Is hyperventilation during general anesthesia

25th Symposium Intensive Care Bremen - Germany

19 Feb 2015

Is hyperventilation during general anesthesia potentially hazardous? F. Grüne Erasmus MC Dept. of Anesthesiology [email protected] https://www.researchgate.net/profile/Frank_Gruene 1

No conflict of interests

ABP 120 mmHg

No conflicts of interest!

flow = resistance * driving pressure CBF = CVR * CPP driving pressure = EUP – EDP EUP = MAP EDP

ICP or ZFP

No problem ! But why not ????

MAP 200 mmHg

Dr. Frank Grune - Erasmus MC Rotterdam

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19 Feb 2015

Epilepsy when drinking?

? No problem ! But why not ???? 4

Jugular'venous'pooling'during'lowering'of'the'head'' affects'blood'pressure'above'the'heart.'' V. jug.

Brondum E et al.: Am J Physiol Regul Integr Comp Physiol 2009

A. car.

V. jug. A. car.


MAP= 193 mmHg CBF = 700 ml/min

MAP= 131 mmHg CBF = 500 ml/min

CPPe 120 mmHg

CPPe = 100 mmHg5

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19 Feb 2015

Blood'8low'uphill'and'downhill:' Does'a'siphon'faciliate'circulation'above'the'heart?' Seymour R, Johansen K. Comp Biochem Physiol 1987

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Inside nature’s giants

Inside Nature’s Giants National Geographic - TV 2009 (DVD/Book) 7


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19 Feb 2015

Hydrostatic'pressure'is'challenging'human’s'brain:' Humans'='giraffes?'

n=1

TCD in steep Trendelenburg

A mm Hg Vmca = 39 MAP = 89 ZFP = 51

Vmca = ABP = ZFP =

CPPe = 38 mmHg

CPPe

40 41 35 10430 6225 20 = 42 15 10 5 0

CVP

ZFP

ZFPCzosnyka

ZFPSchmidt

PE¢CO2

Vmca = 46 ABP = 133 ZFP = 94

mmHg

Pre

T1

B mm Hg

CPPe = 39 mmHg

T2

T3

T4

T5

Pulsatility Index

T6

T7

T8

8

T9 T10 T11 T12 T13 T14 T15 T16 T17

Resistivity Index

S1

S2

S1

S2

S1

S2

PE¢CO2

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Cerebral'haemodynamic'physiology'during'steep' Trendelenburg'position'and'CO2'pneumoperitoneum.'' TCD in steep Trendelenburg

Pre

A mm Hg

CVP

C mm Hg ZFPCzosnyka 120

ZFP

40 35 30 25 20 15 10 5 0 Pre

T1

T2

T3

T4

T5

T6

T7

T8

T1

T2

CVP ZFPSchmidt

T3

T4

T5

T6

MAPPE¢CO2 CPP

T7

T8

T9 T10 T11 T12 T13 T14 T15 T16 T17

eCPPBelfort

kPa 6

100

5

80

4

60

3

40

2

20

1

0 T9 Pre T10 T1 T11 T12 T2 T13 T3 T14 T4 T15 T5 T16 T6 T17 T7 T8

0 S1 T10 S2 T11 S3 T12 T13 T14 T15 T16 T17 T9

Fig 3 (AIndex ) CVP, ZFP calculated by linear regression (ZFP), ZFP as described by Czosnyka and colleagues6 and Schmidt and colleag kPa Resistivity PE¢CO end-tidal CO2 pressure (P2E′CO2 ). (B) PI, RI, and PE′CO2 . (C) The course of the CVP, invasive MAP, CPP determined as (CPP¼MAP2CVP), an 6 15 by Belfort and colleagues (eCPPMAP The variables are shown as mean values at 10 min intervals. Pre-values are d Belfort). changes ZFP described proportional changes to CVP and 5 induction of anaesthesia. All data are synchr average of the 30 s interval at 5 min before steep Trendelenburg repositioning, after moment of initiating Trendelenburg positioning and resynchronized at resumption4 of the supine position. The variables are sho CPP nearly constant values at 10 min intervals from 5 min before to 165 min after institution of the Trendelenburg position. At reassuming the sup 3 the curves are resynchronized and values are shown for another 20 min. 2

