Effects of pneumoperitoneum and steep Trendelenburg position on cerebral hemodynamics during robotic-assisted laparoscopic radical prostatectomy: A randomized controlled study

Ke Chen, Lizhen Wang, Qing Wang, Xuesheng Liu, Yao Lu, Yuanhai Li, Gordon Tin Chun Wong, Ke Chen, Lizhen Wang, Qing Wang, Xuesheng Liu, Yao Lu, Yuanhai Li, Gordon Tin Chun Wong

Abstract

Background: We evaluated the relationship between ultrasonographical acquired parameters and short-term postoperative cognitive function in patients undergoing robotic-assisted radical prostatectomy (RALP).

Methods: Ninety elderly patients scheduled for RALP had their optic nerve sheath diameter (ONSD), the cross-sectional area (CSA) of the internal jugular vein (IJV) and the IJV valve (IJVV) competency assessed by ultrasound. The patients were analyzed in 2 groups based on whether displayed IJVV incompetency (IJVVI). The 3 parameters were measured before anesthesia (T0), immediately after induction of general anesthesia (T1), 5 minutes after establishing pneumoperitoneum (T2), 5 minutes after placing the patient in the Trendelenburg position (T3), and 5 minutes after the release of the pneumoperitoneum in the supine position (T4). Regional cerebral tissue oxygen saturation (rSO2) was also measured by near-infrared spectroscopy intraoperatively. The Mini-Mental State Examination (MMSE) and Confusion Assessment Method (CAM) were performed the day before surgery and on postoperative days 1, 3, and 7.

Results: We found that 52% of patients had evidence of IJVVI after being placed in the Trendelenburg position after pneumoperitoneum was established (T4). Patient with IJVVI showed a significant increase of ONSD and CSA at T1, T2, T3, T4 but there was no associated decrease in rSO2. MMSE scores were reduced at postoperative day 1 and the 7 patients that developed postoperative delirium came from Group IJVVI.

Conclusions: Our observations suggest that elderly patients that show IJVVI after adequate positioning for RALP may develop elevated intracranial pressure as well as mildly compromised postoperative cognitive function in the short term.

Conflict of interest statement

All authors have no conflicts of interest or financial ties to disclose.

Figures

Figure 1
Figure 1
CONSORT flow diagram. All patients were performed MMSE the day before operation. Four of 90 patients were not finished MMSE. The patients were grouped by presence or absence of IJVVI which was considered positive that retrograde flow >0.88 seconds at any side. During the operation, ONSD and CSA were measured by ultrasound. Four patients in groups were lost to follow because of pain and bleeding. MMSE and CAM were diagnosed postoperative cognitive function which was performed by a skilled nurse. CAM = Confusion Assessment Method, CSA = cross-sectional area, MMSE = Mini-Mental State Examination, ONSD = optic nerve sheath diameter.
Figure 2
Figure 2
A, ONSD means and standard deviation, in different time. B, CSA means and standard deviation, in different time. ∗P < .05 significantly different from Group IJVVC. T0, before anesthesia; T1, immediately after induction of general anesthesia; T2, in the supine position after pneumoperitoneum insufflation; T3, after Trendelenburg positioning; and T4, again at the end of the procedure. CSA = cross-sectional area, ONSD = optic nerve sheath diameter.
Figure 3
Figure 3
MMSE scores were measured at preoperation and postoperation 1, 3, 7 days; ∗P < .05 significantly different from Group IJVVC. MMSE = Mini-Mental State Examination, P1 = postoperation day 1, P3 = postoperation day 3, P7 = postoperation day 7, Pre = preoperation.

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Source: PubMed

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