OBEZ HASTALARDA LAPAROSKOPİK CERRAHİLERDE FARKLI PEEP UYGULAMALARININ OPTİK SİNİR KILIF ÇAPINA ETKİSİNİN DEĞERLENDİRİLMESİ

Yıl 2024, Cilt: 25 Sayı: 1 - OCAK 2024 SAYISI, 103 - 110, 17.01.2024

Ömer Sert , Elif Doğan Bakı , Murat Akıcı , Çiğdem Özer Gökaslan , Elif Büyükerkmen , Remziye Sıvacı , Bilge Banu Taşdemir Mecit

https://doi.org/10.18229/kocatepetip.1184680

Öz

AMAÇ: Alveollerin açık kalmasını sağlayarak oksijenasyonu düzeltmek amacıyla kullanılan positive end-expiratory pressure (PEEP) uygulaması obez hastalarda pnömoperitonyum sırasında intrakranyal basınçta (İKB) ek bir artışa neden olabilir. Bu çalışmada laparoskopik cerrahi yapılacak obez hastalarda farklı PEEP uygulamalarının optik sinir kılıf çapına (OSKÇ) etkisi değerlendirildi.
GEREÇ VE YÖNTEM: Çalışmaya ters trendelenburg pozisyonunda laparoskopik cerrahi uygulanacak Amerikan Anesteziyologlar Derneği Fiziksel Statü Sınıflandırmaları (ASA) 1-2 grubunda 18- 65 yaş arası Vücut Kitle İndeksi (VKİ) 30 ve üzeri obez 26 hasta dahil edildi. Anestezi indüksiyonu sonrası hastalar PEEP 5 grubu ve PEEP 8 grubuna randomize edilerek ayrıldı. Hastaların cinsiyet, yaş, VKİ’leri, ASA sınıflaması, vaka sırasında belirli aralıklarla kaydedilen hemodinamik verileri ve OSKÇ değerleri karşılaştırılırıldı.
BULGULAR: Çalışmayı 22 hasta tamamladı. Cinsiyet dışında (p=0,020), gruplar arası demografik ve hemodinamik verilerde farklılık yoktu. Hastaların OSKÇ’larında ölçülen tüm zamanlarda iki grup arasında farklılık gözlenmemiştir. OSKÇ’larını grup içi karşılaştırdığımızda, PEEP 5 grubunda grup içi farklılık gözlenmezken PEEP 8 grubunda pnomoperitonyum sonrası 5.dk (T2), 30.dk (T3) ve cerrahi bitişteki (T4) ölçümler bazal ölçümlerinden (T1) anlamlı bir şekilde yüksek bulunmuştur (p=0,010, p=0,003, p=0,012).
SONUÇ: PEEP 8 ve PEEP 5 uygulamasının İKB artışına benzer etkileri olsa da PEEP artışlarının ultrasonografi ile OSKÇ ölçülerek yapılmasının daha güvenli olacağını düşünmekteyiz.

Anahtar Kelimeler

Obezite, Laparoskopi, OSKÇ, PEEP, Ultrasonografi

EVALUATION OF THE EFFECT OF DIFFERENT PEEP APPLICATIONS ON OPTIC NERVE SHEATH DIAMETER IN OBESE PATIENTS UNDERGOING LAPAROSCOPIC SURGERY

Öz

OBJECTIVE: Positive end-expiratory pressure (PEEP) application, which is used to improve oxygenation by keeping the alveoli open, may cause an additional increase in intracranial pressure (ICP) during pneumoperitoneum in obese patients. In this study, the effect of different PEEP applications on the optic nerve sheath diameter (ONSD) in obese patients undergoing laparoscopic surgery was evaluated.
MATERIAL AND METHODS: The study included 26 patients with a Body Mass Index (BMI) of ≥ 30 and the American Society of Anesthesiologists (ASA) I-II status undergoing laparoscopic surgery in the reverse Trendelenburg position. After anesthesia induction, the patients were randomly allocated to either the PEEP 5 group or the PEEP 8 group. The patients were compared with respect to age, gender, BMI, ASA status, operations performed, and the hemodynamic data and ONSD values recorded intraoperatively at regular intervals.
RESULTS: 22 patients completed the study. Except for gender (p=0.020), there was no difference in demographic and hemodynamic data between the groups. No difference was observed between the groups in respect of ONSD measurements at all times. In the intra-group comparisons, there was no difference in the ONSD values within the PEEP 5 group, whereas in the PEEP 8 group, the measurements at 5 minutes (T2) and 30 minutes (T3) after pneumoperitoneum, and at the end of surgery (T4) were significantly higher than the basal measurements (T1) (p=0.010, p=0.003, p=0.012).
CONCLUSIONS: Although PEEP 8 and PEEP 5 applications have similar effects to ICP increase, we thought that it would be safer to apply PEEP increments by measuring ONSD via ultrasonography.

Anahtar Kelimeler

Obesity, Laparoscopy, ONSD, PEEP, Ultrasonography.

