Posizione di Trandelemburg. G.M.S. Vasdev, MD

Transcription

1 Posizione di Trandelemburg Evoluzione Della Chirurgia Ginecologica ed Oncologica Centro Congressi Giovanni XXIII Bergamo, Maggio 2017 G.M.S. Vasdev, MD Consultant Anesthesiologist Department of Anesthesiology and Perioperative Medicine Mayo Clinic 200 First St SW Rochester, MN Tel:

2 Disclosures No financial relationships to any products or procedures presented No off label use of drugs. All drugs mentioned are FDA approved for use in USA

3 Trendelenburg Position Overview Indications Trendelenburg position Ventilation perfusion (V/Q) mismatch Morbid obesity Nerve injury Prevention of falls and slipping

4 Thank you to Friedrich Trendelenburg Originally described the position for access to pelvic surgery vesico-vaginal fistula By German surgeon Bernhard Bardenheuer ( ) Willy Meyers brought to USA in 1885 He wrongly called it Trendelenburg s position Origins date back to 45BC Celsus Greek not German 1909 American Physiologist Walter Canon Resuscitation of hypovolemia Originally 45 head down tilt Current patient position during diagnostic is identical to the semi-inverted posture described by Hewitt & Shield in 1896

5 We have come a long way Dark Room Head down <45 Straps Pneumoperitoneum Long procedure Older, sicker patients

6 Optimal Ventilation BJA 100:709-16,2008 CO 2 elimination determined by minute ventilation (rate x volume) O 2 determined by FRC Insufflation decrease venous return. Decreasing perfusion. Ventilation decreased with abdominal contents and air Ventilation to Perfusion mismatch major contributor to hypoxia and hypercarbia Benefit of using pressure controlled ventilation, but need to fix insufflation pressure and flow

7 What about elevated BMI? Does the Trendelenburg Position Actually Make Mechanical Ventilation More Difficult? Study of Women Undergoing Major Gyn Lap Surgery. Bates et al. McMaster University BMI did not have a statistically significant influence on this increase. (p=0.47) Pneumoperitoneum pressures, not the Trendelenburg position, were strong predictors of airway pressures 5 mmhg decrease in pneumoperitoneum pressure, ~ 10 % decline in ventilator pressures Not always so for the super morbid obese Personal record BMI 65

8 Nerve Damage Anesthesiology 93: 938, 2000 Loss of lordosis can lead to back pain Arm boards are recommended to keep the fingers safe Common peroneal nerve injury is most common, accounting for 40-78% of nerve injuries in this position Risk factors include low BMI, prolonged duration, and recent cigarette use Duration > 2 hrs is a significant risk factor Compartment syndrome risk is approximately 1:9000

9 Ulnar Nerve Should be kept at < 90 degrees abduction Supinated or neutral Spiral groove protected Non-surgical contributing risk factors: Male BMI > 38 Do not complain about symptoms until 48 hrs post-op Outcome if the deficit is sensory, better within 5 days A motor deficit is more important, less common, and requires immediate neurologic consultation

10 Brachial Plexus Injuries Often presents as an ulnar nerve sensory deficit Incidence 0.02% and associated with: Abduction arm > 90 degrees Lateral rotation of the head Sternal retraction

11 Case 69-year-old female, BMI 45, presents for robotic surgery After GA prep and drape, tested for steep T-Burg for ventilation She slips and head makes contact with floor Surgeon outside scrubbing

12 Now What? Wake patient up and neuro check? Cancel case? MRI-CT scan head and neck? Do nothing carry on? Blame Anesthesiologist? Call Lawyer?

13 MRI

14 Patient Positioning Example: Pink pad by Xodus Medical Inc

15 Summary Access to the pelvis wrongly attributed to Friedrich Positioning related injuries occurs with head down Ventilation perfusion injuries Glaucoma Upper airway edema rare

16 Gracie