{"id":363,"date":"2017-01-16T12:06:50","date_gmt":"2017-01-16T12:06:50","guid":{"rendered":"http:\/\/www.deltexmedical.com\/decision_tree\/?page_id=363"},"modified":"2025-10-10T13:10:13","modified_gmt":"2025-10-10T12:10:13","slug":"pneumoperitoneum-position-and-spinal-anaesthesia","status":"publish","type":"page","link":"https:\/\/www.deltex-academy.com\/decision_tree\/pneumoperitoneum-position-and-spinal-anaesthesia\/","title":{"rendered":"Pneumoperitoneum, Position and Spinal Anaesthesia"},"content":{"rendered":"<style>.entry-title {display:none;}<br \/><\/style>\n<style>.site-info {display: none;}<br \/><\/style>\n<h2 style=\"text-align: center;\"><strong><span style=\"color: #003087;\">PNEUMOPERITONEUM, POSITION AND SPINAL ANAESTHESIA<\/span><\/strong><\/h2>\n<p><div class='content-column one_half'><div style=\"padding-top:0px;\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-364\" src=\"https:\/\/www.deltex-academy.com\/decision_tree\/wp-content\/uploads\/2017\/01\/position-262x300.png\" alt=\"\" width=\"262\" height=\"300\" srcset=\"https:\/\/www.deltex-academy.com\/decision_tree\/wp-content\/uploads\/2017\/01\/position-262x300.png 262w, https:\/\/www.deltex-academy.com\/decision_tree\/wp-content\/uploads\/2017\/01\/position.png 738w\" sizes=\"auto, (max-width: 262px) 85vw, 262px\" \/><\/div><\/div>\u00a0<div class='content-column one_half last_column'><div style=\"padding-top:0px;\">Early image of Trendelenburg position.<br \/>\n&#8220;Trendelenburg-Lagerung&#8221; by Willy Meyer<br \/>\n(1854-1932).<\/p>\n<p>\u200b(Original text : Archiv f\u00fcr Chirurgie 1885). Licensed under Public domain via Wikimedia Commons &#8211;<\/p><\/div><\/div><div class='clear_column'><\/div><\/p>\n<p>Oesophageal Doppler monitoring\u00a0has been used widely in laparoscopic surgery [1-8] and has the best <a href=\"https:\/\/www.deltex-academy.com\/decision_tree\/new-accuracy-and-precision\/\"target=\"_blank\" rel=\"noopener noreferrer\"> precision <\/a> to see small changes in SV following fluid challenges, carefully and safely guiding the user to give the correct amount for individual patients. It is also capable of preventing over filling which could develop into a \u2018heart failure\u2019 situation.<\/p>\n<h3><strong><span style=\"color: #003087;\">Laparoscopic Sugery<\/span><\/strong><\/h3>\n<p>Laparoscopic surgery results in smaller incisions and shorter length of stay as well as less\u00a0preoperative pain.\u00a0A pneumoperitoneum is formed by the surgical team in order to perform laparoscopic surgery. This is achieved by insufflating the abdomen with carbon dioxide (CO). The main haemodynamic changes expected would be a\u00a0decrease in cardiac output\/index and increases in mean arterial pressure and systemic vascular resistance, followed possibly by some partial restoration of cardiac output\/index, yet blood pressure and heart rate may not change. This often results because of the interaction between increased abdominal pressure, neurohumoral responses and the absorption of CO. Different patients may respond to a greater or lesser degree depending on their age and any existing comorbidities as well as the current clinical situation.<\/p>\n<p><strong>Note:\u00a0<\/strong>\u200bDynamic predictors of fluid responsiveness (SVV and PPV) have been found to vary notably with pneumoperitoneum, and their performance in this condition is at best understudied. [9]<\/p>\n<p><strong><em>Deltex Medical suggests:<\/em><\/strong><\/p>\n<p>The clinician should be aware of any\u00a0potential haemodynamic changes following abdominal insufflation, taking into\u00a0account any underlying medical conditions as well as the current clinical situation\u00a0and try to <a href=\"https:\/\/www.deltex-academy.com\/decision_tree\/stoke-volume-optimisation\/\" target=\"_blank\" rel=\"noopener noreferrer\">fluid optimise<\/a> as early as possible during surgery [8], [14] and ideally before pneumoperitoneum.<br \/>\nIf there is a suspicion of hypovolaemia after abdominal insufflation, the user\u00a0may consider that\u00a0a fluid challenge should be given, but a new baseline of ODM+ results should be set and\u00a0not compared to previous results. Fluid optimisation can be continued once the\u00a0abdomen has been desufflated, if required.