Abstract
BackgroundLung protective ventilation with low tidal volume (TV) and increased positive end-expiratory pressure (PEEP) can have unfavorable effects on the cardiovascular system. We aimed to investigate whether lung protective ventilation has adverse impact on hemodynamic, renal and hormonal variables.MethodsIn this randomized, single-blinded, placebo-controlled study, 24 patients scheduled for robot-assisted radical prostatectomy were included. Patients were equally randomized to receive either ventilation with a TV of 6 ml/IBW and PEEP of 10 cm H2O (LTV-h.PEEP) or ventilation with a TV of 10 ml/IBW and PEEP of 4 cm H2O (HTV-l.PEEP). Before, during and after surgery, hemodynamic variables were measured, and blood and urine samples were collected. Blood samples were analyzed for plasma concentrations of electrolytes and vasoactive hormones. Urine samples were analyzed for excretions of electrolytes and markers of nephrotoxicity.ResultsComparable variables were found among the two groups, except for significantly higher postoperative levels of plasma brain natriuretic peptide (p = 0.033), albumin excretion (p = 0.012) and excretion of epithelial sodium channel (p = 0.045) in the LTV-h.PEEP ventilation group compared to the HTV-l.PEEP ventilation group. In the combined cohort, we found a significant decrease in creatinine clearance (112.0 [83.4;126.7] ml/min at baseline vs. 45.1 [25.4;84.3] ml/min during surgery) and a significant increase in plasma concentrations of renin, angiotensin II, and aldosterone.ConclusionLung protective ventilation was associated with minor adverse hemodynamic and renal effects postoperatively. All patients showed a substantial but transient reduction in renal function accompanied by activation of the renin-angiotensin-aldosterone system.Trial registrationClinicalTrials, NCT02551341. Registered 13 September 2015.
Highlights
Lung protective ventilation with low tidal volume (TV) and increased positive end-expiratory pressure (PEEP) can have unfavorable effects on the cardiovascular system
In this paper we report the effects of ventilation strategy and increased intraabdominal pressure (IAP) during robot-assisted radical prostatectomy (RARP) on the following variables: (1) Hemodynamics: Systolic blood pressure, diastolic blood pressure, and heart rate (HR); (2) renal function: Creatinine clearance (CrCl), urinary neutrophil gelatinase-associated lipocalin (u-NGAL), urine aquaporin2 (u-AQP2), and urine epithelial sodium channel (u-ENaC); (3) renal excretions of sodium (u-Na), potassium (u-K), creatinine (u-crea) and albumin (u-alb); (4) plasma concentrations of creatinine (p-crea), sodium (p-Na), potassium (p-K), albumin and vasoactive hormones: P-renin, angiotensin-II
Perioperative blood loss was significantly higher in the HTV-l.PEEP group compared to the LTV-h.PEEP group
Summary
Lung protective ventilation with low tidal volume (TV) and increased positive end-expiratory pressure (PEEP) can have unfavorable effects on the cardiovascular system. RARP is performed under general anesthesia and mechanical ventilation with different values of tidal volume (TV) and positive end-expiratory pressure (PEEP). The increased intraabdominal pressure (IAP) associated with pneumoperitoneum results in several hemodynamic alterations, including reduced cardiac output and increased vascular resistance due to compression of the abdominal vasculature and compensatory release of stress hormones [7]. This increases the risk of inadequate organ perfusion, which may affect renal function. Animal studies have shown increased serum creatinine and reduced renal blood flow and urine output when pneumoperitoneum is induced [8]
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