Kaynakça

• 1. Willenberg T, Clemens R, Haegeli LM, Amann-Vesti B, Baumgartner I, Husmann M. The influence of abdominal pressure on lower extremity venous pressure and hemodynamics: a human in-vivo model simulating the effect of abdominal obesity. Eur J Vasc Endovasc Surg. 2011;41(6):84–5.
• 2. Gainsburg DM. Anesthetic concerns for robotic-assisted laparoscopic radical prostatectomy. Minerva Anestesiol. 2012;78(5):596– 604.
• 3. Çelebioğlu B. What is the Effect of Positive End-expiratory Pressure (PEEP) on Postoperative Pulmonary Complications and Mortality During General Anaesthesia? Turk J Anaesthesiol Reanim. 2011;39(3):106-14.
• 4. Severgnini P, Selmo G, Lanza C, et al. Protective mechanical ventilation during general anesthesia for open abdominal surgery improves postoperative pulmonary function. Anesthesiology. 2013;118(6):1307–21.
• 5. Geeraerts T, Merceron S, Benhamou D, Vigue´ B, Duranteau J. Non-invasive assessment of intracranial pressure using ocular sonography in neurocritical care patients. Intensive Care Med. 2008; 34(11):2062–7.
• 6. Dip F, Nguyen D, Sasson M, Menzo E Lo, Szomstein S, Rosenthal R. The relationship between intracranial pressure and obesity: an ultrasonographic evaluation of the optic nerve. Surg Endosc. 2016;30(6):2321–5.
• 7. Krishnan S (Yalçın Ş). Obezite, karaciğer hastalığı ve diğer gastrointestinal sorunları olan hastalarda anestezik yaklaşımlar. In: Barash PG, Gullen BF, Stoelting RK, eds.(Çeviri editörü;Yıldız K). Klinik Anestezi Temelleri. Güneş Tıp Kitabevi;Ankara; 2017:521-2.
• 8. McGuire G, Crossley D, Richards J, Wong D. Effects of varying levels of positive end-expiratory pressure on intracranial pressure and cerebral perfusion pressure. Crit Care Med. 1997; 25(6): 1059–62.
• 9. Georgiadis D, Schwarz S, Baumgartner RW, Veltkamp R, Schwab S. Influence of positive end-expiratory pressure on intracranial pressure and cerebral perfusion pressure in patients with acute stroke. Stroke. 2001;32(9): 2088–92.
• 10. Chin JH, Kim WJ, Lee J, et al. Effect of positive end-expiratory pressure on the sonographic optic nerve sheath diameter as a surrogate for intracranial pressure during robot-assisted laparoscopic prostatectomy: A randomized controlled trial. PLoS One. 2017;12(1):1–11.
• 11. Fahry BG, Barnas GM, Flowers JL, Nagle SE, Njoku MJ. The effects of increased abdominal pressure on lung and chest wall mechanics during laparoscopic surgery. Anesth Analg. 1995;81(4):744–50.
• 12. Muench E, Bauhuf C, Roth H, et al. Effects of positive end-expiratory pressure on regional cerebral blood flow, intracranial pressure, and brain tissue oxygenation. Crit Care Med. 2005;33(10):2367–72.
• 13. Hiler M, Czosnyka M, Hutchinson P, et al. Predictive value of initial computerized tomography scan, intracranial pressure, and state of autoregulation in patients with traumatic brain injury. J Neurosurg. 2006;104(5):731–7.
• 14. Kimberly HH, Shah S, Marill K, Noble V. Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure. Acad Emerg Med. 2008;15(2):201–4.
• 15. Dubourg J, Javouhey E, Geeraerts T, Messerer M, Kassai B. Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure: A systematic review and meta-analysis. Intensive Care Med. 2011;37(7):1059-68.
• 16. Kim EJ, Koo BN, Choi SH, Park K, Kim MS. Ultrasonographic optic nerve sheath diameter for predicting elevated intracranial pressure during laparoscopic surgery: a systematic review and meta-analysis. Surg Endosc. 2018;32(1):175–82.
• 17. Maude RR, Hossain A, Hassan MU, et al. Transorbital Sonographic Evaluation of Normal Optic Nerve Sheath Diameter in Healthy Volunteers in Bangladesh. Plos One. 2013;8(12):e81013.
• 18. Closhen D, Treiber A-H, Berres M, et al. Robotic assisted prostatic surgery in the Trendelenburg position does not impair cerebral oxygenation measured using two different monitors: A clinical observational study. Eur J Anaesthesiol. 2014;31(2):104–9.
• 19. Awad H, Santilli S, Ohr M, et al. The effects of steep trendelenburg positioning on intraocular pressure during robotic radical prostatectomy. Anesth Analg. 2009;109(2):473–8.
• 20. Halverson A, Buchanan R, Jacobs L, et al. Evaluation of mechanism of increased intracranial pressure with insufflation. Surg Endosc. 1998;12(3):266–9.
• 21. Hansen HC, Helmke K. Validation of the optic nerve sheath response to changing cerebrospinal fluid pressure: ultrasound findings during intrathecal infusion tests. J Neurosurg. 1997;87(1):34-40.
• 22. Porchet F, Bruder N, Boulard G, Archer DP, Ravussin P. The effect of position on intracranial pressure. Ann Fr Anesth Reanim. 1998;17(2):149–56.