<\/p>\n<p>It is suggested\u00a0that if\u00a0fluid optimisation has been done early, the patient may have less of a change\u00a0in parameters during the pnuemoperitoneum.<\/p>\n<h3><strong><span style=\"color: #003087;\">Trendelenburg<\/span><\/strong><\/h3>\n<p>In the Trendelenburg position, the body is laid flat on the back (supine) with the feet higher than the head by 15-30 degrees and is used in abdominal and gynaecological surgery for example to allow better access to the pelvic organs. With reverse Trendelenburg position, the body is tilted in the opposite direction. It was named after the German surgeon Friedrich Trendelenburg [10]. It is not recommended for the treatment of hypovolemic shock [11].<\/p>\n<p>There are however many positions that are used for patients in the operating theatre and are specific to surgery types. Each is likely to have different effects on the cardiovascular system. Knight [12] suggests that \u201cEach position carries some degree of risk and this is magnified in the anaesthetised patient who cannot make others aware of compromised positions\u201d<\/p>\n<p>Some expected cardiovascular changes with Trendelenburg could be an increase in venous return to the heart because of a redistribution of pooled venous blood in the lower limbs. An increase in cardiac output may then occur but could partially offset some of the cardiovascular depressant effects of the anaesthetic techniques [9]. Makic [13] summarises the expected haemodynamic responses to Trendelenburg positioning in hypotensive patients and include a slight increase in mean arterial pressure, no increase in preload, dilation of the right ventricle, decrease in right ventricular ejection fraction, decrease in cardiac output and an increase in systemic vascular resistance.<\/p>\n<p><strong><em>Deltex Medical suggests:<\/em><\/strong><\/p>\n<p>The clinician should be aware of any\u00a0potential haemodynamic changes associated with positional changes, taking into\u00a0account any underlying medical conditions as well as the current clinical\u00a0situation. <a href=\"https:\/\/www.deltex-academy.com\/decision_tree\/stoke-volume-optimisation\/\" target=\"_blank\" rel=\"noopener noreferrer\">Fluid optimisation<\/a> is ideally performed early during surgery [8],\u00a0[14] and where possible before any major position change. If there is a suspicion of hypovolaemia\u00a0after change of position, the user\u00a0may consider that\u00a0a fluid challenge should be given, but a new\u00a0baseline of ODM+ results should be set and not compared to previous results. Fluid\u00a0optimisation can then be continued once the patient is returned to a supine\u00a0position, if required.<\/p>\n<h3><strong><span style=\"color: #003087;\">Spinal Anaesthesia<\/span><\/strong><\/h3>\n<p>Leather [15] describes the redistribution of blood flow when lumbar\u00a0epidural anaesthesia is used and suggest that ODM+ may overestimate cardiac\u00a0output during this time. They report \u201cLumbar epidural anaesthesia (LEA)\u00a0increases blood flow to the lower body by sympathetic nerve block, and reduces<br \/>\nflow to the upper body by compensatory vasoconstriction caused by increased\u00a0sympathetic nerve activity.\u201d<\/p>\n<p><em><strong>Deltex Medical suggests:<\/strong><\/em><\/p>\n<p>Linear measurements (<a href=\"https:\/\/www.deltex-academy.com\/decision_tree\/doppler-specific-parameters\/\" target=\"_blank\" rel=\"noopener noreferrer\">SD, FTc, PV<\/a> etc)\u00a0instead of volumetric parameters (<a href=\"https:\/\/www.deltex-academy.com\/decision_tree\/stroke-volume-and-cardiac-output\/\" target=\"_blank\" rel=\"noopener noreferrer\">SV, CO<\/a> etc) can be used when a clinician is\u00a0concerned about the ODM+ results in this situation. Linear measurements do\u00a0not\u00a0rely\u00a0on the percent of cardiac output that flows to descending aorta nor on aortic size to estimate SV, CO etc. Use SD\u00a0as a surrogate of SV since this correlates well with SV and <a href=\"https:\/\/www.deltex-academy.com\/decision_tree\/accuracy-and-precision\/\" target=\"_blank\" rel=\"noopener noreferrer\">can be used to\u00a0observe the 10%<\/a> change following a fluid challenge [16].