Pulsatility Index

1

⇒  ⇒ 

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0 Pre

T1

C mm Hg

T2

T3

CVP

T4 MAP

120

Dr. Frank Grune - Erasmus MC 100 Rotterdam 80 60 40 20

while in a further three patients, adequate signals were not obtainable in the Trendelenburg position. Data of the remainT5 T6ingT7 T8 T9 were T10 T11 T12 T13 T14 T15and T16are T17 S1 14 patients normally distributed presented as mean (SD). The age of the patients was 63 (8) yr. The total timeeCPP spent in the steep Trendelenburg position was 149 (83) CPP Belfort min. All patients left the post-anaesthesia care with an Aldrete13 score of 10/10 and were discharged from hospital after an uneventful postoperative period. CVP and ZFP calculated using linear regression and the Czosnyka formula, but not the Schmidt formula, increased in the Trendelenburg position (Table 1). MAP, CPP, and eCPP were lower in the post-Trendelenburg phase (Table 1). CVP

1 reg increased significantly after T0. and ZFP between 0 these variables remained stable— S2 was S3 2.8 (8.6) mm Hg, greater than CVP during T positioning (P.0.05). Neither variable changed during the period of Trendelenburg positioning The ZFPCzosnyka increased significantly after T0 a closely with ZFPreg (Fig. 3A). After resumption of th ition, it was not significantly different from the Trendelenburg. The ZFPSchmidt did not change after T0 and showed poor correlation with the Z Over the course of the operation, eCPP valu sistently lower than the calculated CPP (

T5

S2

0 Pre

T1

T2

T3

T4

Downloaded from http://bja.oxfordjournals.org/ at Erasmus Universiteit Rotterdam on

B mm Hg

BJA

Kalmar A et al. Brit0 J Anaesth 2012

T6

T7

T8

T9 T10 T11 T12 T13 T14 T15 T16 T17

S1

S3

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19 Feb 2015

Threshold cerebral perfusion: Beachchair position J Clin Anesth 2005

Anesth Analg 2003

Cullen DJ , APSF Newsletter 2007

Panevicius M , APSF Newsletter 2008

Threshold cerebral perfusion: high ICP => low CPP


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19 Feb 2015

in

Q ≈ IN – OUT

PP

IN

OUT

Zero Flow

ICP

MAP

Vascular waterfall

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Resistormodel Ohm resistor

upstream

Pv

Pa

downstream

CVR = (MAP-ICP) / CBF

Starling resistor

Ps upstream

Pa

PV

downstream

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19 Feb 2015

Vascular waterfall Weyland A et al.: Anaesthesist 1995; 44:893 Kottenberg-Assenbacher et al.:Anesthesiology 2009; 110: 379

26,3 mmHg

14,6

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PressureFFlow'plot'after'cardiac'arrest'(cerebral'circulation)' Weyland A et al. (1995) 55 50 45 Relation of ABP and VMCA during cardial arrest van 15 s

VMCA [cm s-1]

40 35 30 25 20 15

ZFP

10 5 0 0

20

40

60

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AP [mmHg]


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120 15

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19 Feb 2015

Aortic valve insufficiency grade 4 Prior OK

100

ZFP

50

cm/s

0

Post OK 100

50

cm/s

0 16

Zero'Flow'Pressure'estimation'(LR)' Weyland A et al (1997)

VMCA

80

t [s]

VMCA [cm s-1]

60

40

ZFP = EDP

Part

20

0 t [s]

0

25

50

75

100

AP [mmHg] 17


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19 Feb 2015

Zero'Flow'Pressure'estimation'(LR)'

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CO2

!


