Evaluation of Cardiac Functions in Deep Trendelenburg Position
Condition: Hemodynamic Instability; Cardiovascular Complication
Study type: Observational

Summary: 
      Robotic-assisted laparoscopic prostatectomy (RALP) is a surgical method with good short-term
      results and accepted as the gold standard because of its minimal invasiveness. The
      pneumoperitoneum and deep Trendelenburg position (at least 25°-45° upside down) required for
      RALP surgeries can cause significant pathophysiological changes in both the pulmonary and
      cardiac systems, as well as complicate hemodynamic management.

      In this study, investigators aimed to determine the changes in the cardiovascular system
      during deep Trendelenburg position with the hemodynamic parameters monitored by the pressure
      record analytical method (PRAM) and the Longitudinal Strain measured with simultaneous
      transesophageal echocardiography.
    

Detailed description: 
      RALP is the gold standard surgical technique in prostate surgery. Many Robotic-laparoscopic
      surgical techniques also require the intraoperative deep Trendelenburg position. However, the
      possible side effects of the deep Trendelenburg position on the cardiovascular system during
      surgery are unknown. Although the Trendelenburg position is a life-saving maneuver in
      hypovolemic patients, it also carries undesirable risks. Although the increase in venous
      return is expected to protect the cardiac output (CO) in the deep Trendelenburg position, the
      increase in intrathoracic pressure due to the intraperitoneal pressure may cause
      deterioration in venous return and a decrease in CO . In addition, the changing heart
      configuration in the deep Trendelenburg position may also cause an increase in the workload
      of the heart. Therefore, the need to evaluate hemodynamic management with advanced monitoring
      techniques, including fluid therapy in the perioperative period, has arisen in patients
      undergoing RALP.

      The pressure Recording Analytical Method (PRAM), is one of the most up-to-date monitoring
      methods designed for continuous CO measurement derived from the arterial pressure wave
      analysis, with a high signal sampling rate (1000 Hz). Many studies have shown that PRAM is a
      reliable monitoring method in major surgery. Cardiac Cycle Efficiency (CCE), which the PRAM
      method adds to our daily practice, is an index that defines hemodynamic performance in terms
      of energy consumption and efficiency. It can be expressed as the ratio of systolic energy
      performance to the total energy expenditure of the cardiac cycle and indicates the ability of
      the cardiovascular system to maintain homeostasis at different energy levels. However, data
      on how cardiac functions change in the deep Trendelenburg position are still limited.

      In this study, investigators aimed to demonstrate the reliability of the CCE value through
      its correlation with the Longitudinal Strain (LS) by observing the effect of the deep
      Trendelenburg position in RALP surgeries on cardiac functions using PRAM and Transesophageal
      Echocardiography (TEE).
    

Intervention name(s): Robotic-assisted laparoscopic prostatectomy in deep Trendelenburg position.
Intervention type(s): Procedure
Intervention description(s): After general anesthesia induction, the patients were placed in the deep Trendelenburg position (at least 25°-45° upside down).
Observational model: Case-Only
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        The patients with ASA (American Society Of Anesthesiology) physical status 1-3 who
        underwent RALP with intra-arterial blood pressure monitoring before anesthesia induction
      
Keywords: Deep Trendelenburg position; Robotic-assisted laparoscopic prostatectomy; Pressure recording analytical method; Transesophageal echocardiography; Cardiac cycle efficiency; Longitudinal Strain; Hemodynamic monitorization