Hemodynamic changes during robotic radical prostatectomy

Abstract

Background: Effect on hemodynamic changes and experience of robot-assisted laparoscopic radical prostatectomy (RALRP) in steep Trendelenburg position (45°) with high-pressure CO(2) pneumoperitoneum is very limited. Therefore, we planned this prospective clinical trial to study the effect of steep Tredelenburg position with high-pressure CO(2) pneumoperitoneum on hemodynamic parameters in a patient undergoing RALRP using FloTrac/Vigileo™1.10.

Methods: After ethical approval and informed consent, 15 patients scheduled for RALRP were included in the study. In the operation room, after attaching standard monitors, the radial artery was cannulated. Anesthesia was induced with fentanyl (2 μg/kg) and thiopentone (4-7 mg/kg), and tracheal intubation was facilitated by vecuronium bromide (0.1 mg/kg). The patient's right internal jugular vein was cannulated and the Pre Sep™ central venous oximetry catheter was connected to it. Anesthesia was maintained with isoflurane in oxygen and nitrous oxide and intermittent boluses of vecuronium. Intermittent positive-pressure ventilation was provided to maintain normocapnea. After CO(2) pneumoperitoneum, position of the patient was gradually changed to 45° Trendelenburg over 5 min. The robot was then docked and the robot-assisted surgery started. Intraoperative monitoring included central venous pressure (CVP), stroke volume (SV), stroke volume variation (SVV), cardiac output (CO), cardiac index (CI) and central venous oxygen saturation (ScvO(2)).

Results: After induction of anesthesia, heart rate (HR), SV, CO and CI were decreased significantly from the baseline value (P>0.05). SV, CO and CI further decreased significantly after creating pneumoperitoneum (P>0.05). At the 45° Trendelenburg position, HR, SV, CO and CI were significantly decreased compared with baseline. Thereafter, CO and CI were persistently low throughout the 45° Trendelenburg position (P=0.001). HR at 20 min and 1 h, SV and mean arterial blood pressure after 2 h decreased significantly from the baseline value (P>0.05) during the 45° Trendelenburg position. CVP increased significantly after creating pneumoperitoneum and at the 45° Trendelenburg position (after 5 and 20 min) compared with the baseline postinduction value (P>0.05). All these parameters returned to baseline after deflation of CO(2) pneumoperitoneum in the supine position. There were no significant changes in SVV and ScvO(2) throughout the study period.

Conclusions: The steep Trendelenburg position and CO(2) pneumoperitoneum, during RALRP, leads to significant decrease in stroke volume and cardiac output.

Keywords: Flotrac/vigileo™; hemodynamic changes; pneumoperitoneum; steep trendelenburg position.

Figure 1

Changes in heart rate (beats/min) with time. T0: baseline (before induction); T1: postinduction; T2: after CO₂ pneumoperitoneum; T3: after 5 min of 45° Trendelenburg position; T4: after 20 min of 45° Trendelenburg position; T5: after 1 h; T6: after 2 T7: after deflation of CO₂ pneumoperitoneum in supine position. *Statistically significant compared with the baseline value (P>0.05)

Figure 2

Changes in mean arterial blood pressure (mmHg) with time. T0: baseline (before induction); T1: postinduction; T2: after CO₂ pneumoperitoneum; T3: after 5 min of 45° Trendelenburg position; T4: after 20 min of 45° Trendelenburg position; T5: after 1 h; T6: after 2 h; T7: after deflation of CO₂ pneumoperitoneum in supine position. *Statistically significant compared with the baseline value (P>0.05)

Figure 3

Changes in stroke volume variation with time. T0: baseline (before induction); T1: postinduction; T2: after CO₂ pneumoperitoneum; T3: after 5 min of 45° Trendelenburg position; T4: after 20 min of 45° Trendelenburg position; T5: after 1 h; T6: after 2 h; T7: after deflation of CO₂ pneumoperitoneum in the supine position

Figure 4

Changes in stroke volume (mL/beat) with time. T0: baseline (before induction); T1: postinduction; T2: after CO₂ pneumoperitoneum; T3: after 5 min of 45° Trendelenburg position; T4: after 20 min of 45° Trendelenburg position; T5: after 1 h; T6: after 2 h; T7: after deflation of CO₂ pneumoperitoneum in the supine position. *Statistically significant compared with the baseline value (P>0.05)

Figure 5

Changes in cardiac output (L/min) with time. T0: baseline (before induction); T1: postinduction; T2: after CO₂ pneumoperitoneum; T3: after 5 min of 45° Trendelenburg position; T4: after 20 min of 45° Trendelenburg position; T5: after 1 h; T6: after 2 h; T7: after deflation of CO₂ pneumoperitoneum in the supine position. *Statistically significant compared with the baseline value (P>0.05)

Figure 6

Changes in central venous pressure (cm H₂O) with time. T1: postinduction (baseline); T2: after CO² pneumoperitoneum; T3: after 5 min of 45° Trendelenburg position; T4: after 20 min of 45° Trendelenburg position; T5: after 1 h; T6: after 2 h; T7: after deflation of CO² pneumoperitoneum in the supine position. *Statistically significant compared with the baseline value (P>0.05)

Figure 7

Changes in central venous oxygen saturation (ScvO₂) with time. T1: postinduction (baseline); T2: after CO² pneumoperitoneum; T3: after 5 min of 45° Trendelenburg position; T4: after 20 min of 45° Trendelenburg position; T5: after 1 h; T6: after 2 h; T7: after deflation of CO² pneumoperitoneum in the supine position