Physiology of the abdominal pressure volume relation in morbid obese patients. Impact on the treatment of morbid obese patients at the intensive care ? J P Mulier, MD PhD. Sint Jan Brugge-Oostende www.publicationslist.org/jan.mulier. Why was this research needed?. Surgical complaints - PowerPoint PPT Presentation
Physiology APVR and impact on ITE? 12 jan 2010 Sint Jan Brugge-Oostende Sint Jan Brugge-Oostende www.publicationslist.org/jan.mulier www.publicationslist.org/jan.mulier Physiology of the abdominal pressure Physiology of the abdominal pressure volume relation in morbid obese volume relation in morbid obese patients. patients. Impact on the treatment of morbid obese Impact on the treatment of morbid obese patients at the intensive care patients at the intensive care ? ? J P Mulier, MD PhD J P Mulier, MD PhD
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Physiology APVR and impact on ITE? 12 jan 2010
Sint Jan Brugge-OostendeSint Jan Brugge-Oostendewww.publicationslist.org/jan.mulier www.publicationslist.org/jan.mulier
Physiology of the abdominal pressure Physiology of the abdominal pressure volume relation in morbid obese volume relation in morbid obese
patients.patients.
Impact on the treatment of morbid obese Impact on the treatment of morbid obese
patients at the intensive carepatients at the intensive care??
J P Mulier, MD PhDJ P Mulier, MD PhD
Physiology APVR and impact on ITE? 12 jan 2010
Why was this research Why was this research needed?needed?
Surgical complaintsSurgical complaints Patient presses.Patient presses. Insufficient workspace in morbid obese Insufficient workspace in morbid obese
patients.patients. Request for extra dose, although full Request for extra dose, although full
relaxation is given.relaxation is given. High dose muscle relaxants does not work.High dose muscle relaxants does not work.
Need to show the active impact of Need to show the active impact of anesthesiology.anesthesiology. Improving total outcome by helping to Improving total outcome by helping to
improve the surgical results.improve the surgical results. Transdisciplinary workTransdisciplinary work
Physiology APVR and impact on ITE? 12 jan 2010
Volume inflated at 15 mmHg with or Volume inflated at 15 mmHg with or without muscle relaxation.without muscle relaxation.
Large variation in abdominal Large variation in abdominal volumevolume
Muscle relaxation has variable Muscle relaxation has variable effect!effect!
JPMulier, B Dillemans ESA 2007
Physiology APVR and impact on ITE? 12 jan 2010
Description?Description?
Measure the Measure the pressure volume pressure volume relationrelation
Angle is compliance Angle is compliance or elastanceor elastance
Section with Y axis Section with Y axis is PV0: is PV0: pressure at zero pressure at zero volumevolume
0
2
4
6
8
10
12
14
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18
0 0,5 1 1,5 2 2,5
liter
mm
Hg
P = 3,30 V + 8,40 mmHgSquared R = 0,96
E : 3,3 mmHg/LPV0 : 8,4 mmHg
On the abdominal pressure volume relationship Mulier JP ISPUB 2009;21:1
diminishes instead of diminishes instead of rises with increasing rises with increasing volumevolume
JPMulier, ESA 2007, 3AP1
Physiology APVR and impact on ITE? 12 jan 2010
CT scanCT scan
•Mulier J.P., Coenegrachts CT analysis of the elastic deformation and elongation of the abdominal wall during colon inflation for virtual coloscopy Eur J Anesthesia 2008 Suppl
Physiology APVR and impact on ITE? 12 jan 2010
Muscle relaxation effect on Muscle relaxation effect on PV0PV0
E or Compliance no changeE or Compliance no change E is by fascia, size en shape determinedE is by fascia, size en shape determined
PV0 lowerPV0 lower Relaxants identical to 2 MAC Sevo or Relaxants identical to 2 MAC Sevo or
Patient with no effect of Patient with no effect of muscle relaxantsmuscle relaxants
0
5
10
15
20
25
0 1 2 3 4 5
No muscles in abd wall, No muscles in abd wall, diaphragm ?diaphragm ?
Fully relaxed by other factors ?Fully relaxed by other factors ? TOF > 90%TOF > 90% TOF = ¼TOF = ¼ TOF 0/4 and PTC < 5TOF 0/4 and PTC < 5
Physiology APVR and impact on ITE? 12 jan 2010
Why sometimes no effect ?Why sometimes no effect ?
Already total relaxed before Already total relaxed before Inhalation 2 MAC Inhalation 2 MAC
Muscle and fascia in parallel: fascia takes Muscle and fascia in parallel: fascia takes all tension, further muscle relaxation no all tension, further muscle relaxation no length increase. length increase. Diaphragm, rectus tension in lengthDiaphragm, rectus tension in length
Muscle thin, in relaxation fascia not longer.Muscle thin, in relaxation fascia not longer. Rectus cross tensionRectus cross tension
Expansion abdominal wall or shape Expansion abdominal wall or shape change?change?
