Effects of pneumoperitoneum and Trendelenburg position on intracranial pressure assessed using different non-invasive methods

Abstract

$\textbf{Background:}$ The laparoscopic approach is becoming increasingly frequent for many different surgical procedures. However, the combination of pneumoperitoneum and Trendelenburg positioning associated with this approach may increase the patient's risk for elevated intracranial pressure (ICP). Given that the gold standard for the measurement of ICP is invasive, little is known about the effect of these common procedures on ICP. $\textbf{Methods:}$ We prospectively studied 40 patients without any history of cerebral disease who were undergoing laparoscopic procedures. Three different methods were used for non-invasive estimation of ICP: ultrasonography of the optic nerve sheath diameter (ONSD); transcranial Doppler-based (TCD) pulsatility index (ICP$_{\text{PI}}$); and a method based on the diastolic component of the TCD cerebral blood flow velocity (ICP$_{\text{FVd}}$). The ONSD and TCD were measured immediately after induction of general anaesthesia, after pneumoperitoneum insufflation, after Trendelenburg positioning, and again at the end of the procedure. $\textbf{Results:}$ The ONSD, ICP$_{\text{FVd}}$, and ICP$_{\text{PI}}$ increased significantly after the combination of pneumoperitoneum insufflation and Trendelenburg positioning. The ICP$_{\text{FVd}}$ showed an area under the curve of 0.80 [95% confidence interval (CI) 0.70-0.90] to distinguish the stage associated with the application of pneumoperitoneum and Trendelenburg position; ONSD and ICP$_{\text{PI}}$ showed an area under the curve of 0.75 (95% CI 0.65-0.86) and 0.70 (95% CI 0.58-0.81), respectively. $\textbf{Conclusions:}$ The concomitance of pneumoperitoneum and the Trendelenburg position can increase ICP as estimated with non-invasive methods. In high-risk patients undergoing laparoscopic procedures, non-invasive ICP monitoring through a combination of ONSD ultrasonography and TCD-derived ICP$_{\text{FVd}}$ could be a valid option to assess the risk of increased ICP.Cambridge Commonwealth European and International Trust Scholarship (D.C.); Woolf Fisher Trust Scholarship (J.D.); Gates Cambridge Trust Scholarship (X.L.); CNPQ Scholarship (Research Project 203792/2014-9 to B.C.); NIHR Brain Injury Healthcare Technology Co-operative, Cambridge (M.C. and D.C.)