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19 Feb 2015

Cerebral autoregulation: MAP, CO2, O2

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ICP vs. ZFP Influence of PaCO2 Weyland A et al. (2000) J. Neurosurg Anesthesiol; 12: 210-216

•  16 ICU patients after T •  ICP epidural transduce •  Variation in PaCO2 (R

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19 Feb 2015

Cerebrovascular tone rather than ICP determines the effective downstream pressure of the cerebral circulation in the absence of intracranial hypertension

•  16 ICU patients after T •  ICP epidural transduce •  Variation in PaCO2 (R

Weyland A et al. (2000) J. Neurosurg Anesthesiol; 12: 210-216

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Adapted model of cerebral cerebral vasculation

PCSF/ICP PA

PCV

CCP1

PV

CCP2

Part CCPart CCPven (ICP) Weyland A et al. (2000) J. Neurosurg Anesthesiol; 12: 210-216


Pven 23

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19 Feb 2015

Adapted model of cerebral vasculation Ein modifiziertes Konzept dercerebral zerebralen Zirkulation: Vaskuläre Wasserfälle in serieller Verbindung ICB

CPP

Part CCPart CCPven (ICP)

Pven

Weyland A et al. (2000) J. Neurosurg Anesthesiol; 12: 210-216

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y = b*x

Flow

Ohm / Darcey

Pressure

Pressure

Resistance & Tone

y = b*x + a

Flow

CCP concept 26


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19 Feb 2015

General anaesthesia: What happens?!

Normal CBF" " 50 mL / 100g / min!

Lassen NA J Cereb Blood Flow Metabol 1985; 5: 347-9


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19 Feb 2015

Awake versus Anesthesia: CBF Weyland A et al. (2000) J. Neurosurg Anesthesiol; 12: 210-216

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Awake versus Anesthesia: CMRO2

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Awake versus Anesthesia: CVR

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Anesthesia & CO2

!


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19 Feb 2015

Anesthesia: CBF versus PaCO2

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Anesthesia: CMRO2 versus PaCO2

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19 Feb 2015

Anesthesia: SjvO2 versus PaCO2

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Anesthesia: AjvD-Lactate

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19 Feb 2015

Anesthesia: CMR-lactate versus PaCO2

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Is Hyperventilation perhaps dangerous?!


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19 Feb 2015

Moderate'hyperventilation'during'intravenous'anesthesia' increases'net'cerebral'lactate'ef8lux.''' Grüne F, Kazmaier S, (Sonntag H #), Stolker RJ, Weyland A. Anesthesiology 2014;120:335-42

-  30 cardiovascular patients -  ANE = Fe / Mi -  CBF = Kety Schmidt (Argon) -  ZFP = TCD (LR) -  PaCO2 changes = 30 vs 50 mmHg -  Endpoints= CBF, VMCA, CMRO2, CMR-Gluc, CMR-Lac

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Astrocyte-neuron lactate shuttle hypothesis ?

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19 Feb 2015

Hyperventilation and clinical outcome Wax et al. Eur J Anaesthesiol 2010;27:819 – 823

Cases = 3421 colorectal surgery, open n= 975 colorectal surgery, scopic n= 763 Hysterectomy, open n= 1127

median PetCO2 = 31 mmHg

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Comparison'of'cerebral'vascular'reactivity'measures' obtained'using'breathFholding'and'CO2'inhalation' Nagata et al. Annals of the New York Academy of Sciences, 826: 272–81

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19 Feb 2015

Misery'perfusion'with'preserved'vascular'reactivity' in'Alzheimer's'Disease' Nagata et al. Annals of the New York Academy of Sciences, 826: 272–81

10 AD patients vs. 15 healthy controls hyper vs. hypocapnia CBF 77% ! CMRO2 88% ! OEF 12% "" Regional differences -  supramarginal ! -  superior temporal ! 45

Rotterdam 46


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Eramus MC - Rotterdam

19 Feb 2015

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Erasmus MC – multiculti-working 48


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19 Feb 2015

Erasmus MC – Central OR 49

Next week on the OR!!

Normal !


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19 Feb 2015

How to improve patients outcome?! •  •  •  •  •  • 

Optimal medical treatment WHO - Sign In / Sign Out Antibiotics 30 min before incision Protocols-adherence (Pain/PONV/ERAS) Hygienic protocols Double-checks medication

•  •  •  •  •  • 

Temp control HR control MAP control PPV SpO2 control PetCO2 control

36-37°C 60-80/min >65 mmHg 96% 35-40 mmHg

Do not hyperventilate patients ! CBF / CPPe / cDO2 / pvO2 / CPPe " cerebral Lactate efflux

Hyperventilation - special indications

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19 Feb 2015

Epilepsy when drinking?

Questions?

No problem ! But why not ???? 53


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