluation of optic nerve sheath expansion under intracranial hypertension , 1996, Pediatric Radiology.

[9]  B. Bissonnette,et al.  Effect of nitrous oxide on cerebrovascular reactivity to carbon dioxide in children during sevoflurane anaesthesia. , 2003, British journal of anaesthesia.

[10]  R. Garg,et al.  Unpredicted neurological complications after robotic laparoscopic radical cystectomy and ileal conduit formation in steep trendelenburg position: two case reports. , 2010, Acta anaesthesiologica Belgica.

[11]  T. Ponsky,et al.  Technical options of the laparoscopic pediatric inguinal hernia repair. , 2014, Journal of laparoendoscopic & advanced surgical techniques. Part A.

[12]  S. Choi,et al.  Increase in intracranial pressure during carbon dioxide pneumoperitoneum with steep trendelenburg positioning proven by ultrasonographic measurement of optic nerve sheath diameter. , 2014, Journal of endourology.

[13]  J. Pickard,et al.  Reliability of the Blood Flow Velocity Pulsatility Index for Assessment of Intracranial and Cerebral Perfusion Pressures in Head-Injured Patients , 2012 .

[14]  B. Cabella,et al.  Prospective Study on Noninvasive Assessment of Intracranial Pressure in Traumatic Brain-Injured Patients: Comparison of Four Methods. , 2016, Journal of neurotrauma.

[15]  W. Hand,et al.  Detection of Elevated Intracranial Pressure in Robot-assisted Laparoscopic Radical Prostatectomy Using Ultrasonography of Optic Nerve Sheath Diameter , 2015, Journal of neurosurgical anesthesiology.

[16]  A. Mottrie,et al.  Optic Nerve Sheath Diameter Remains Constant during Robot Assisted Laparoscopic Radical Prostatectomy , 2014, PloS one.

[17]  C. Haberthür,et al.  Transcranial color-coded duplex sonography allows to assess cerebral perfusion pressure noninvasively following severe traumatic brain injury , 2010, Acta Neurochirurgica.

[18]  J. Pickard,et al.  Non-invasively estimated ICP pulse amplitude strongly correlates with outcome after TBI. , 2012, Acta neurochirurgica. Supplement.

[19]  S. Cencetti,et al.  Transcranial Doppler Ultrasonography in Intensive Care , 2013 .

[20]  C. Sainte-Rose,et al.  Transcranial Doppler can predict intracranial hypertension in children with severe traumatic brain injuries , 2011, Child's Nervous System.

[21]  A. Pesenti,et al.  Induced abdominal compartment syndrome increases intracranial pressure in neurotrauma patients: A prospective study , 2001, Critical care medicine.

[22]  E. Papavassiliou,et al.  Effect of abdominal insufflation for laparoscopy on intracranial pressure. , 2014, JAMA surgery.

[23]  J. Hiatt,et al.  Intracranial pressure. Effects of pneumoperitoneum in a large-animal model. , 1997, Surgical Endoscopy.

[24]  Louise Yeung,et al.  Sonographic optic nerve sheath diameter as an estimate of intracranial pressure in adult trauma. , 2011, The Journal of surgical research.

[25]  M. Blaivas,et al.  Elevated intracranial pressure detected by bedside emergency ultrasonography of the optic nerve sheath. , 2003, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[26]  M. Menon,et al.  Anesthesia considerations for robotic-assisted laparoscopic prostatectomy: a review of 1,500 cases , 2007, Journal of robotic surgery.

[27]  A. Lavinio,et al.  Transcranial Doppler ultrasonography in intensive care , 2008, European journal of anaesthesiology. Supplement.

[28]  P. Mavrocordatos,et al.  Effects of neck position and head elevation on intracranial pressure in anaesthetized neurosurgical patients: preliminary results. , 2000, Journal of neurosurgical anesthesiology.

[29]  J. Pickard,et al.  Cerebral perfusion pressure in head-injured patients: a noninvasive assessment using transcranial Doppler ultrasonography. , 1998, Journal of neurosurgery.

[30]  S. Cohn,et al.  Low-pressure laparoscopy may ameliorate intracranial hypertension and renal hypoperfusion. , 2002, Journal of laparoendoscopic & advanced surgical techniques. Part A.

[31]  S. Paterson-Brown,et al.  Association between laparoscopic abdominal surgery and postoperative symptoms of raised intracranial pressure , 2001, Surgical Endoscopy.

[32]  A. Marmarou,et al.  A proposed relationship between increased intra-abdominal, intrathoracic, and intracranial pressure. , 1997, Critical care medicine.

[33]  A. Mottrie,et al.  Influence of steep Trendelenburg position and CO(2) pneumoperitoneum on cardiovascular, cerebrovascular, and respiratory homeostasis during robotic prostatectomy. , 2010, British journal of anaesthesia.

[34]  Min-Soo Kim,et al.  Ultrasonographic assessment of optic nerve sheath diameter during pediatric laparoscopy. , 2015, Ultrasound in medicine & biology.

[35]  M. Menon,et al.  Retropubic, laparoscopic, and robot-assisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies. , 2009, European urology.

[36]  P. Smielewski,et al.  Doppler Non-invasive Monitoring of ICP in an Animal Model of Acute Intracranial Hypertension , 2015, Neurocritical Care.

[37]  H. Hansen,et al.  Fundamentals of transorbital sonographic evaluation of optic nerve sheath expansion under intracranial hypertension , 2005, Pediatric Radiology.

[38]  M. Struys,et al.  Cerebral haemodynamic physiology during steep Trendelenburg position and CO(2) pneumoperitoneum. , 2012, British journal of anaesthesia.

[39]  H. J. Kim,et al.  Position does not affect the optic nerve sheath diameter during laparoscopy , 2015, Korean journal of anesthesiology.

[40]  M. Czosnyka,et al.  Non‐invasive assessment of intracranial pressure , 2016, Acta neurologica Scandinavica.

[41]  Muhammad Rafiqul Islam,et al.  Haemodynamic and end tidal CO₂ changes during laparoscopic cholecystectomy under general anaesthesia. , 2013, Mymensingh medical journal : MMJ.

[42]  E. Sağlam,et al.  Open Versus Laparoscopic Surgery for Rectal Cancer: Single-Center Results of 587 Cases , 2016, Surgical laparoscopy, endoscopy & percutaneous techniques.

[43]  Daniel Binz,et al.  Hemorrhagic Complications of Ventriculostomy Placement: A Meta-Analysis , 2009, Neurocritical care.

[44]  P. Minneci,et al.  Laparoscopic pyloromyotomy decreases postoperative length of stay in children with hypertrophic pyloric stenosis. , 2016, Journal of pediatric surgery.