<\/p>\n<h3><strong><span style=\"color: #003087;\">Deltex Medical Take Home Messages<\/span><\/strong><\/h3>\n<p>The user should\u00a0consider:<\/p>\n<ul>\n<li>The expected\u00a0haemodynamic changes with pnuemoperitoneum and\/or different patient positions\u00a0and\/or with the use of spinal anaesthesia.<\/li>\n<li>The age of the\u00a0patient and any underlying comorbidities.<\/li>\n<li>The current clinical\u00a0situation.<\/li>\n<li>Try to fluid optimise\u00a0as early as possible.<\/li>\n<li>Monitor during\u00a0surgery and only give fluid during change of position or pnuemoperitoneum if\u00a0there is evidence of hypovolaemia and a clinical need.<\/li>\n<li>If fluid is given\u00a0during pnumoperitoneum or when the position is changing, create new ODM+\u00a0parameter baselines and generally these data should not be compared periods\u00a0outside of these i.e. do not \u2018chase\u2019 or compare previous values.<\/li>\n<li>Further fluid\u00a0optimisation may be required towards the end of surgery when the patient is\u00a0supine and desufflation of the abdomen has occurred.<\/li>\n<li>SD can be used\u00a0instead of SV to manage fluid and\/or vasoactive drugs\u00a0if required.<\/li>\n<\/ul>\n<h3><strong><span style=\"color: #003087;\">References<\/span><\/strong><\/h3>\n<p>1.\u00a0<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/22710266\" target=\"_blank\" rel=\"noopener noreferrer\">Brandstrup, B., et al., Which goal for fluid therapy during\u00a0<\/a><a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/22710266\" target=\"_blank\" rel=\"noopener noreferrer\">colorectal surgery is followed by the best outcome: near-maximal stroke volume\u00a0or zero fluid balance? Br J Anaesth, 2012. 109(2): p. 191-9.<\/a><\/p>\n<p>2.\u00a0<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/21873370\" target=\"_blank\" rel=\"noopener noreferrer\">Challand,\u00a0C., et al., Randomized controlled trial\u00a0of intraoperative goal-directed fluid therapy in aerobically fit and unfit\u00a0patients having major colorectal surgery. Br J Anaesth, 2012. 108(1): p. 53-62.<\/a><\/p>\n<p>3.\u00a0<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/9175964\" target=\"_blank\" rel=\"noopener noreferrer\">Haxby,\u00a0E.J., et al., Assessment of cardiovascular\u00a0changes during laparoscopic hernia repair using oesophageal Doppler. Br J\u00a0Anaesth, 1997. 78(5): p. 515-9.<\/a><\/p>\n<p>4.\u00a0<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/19571699\" target=\"_blank\" rel=\"noopener noreferrer\">Levy,\u00a0B.F., et al., 23-hour-stay laparoscopic\u00a0colectomy. Diseases of the colon and rectum, 2009. 52(7): p. 1239-43.<\/a><\/p>\n<p>5.\u00a0<a href=\"http:\/\/www.dingleconference.co.uk\/\" target=\"_blank\" rel=\"noopener noreferrer\">McKenny,\u00a0M., N. Dowd, and C. O&#8217;Malley. Oesophageal\u00a0Doppler Monitor guided fluid management in laparoscopic gastrointesintal\u00a0surgery.\u00a0Anaesthesia &amp; Perioperative Medicine. 2011. Dingle, Ireland.<\/a><\/p>\n<p>6.\u00a0<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/19934912\" target=\"_blank\" rel=\"noopener noreferrer\">Senagore,\u00a0A.J., et al., Fluid management for\u00a0laparoscopic colectomy: a prospective, randomized assessment of goal-directed\u00a0administration of balanced salt solution or hetastarch coupled with an enhanced\u00a0recovery program. Dis Colon Rectum, 2009. 52(12): p. 1935-40.<\/a><\/p>\n<p>7.\u00a0<a href=\"http:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/cdi.2007.9.issue-s1\/issuetoc\" target=\"_blank\" rel=\"noopener noreferrer\">Noblett,\u00a0S.E. and A.F. Horgan, Fluid Optimisation\u00a0in Laparoscopic Colorectal Resection: Is it Beneficial? Colorectal Disease,\u00a02007. 9(1): p. 16.<\/a><\/p>\n<p>8.\u00a0<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/16888706\" target=\"_blank\" rel=\"noopener noreferrer\">Noblett,\u00a0S.E., et al., Randomized clinical trial\u00a0assessing the effect of Doppler-optimized fluid management on outcome after\u00a0elective colorectal resection. Br J Surg, 2006. 93(9): p. 1069-76.<\/a><\/p>\n<p>9. <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/22288953\" target=\"_blank\" rel=\"noopener noreferrer\">H\u00f8iseth L\u00d81,\u00a0Hoff IE,\u00a0Myre K,\u00a0Landsverk SA,\u00a0Kirkeb\u00f8en KA.