Prediction of hypotension after postural change in robot-assisted laparoscopic prostatectomy using esophageal Doppler monitoring: a prospective observational trial

Postural change from a steep Trendelenburg position to a supine position (T-off) during robot-assisted laparoscopic prostatectomy (RALP) induces a considerable abrupt decrease in the mean arterial pressure (MAP). We investigated the variables for predicting postural hypotension induced by T-off using esophageal Doppler monitoring (EDM). One hundred and twenty-five patients undergoing RALP were enrolled. Data on the MAP, heart rate, stroke volume index (SVI), cardiac index, peak velocity, corrected flow time, stroke volume variation, pulse pressure variation, arterial elastance (Ea), and dynamic arterial elastance were collected before T-off and at 1, 3, 5, 7, and 10 min after T-off using EDM. MAP < 60 mmHg within 10 min after T-off was considered to indicate hypotension, and 25 patients developed hypotension. The areas under the curves of the MAP, SVI, and Ea were 0.734 (95% confidence interval [CI] 0.623–0.846; P < 0.001), 0.712 (95% CI 0.598–0.825; P < 0.001), and 0.760 (95% CI 0.646–0.875; P < 0.001), respectively, with threshold values of ≤ 74 mmHg, ≥ 42.5 mL/m2, and ≤ 1.08 mmHg/mL, respectively. If patients have MAP < 75 mmHg with SVI ≥ 42.5 mL/m2 or Ea ≤ 1.08 mmHg/mL before postural change from T-off during RALP, prompt management for ensuing hypotension should be considered.Trial registration: NCT03882697 (ClinicalTrial.gov, March 20, 2019).

The usefulness of the transesophageal Doppler in the anesthetic management of Morgagni hernia repair - A case report

Morgagni hernia in adults is a rare condition and is associated with complications such as recurrent chest infections, respiratory failure and cardiac tamponade. Its correction represents an anesthetic challenge. Intraoperative esophageal Doppler provides important information in real time about the patient’s cardiac function and vascular filling, aiding in decision making by the anesthesiologist. We report a case of a 70–year–old woman, ASA Physical Status–III, and presented with chest pain, dyspnea and hypoxemia. Her chest x-ray revealed opacification of 2/3 of the left hemithorax and 1/2 of the right. Computed tomography confirmed a bilateral Morgagni hernia. The patient underwent immediate corrective surgery. Intraoperative cardiovascular function was monitored with esophageal Doppler. Compression and decompression of thoracic structures produces enormous hemodynamic and respiratory impact. After herniated contents removal it showed an increase in systolic volume and cardiac index and a correction of flow time. Transient arterial hypotension was verified, requiring fluid therapy and vasopressor support. Diaphragmatic defect was corrected and general hemodynamic stabilization was achieved. Patient was discharged asymptomatic. The esophageal Doppler was important in this case because it allowed us to measure fundamental hemodynamic variables in real time, such as cardiac index or systolic volume, and to subsequently act accordingly. Key words: Esophageal; Doppler; Morgagni hernia; Anesthesia Citation: Babo NM, Monteiro MT, Santos AB, Carreira CR. The usefulness of the transesophageal Doppler in the anesthetic management of Morgagni hernia repair - A case report. Anaesth pain intensive care 2021;25(2):206-211. DOI: 10.35975/apic.v25i2.1467 Received: 19 November 2020, Reviewed: 22 December 2020, Accepted: 12 January 2021

Are Noninvasive Continuous Cardiac Output Monitoring Interchangeable with Esophageal Doppler?

Objective: To compare the trending ability, accuracy, and precision of non-invasive stroke volume (SV) measurement based on a bioreactance technique and measurement of the pulse wave transit time (PWTT) versus the esophageal Doppler monitoring (EDM). Materials and Methods: Two hundred twenty-seven paired measurements from 10 patients who underwent abdominal surgery under general anesthesia were included for SV measurements. Pearson’s correlation coefficient was calculated, and Bland-Altman analysis was performed to evaluate the agreement between EDM and bioreactance (EDM-bioreactance) and between EDM and PWTT (EDM-PWTT). Results: EDM-bioreactance had a correlation coefficient of 0.75 (95% confidence interval [CI] 0.62 to 0.78; p<0.001), bias of 0.28 ml (limits of agreement –30.92 to 31.38 ml), and percentage error of 46.82%. EDM-PWTT had a correlation coefficient of 0.48 (95% CI 0.44 to 0.72; p<0.001), bias of –0.18 ml (limits of agreement –40.28 to 39.92 ml), and percentage error of 60.17%. A subgroup analysis of data from patients who underwent crystalloid loading was performed to detect the trending ability. The four-quadrant plot analysis between EDM-bioreactance and EDM-PWTT demonstrated concordance rates of 70.00% and 73.68%, respectively. Conclusion: SV measurement based on bioreactance technique and measurement of PWTT are not interchangeable with EDM. Trial registration: Thai Clinical Trials Registry, TCTR 20181217003 Keywords: Stroke volume, Cardiac output, Doppler, Perioperative care, Pulse, Time