Physiology APVR and impact on ITE? 12 jan 2010
Effect deep muscle Effect deep muscle relaxation on IAP with relaxation on IAP with
constant IAVconstant IAV Gradueel druk daling tot vlakke lijnGradueel druk daling tot vlakke lijn Max effect bij bereikenTOF 0/4Max effect bij bereikenTOF 0/4 Aan PTC 0 geen extra drukdalingAan PTC 0 geen extra drukdaling
Contraction shortens Contraction shortens abdominal wall in two abdominal wall in two directionsdirections Muscle directionMuscle direction Perpendicular on musclePerpendicular on muscle
No change in fascia No change in fascia elasticity elasticity Curve keeps same angleCurve keeps same angle
Shortening fascia has Shortening fascia has same effect as increase same effect as increase in intra abd volumein intra abd volume PV0 increasesPV0 increases
Contraction Rest Relaxation
Physiology APVR and impact on ITE? 12 jan 2010
Moderate, deep or very Moderate, deep or very deep?deep?
TOF needed to measureTOF needed to measure Diaphragm and vocal cords are Diaphragm and vocal cords are
most resistant to MRmost resistant to MR
No active contraction No active contraction sufficient sufficient
passive relaxationpassive relaxation Diaphragm is never 100% blockedDiaphragm is never 100% blocked
At PTC count zero ventilator can still At PTC count zero ventilator can still be triggered!be triggered!
Physiology APVR and impact on ITE? 12 jan 2010
PSV prevent breathing PSV prevent breathing against ventilator, is more against ventilator, is more
physiologicphysiologic
PSV is PSV is possible possible during deep during deep muscle muscle relaxation!relaxation!
Diaphragm is Diaphragm is never total never total relaxed.relaxed.
Morfine stops Morfine stops PSV!PSV!
PSVPro during esmeron infusion
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0
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25
time
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40
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EtCO2
NMT count
RR(CO2)
PTCount
SpO2
PROFOUND MUSCLE RELAXATION DOES NOT DISTURB PROFOUND MUSCLE RELAXATION DOES NOT DISTURB PRESSURE SUPPORT VENTILATION. PRESSURE SUPPORT VENTILATION.
Mulier J, Blacoe D PGA 2009Mulier J, Blacoe D PGA 2009
Physiology APVR and impact on ITE? 12 jan 2010
Is muscle relaxation needed Is muscle relaxation needed ??
Gynecologic laparoscopy without curareGynecologic laparoscopy without curare is is possible.possible. ChassardChassard D D. Ann Fr Anesth Reanim. 1996;15(7):1013-7. Ann Fr Anesth Reanim. 1996;15(7):1013-7
Only when compliance is very highOnly when compliance is very high
Effect of valsalva: Effect of valsalva: tegenadementegenademen
PV loops with fit
0
10
20
30
40
-0,5 0 0,5 1 1,5 2 2,5
IAV liter
IAP
mm
Hg
IAP
Valsalva is an active muscle contraction Valsalva is an active muscle contraction different from breathing to increase the different from breathing to increase the abdominal pressureabdominal pressure
Happens when patient reacts on Happens when patient reacts on Controlled VentilationControlled Ventilation
0
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40
45
0 500 1000 1500 2000 2500 3000
IAP
mm
hg
-0,5
0
0,5
1
1,5
2
2,5
IAV
lite
r
IAP
IAV
no relaxation valsalva contract relaxation
Physiology APVR and impact on ITE? 12 jan 2010
Factor: PV0 PVO sig E E sig
Age Neg 0.828 Pos 0.003*
Length Neg 0.356 Neg 0.245
Body weigth Pos 0.012* Pos 0.294
Bmi neg 0.054 Neg 0.272
Sex Neg 0.596 Neg 0.536
Gravidity Neg 0.305 Neg 0.049*
Prev abd operation Neg 0.191 Neg 0.009*
Muscle relaxation Neg 0.001* Neg 0.376
* Sig p<0.05
E and PV0 determined by E and PV0 determined by ??