\u00a0Dynamic variables of fluid responsiveness during pneumoperitoneum and laparoscopic surgery.\u00a0<\/a><\/span><span style=\"font-family: arial, helvetica, sans-serif;\"><a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/22288953\" target=\"_blank\" rel=\"noopener noreferrer\">Acta Anaesthesiol Scand.\u00a02012\u00a0Jul;56(6):777-86.<\/a><\/p>\n<p>10.\u00a0<a href=\"http:\/\/emj.bmj.com\/content\/27\/11\/877.extract\" target=\"_blank\" rel=\"noopener noreferrer\">Emerg Med J 2010;27:877-878\u00a0doi:10.1136\/emj.2010.104893http:\/\/emj.bmj.com\/content\/27\/11\/877.<\/a><\/p>\n<p>\u200b11.\u00a0<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/16120887\" target=\"_blank\" rel=\"noopener noreferrer\">Bridges N, Jarquin-Valdivia AA.\u00a0&#8220;Use of the Trendelenburg position as the resuscitation position: to T or not to T?&#8221;.\u00a0Am. J. Crit. Care\u00a02005. 14\u00a0(5): 364\u20138.<\/a><\/p>\n<p>12. <a href=\"http:\/\/e-safe-anaesthesia.org\/e_library\/05\/Patient_positioning_in_anaesthesia_CEACCP_2004.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Knight,\u00a0D.J. and R.P. Mahajan, Patient\u00a0positioning in anaesthesia. Continuing Education in Anaesthesia, Critical\u00a0Care &amp; Pain, 2004. 4(5): p.\u00a0160-163.<\/a><\/span><\/p>\n<p>13.\u00a0<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/21459864\" target=\"_blank\" rel=\"noopener noreferrer\">Makic,\u00a0M.B., et al., Evidence-based practice\u00a0habits: putting more sacred cows out to pasture. Crit Care Nurse, 2011. 31(2): p. 38-61; quiz 62.<\/a><\/p>\n<p>14.\u00a0<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/22014804\" target=\"_blank\" rel=\"noopener noreferrer\">Pillai,\u00a0P., et al., A double-blind randomized\u00a0controlled clinical trial to assess the effect of Doppler optimized\u00a0intraoperative fluid management on outcome following radical cystectomy. J\u00a0Urol, 2011.\u00a06(6): p. 2201-6.<\/a><\/p>\n<p>15.\u00a0<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/11573585\" target=\"_blank\" rel=\"noopener noreferrer\">Leather,\u00a0H.A. and P.F. Wouters, Oesophageal\u00a0Doppler monitoring overestimates cardiac output during lumbar epidural\u00a0anaesthesia. Br J Anaesth, 2001. 86(6):\u00a0p. 794-7.<\/a><\/p>\n<p>16. <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/2651004\" target=\"_blank\" rel=\"noopener noreferrer\">Singer, M., et al., Continuous haemodynamic monitoring by\u00a0oesophageal Doppler.\u00a0Brit Care Med., 1989. 17(5): p. 447-52.<\/a>\u00a0<\/span><\/p>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>PNEUMOPERITONEUM, POSITION AND SPINAL ANAESTHESIA \u00a0 Oesophageal Doppler monitoring\u00a0has been used widely in laparoscopic surgery [1-8] and has the best precision to see small changes in SV following fluid challenges, carefully and safely guiding the user to give the correct amount for individual patients. It is also capable of preventing over filling which could develop &hellip; <a href=\"https:\/\/www.deltex-academy.com\/decision_tree\/pneumoperitoneum-position-and-spinal-anaesthesia\/\" class=\"more-link\">Continue reading<span class=\"screen-reader-text\"> &#8220;Pneumoperitoneum, Position and Spinal Anaesthesia&#8221;<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-363","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.deltex-academy.com\/decision_tree\/wp-json\/wp\/v2\/pages\/363","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.deltex-academy.com\/decision_tree\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.deltex-academy.com\/decision_tree\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.deltex-academy.com\/decision_tree\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.deltex-academy.com\/decision_tree\/wp-json\/wp\/v2\/comments?post=363"}],"version-history":[{"count":5,"href":"https:\/\/www.deltex-academy.com\/decision_tree\/wp-json\/wp\/v2\/pages\/363\/revisions"}],"predecessor-version":[{"id":1316,"href":"https:\/\/www.deltex-academy.com\/decision_tree\/wp-json\/wp\/v2\/pages\/363\/revisions\/1316"}],"wp:attachment":[{"href":"https:\/\/www.deltex-academy.com\/decision_tree\/wp-json\/wp\/v2\/media?parent=363"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}