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Sint Jan Brugge-Oostende publicationslist/jan.mulier

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

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Sint Jan Brugge-Oostende publicationslist/jan.mulier

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  1. 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 Physiology APVR and impact on ITE? 12 jan 2010

  2. Why was this research needed? • Surgical complaints • Patient presses. • Insufficient workspace in morbid obese patients. • Request for extra dose, although full relaxation is given. • High dose muscle relaxants does not work. • Need to show the active impact of anesthesiology. • Improving total outcome by helping to improve the surgical results. • Transdisciplinary work Physiology APVR and impact on ITE? 12 jan 2010

  3. Volume inflated at 15 mmHg with or without muscle relaxation. • Large variation in abdominal volume • Muscle relaxation has variable effect! JPMulier, B Dillemans ESA 2007 Physiology APVR and impact on ITE? 12 jan 2010

  4. Description? • Measure the pressure volume relation • Angle is compliance or elastance • Section with Y axis is PV0: pressure at zero volume P = 3,30 V + 8,40 mmHg Squared R = 0,96 E : 3,3 mmHg/L PV0 : 8,4 mmHg On the abdominal pressure volume relationship Mulier JP ISPUB 2009;21:1 Physiology APVR and impact on ITE? 12 jan 2010

  5. Why linear ? • exceptional lineair ? • Physical (not physiologic) explanation • A balloon is never linear • No organ has a linear relation • Half balloon radius diminishes instead of rises with increasing volume JPMulier, ESA 2007, 3AP1 Physiology APVR and impact on ITE? 12 jan 2010

  6. CT 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

  7. Muscle relaxation effect on PV0 • E or Compliance no change • E is by fascia, size en shape determined • PV0 lower • Relaxants identical to 2 MAC Sevo or Desflu J Mulier IFSO Obes Surg 2008 Physiology APVR and impact on ITE? 12 jan 2010

  8. P V loops JPMulier ASA 2008 JPMulier, ESA 2009 Physiology APVR and impact on ITE? 12 jan 2010

  9. Effect of deep muscle relaxation on abdominal PV loop • TOF > 90% • TOF = ¼ • TOF 0/4 and PTC < 5 Physiology APVR and impact on ITE? 12 jan 2010

  10. No muscles in abd wall, diaphragm ? Fully relaxed by other factors ? Patient with no effect of muscle relaxants • TOF > 90% • TOF = ¼ • TOF 0/4 and PTC < 5 Physiology APVR and impact on ITE? 12 jan 2010

  11. Why sometimes no effect ? • Already total relaxed before • Inhalation 2 MAC • Muscle and fascia in parallel: fascia takes all tension, further muscle relaxation no length increase. • Diaphragm, rectus tension in length • Muscle thin, in relaxation fascia not longer. • Rectus cross tension • Expansion abdominal wall or shape change? Physiology APVR and impact on ITE? 12 jan 2010

  12. Effect deep muscle relaxation on IAP with constant IAV • Gradueel druk daling tot vlakke lijn • Max effect bij bereikenTOF 0/4 • Aan PTC 0 geen extra drukdaling TOF 4/4 TOF ¼ PTC 10 PTC 5 PTC 0 Physiology APVR and impact on ITE? 12 jan 2010

  13. Contraction shortens abdominal wall in two directions • Muscle direction • Perpendicular on muscle • No change in fascia elasticity • Curve keeps same angle • Shortening fascia has same effect as increase in intra abd volume • PV0 increases Contraction Rest Relaxation Physiology APVR and impact on ITE? 12 jan 2010

  14. Moderate, deep or very deep? • TOF needed to measure • Diaphragm and vocal cords are most resistant to MR • No active contraction msufficient passive relaxation • Diaphragm is never 100% blocked • At PTC count zero ventilator can still be triggered! Physiology APVR and impact on ITE? 12 jan 2010