J P Mulier ESA 2007J P Mulier ESA 2007
Physiology APVR and impact on ITE? 12 jan 2010
BMI effect on abdominal P/V BMI effect on abdominal P/V relationrelation
Effect of BMI on PV0
-4
-2
0
2
4
6
8
10
0 10 20 30 40 50 60
BMI
PV
0 in
mm
Hg
Effect of BMI on E
0
0,002
0,004
0,006
0,008
0,01
0,012
0 20 40 60
BMI
E in
mm
Hg
/l
J Mulier ISPUB 2009J Mulier ISPUB 2009 Pressure volume relation is linearPressure volume relation is linear PV0 and E define each patientPV0 and E define each patient
J P Mulier IFSO 2007J P Mulier IFSO 2007
Physiology APVR and impact on ITE? 12 jan 2010
Waist to Hip ratio Waist to Hip ratio (WHR)(WHR)
Man normal WHR: 0,9Man normal WHR: 0,9 Woman normal WHR: 0,7Woman normal WHR: 0,7
Android fat distributionAndroid fat distribution WHR > 0,8WHR > 0,8
Gynoid fat distributionGynoid fat distribution WHR < 0,8WHR < 0,8
Physiology APVR and impact on ITE? 12 jan 2010
Attractiveness in WHR from 4000 BC until 2000 Attractiveness in WHR from 4000 BC until 2000 ACAC
1,5 1,1 1,5 0,5 0,7 1,5 1,1 1,5 0,5 0,7
Physiology APVR and impact on ITE? 12 jan 2010
WHR vs BMIWHR vs BMI
Physiology APVR and impact on ITE? 12 jan 2010
Obesity typeObesity type
Android Android vsvs GynoidGynoid
Physiology APVR and impact on ITE? 12 jan 2010
Android versus Gynoid fat Android versus Gynoid fat distribution has a different distribution has a different
ElastanceElastance
Abdominal pressure volume relation: Android vs Gynoid
0
5
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20
25
0 1 2 3 4
IAV Liter
IAP
mm
Hg
android
gynoid
J P Mulier 2009J P Mulier 2009
Physiology APVR and impact on ITE? 12 jan 2010
Two types of android Two types of android obesityobesity
Intra visceral adiposity Intra visceral adiposity Extra visceral adiposity Extra visceral adiposity Subcutaneus fat is scant and Subcutaneus fat is thick and Subcutaneus fat is scant and Subcutaneus fat is thick and
intra abdominal fat is thick and intra abdominal fat is scant.intra abdominal fat is thick and intra abdominal fat is scant.
Large intra visceral fat volume, or Large intra visceral fat volume, or liver steatosis makes the relation non liver steatosis makes the relation non
linear !linear !
-50
0
50
0 0,5 1 1,5 2 2,5 3 3,5 4
vol lit er
meting 2
meting 3
meting 4
meting 5
meting 6
0
0,5
1
1,5
0 0,2 0,4 0,6 0,8 1 1,2
meting 1
meting 2
meting 3
meting 4
meting 5
abdominal pressure in android shape with intra visceral fat
0
5
10
15
20
25
0 1 2 3 4
IAV in liter
IAP
in m
mH
g
If the abdominal fascia is already circular If the abdominal fascia is already circular instead of ellipticinstead of elliptic No deformation possibleNo deformation possible No radius decrease with increasing volumeNo radius decrease with increasing volume
Physiology APVR and impact on ITE? 12 jan 2010
Metabolic syndrome: Metabolic syndrome: 3 of the 43 of the 4
HypertensionDiabetus
Visceral obesityDyslipidemia
Physiology APVR and impact on ITE? 12 jan 2010
What can we do to improve What can we do to improve the abdominal physiology?the abdominal physiology?
The obese patient is a challenge The obese patient is a challenge for anaesthesia, if patient has an for anaesthesia, if patient has an
android shape with intra visceral fat.android shape with intra visceral fat.
Physiology APVR and impact on ITE? 12 jan 2010
Impact on ICU?Impact on ICU?
Ventilation optimalisationVentilation optimalisation Beach chair position if difficult to breath, if Beach chair position if difficult to breath, if
higher intra abd pressures.higher intra abd pressures. Curarisation useful if higher intra abdominal Curarisation useful if higher intra abdominal
pressure pressure Who is at risk for abd compartment Who is at risk for abd compartment
syndrome?syndrome? History of previous laparoscopy, laparatomy, History of previous laparoscopy, laparatomy,
multipara lowers risk on IACSmultipara lowers risk on IACS CT abd circle versus ellipsCT abd circle versus ellips
Post operative pain is stretching dependentPost operative pain is stretching dependent First laparoscopy is more painfulFirst laparoscopy is more painful
Physiology APVR and impact on ITE? 12 jan 2010
Ventilation Ventilation improvement improvement only in difficult to only in difficult to ventilate patientsventilate patients
Physiology APVR and impact on ITE? 12 jan 2010
Who is at risk ?Who is at risk ?
Patients with large EPatients with large E Never pregnant, never laparatomy, Never pregnant, never laparatomy,
never laparoscopy, sportnever laparoscopy, sport Android obese personAndroid obese person
Patients with high PV0Patients with high PV0 Intra abdominal fat, hepatomegalyIntra abdominal fat, hepatomegaly Android obese personAndroid obese person
Physiology APVR and impact on ITE? 12 jan 2010
How to measure E on ICU: How to measure E on ICU: Vol change is neededVol change is needed
Urine bladder complianceUrine bladder compliance Bladder has its own complianceBladder has its own compliance
