The impact of pneumoperitoneum and Trendelenburg positioning on respiratory system mechanics during laparoscopic pelvic surgery in children: a prospective observational study

Abstract

Purpose The aim of this study was to describe the changes in respiratory system compliance and other measures of respiratory mechanics associated with peritoneal insufflation (12 mmHg pressure) with carbon dioxide (PNP12) and 20°Trendelenburg positioning (TDG20) in pediatric patients undergoing laparoscopic surgery for abdominal cryptorchidism.Methods Twelve subjects with abdominal cryptorchidism undergoing orchiopexy were enrolled in the study. General anesthesia was conducted with sevoflurane/O 2 /air, fentanyl, and rocuronium. Pressure-controlled ventilation with a peak inspiratory pressure (PIP) of 10-15 cm H 2 O and a positive end-expiratory pressure of 5 cm H 2 O was titrated to achieve a tidal volume (VT/kg) of 6-10 mLÁkg -1 and end-tidal carbon dioxide (EtCO 2 ) of 35-40 mmHg. Adjustments of PIP and respiratory rate (RR) were made to maintain the initial VT/kg and EtCO 2 \ 50 mmHg. Measurements of weight-corrected dynamic compliance (Cdyn/kg), VT/kg, and EtCO 2 were recorded at baseline, after PNP12, at TDG20, and again after deflation and return to the level position. Results Adjustments in PIP were required in all subjects to maintain the target VT/kg. The Cdyn/kg decreased 42% (95% confidence interval [CI]: 30 to 51; P \ 0.001) after PNP12, and it remained below baseline until deflation. The Author contributions Victor M. Neira was the principal investigator for the study. Victor M. Neira, Thomas Kovesi, Luis Guerra, Nicholas Barrowman, and William Splinter contributed to the study design. Victor M. Neira and Luis Guerra contributed to data acquisition. Thomas Kovesi, Maria Campos, and Nicholas Barrowman contributed to the data analysis. Victor M. Neira, Thomas Kovesi, Luis Guerra, and Maria Campos contributed to data interpretation. Victor M. Neira was the principal author of the manuscript with contributions from Thomas Kovesi, Maria Campos, Luis Guerra, Nicholas Barrowman, and William Splinter. 123Can J Anesth/J Can Anesth (2015) 62:798-806 DOI 10.1007/s12630-015-0369-0 TDG20 caused only minimal additional reductions in Cdyn/kg (10% decrease; 95% CI: 0 to 19; P = 0.048). The VT/kg decreased 42% (95% CI: 31 to 52; P = 0.048) with PNP12, and after TDG20, it decreased a further 10% (95% CI: 4 to 19; P = 0.038). After deflation, the VT/kg increased by 56% (95% CI: 28 to 90; P = 0.001) and was then adjusted back to the initial values. Conclusion The PNP12 significantly decreases Cdyn/kg and VT/kg in pediatric patients. The use of TDG20 produces a relatively minor additional impact in respiratory mechanics. This study emphasizes the need to adjust ventilator settings to maintain normal gas exchange during this procedure. RésuméObjectif L'objectif de cette étude était de décrire les changements de compliance du système respiratoire et d'autres mesures de la mécanique respiratoire associés à une insufflation péritonéale (pression de 12 mmHg) à l'aide de dioxyde de carbone (PNP12) et d'une position de Trendelenburg à 20°(TDG20) chez les patients pédiatriques subissant une chirurgie par laparoscopie...

Pneumoperitoneum deteriorates intratidal respiratory system mechanics: an observational study in lung-healthy patients

“…In our study, under the condition of unchanged PEEP, C RS and C lung decreased during pneumoperitoneum as was expected [14,15]; however, in contrast to our hypothesis, compliance did not fully recover after removal of the pneumoperitoneum. Closely related, the analysis of the intratidal compliance profiles revealed an increase in intratidal recruitment/derecruitment during and only a partial recovery after removal of the pneumoperitoneum.…”

Post‐extubation continuous positive airway pressure improves oxygenation after pediatric laparoscopic surgery: A randomized controlled trial

“…Spadaro et al have investigated the effect of three different levels of PEEP (0, 5, and 10 cmH 2 O) in adult patients undergoing either laparotomy or laparoscopic surgeries using intraoperative shunt levels and dynamic compliance as assessment parameters . They concluded that a more aggressive PEEP level is required to reduce shunt and to normalize respiratory compliance during laparoscopic surgery because of the reduction of FRC caused by the pneumoperitoneum . Acosta et al suggested that PEEP levels higher than the usual 5 cmH 2 O would be required to preserve normal lung aeration during pneumoperitoneum in pediatric laparoscopic surgeries .…”

“…Atelectasis and poorly ventilated lung areas are negative consequences of general anesthesia observed in adults as well as in children secondary to the reduction of the end‐expiratory lung volume (FRC) and the resultant airway closure, consequently leading to decreased lung compliance, impairment of oxygenation, increased pulmonary vascular resistance, and development of lung injury . Laparoscopic surgery with associated pneumoperitoneum further worsens respiratory mechanics accentuating atelectasis formation . Studies show a strong correlation between the development of atelectasis and postoperative pulmonary complications (PPCs)…”

Modified 2-port laparoscopic herniorrhaphy with Kirschner wire in children

“…The single incision laparoscopy needs sufficient operating room inner the abdomen; thus, the high pressure of pneumoperitoneum might affect the respiratory system. [29,30] For an enhanced cosmetic look of the 2-port laparoscopy, the infra-umbilical incision and 3 mm scars near the umbilical were made nearly invisible with the help of topical skin adhesive to avoid suturing.…”