  15. PSV prevent breathing against ventilator, is more physiologic • PSV is possible during deep muscle relaxation! • Diaphragm is never total relaxed. • Morfine stops PSV! PROFOUND MUSCLE RELAXATION DOES NOT DISTURB PRESSURE SUPPORT VENTILATION. Mulier J, Blacoe D PGA 2009 Physiology APVR and impact on ITE? 12 jan 2010

  16. Is muscle relaxation needed ? • Gynecologic laparoscopy without curare is possible. • Chassard D. Ann Fr Anesth Reanim. 1996;15(7):1013-7 • Only when compliance is very high Physiology APVR and impact on ITE? 12 jan 2010

  17. Valsalva is an active muscle contraction different from breathing to increase the abdominal pressure Happens when patient reacts on Controlled Ventilation Effect of valsalva: tegenademen Physiology APVR and impact on ITE? 12 jan 2010

  18. E and PV0 determined by ? J P Mulier ESA 2007 Physiology APVR and impact on ITE? 12 jan 2010

  19. J Mulier ISPUB 2009 Pressure volume relation is linear PV0 and E define each patient BMI effect on abdominal P/V relation J P Mulier IFSO 2007 Physiology APVR and impact on ITE? 12 jan 2010

  20. Waist to Hip ratio (WHR) • Man normal WHR: 0,9 • Woman normal WHR: 0,7 • Android fat distribution • WHR > 0,8 • Gynoid fat distribution • WHR < 0,8 Physiology APVR and impact on ITE? 12 jan 2010

  21. Attractiveness in WHR from 4000 BC until 2000 AC 1,5 1,1 1,5 0,5 0,7 Physiology APVR and impact on ITE? 12 jan 2010

  22. WHR vs BMI Physiology APVR and impact on ITE? 12 jan 2010

  23. Obesity type • Android vs Gynoid Physiology APVR and impact on ITE? 12 jan 2010

  24. Android versus Gynoid fat distribution has a different Elastance J P Mulier 2009 Physiology APVR and impact on ITE? 12 jan 2010

  25. Two types of android obesity Subcutaneus FatVisceral fat Intra visceral adiposity Extra visceral adiposity Subcutaneus fat is scant and Subcutaneus fat is thick and intra abdominal fat is thick and intra abdominal fat is scant. Physiology APVR and impact on ITE? 12 jan 2010

  26. If the abdominal fascia is already circular instead of elliptic No deformation possible No radius decrease with increasing volume Large intra visceral fat volume, or liver steatosis makes the relation non linear ! Physiology APVR and impact on ITE? 12 jan 2010

  27. Metabolic syndrome: 3 of the 4 Diabetus Hypertension Dyslipidemia Visceral obesity Physiology APVR and impact on ITE? 12 jan 2010

  28. What can we do to improve the abdominal physiology? • Improve surgical workspace • Facilitate ventilation • Reduce mortality • Methods available ? Physiology APVR and impact on ITE? 12 jan 2010

  29. Table inclination changes PVO J P Mulier IFSO 2009 Physiology APVR and impact on ITE? 12 jan 2010

  30. Leg flexion lowers E J P Mulier IFSO 2009 Physiology APVR and impact on ITE? 12 jan 2010

  31. Lapararoscopy lowers E • Mean IAP: 15,4 +/- 1,5 mmHg • Mean pneumoperitoneum time: 59 +/- 19 minutes • J Mulier PGA 2009 J P Mulier PGA 2009 Physiology APVR and impact on ITE? 12 jan 2010

  32. The obese patient is a challenge for anaesthesia, if patient has an android shape with intra visceral fat. Physiology APVR and impact on ITE? 12 jan 2010

  33. Impact on ICU? • Ventilation optimalisation • Beach chair position if difficult to breath, if higher intra abd pressures. • Curarisation useful if higher intra abdominal pressure • Who is at risk for abd compartment syndrome? • History of previous laparoscopy, laparatomy, multipara lowers risk on IACS • CT abd circle versus ellips • Post operative pain is stretching dependent • First laparoscopy is more painful Physiology APVR and impact on ITE? 12 jan 2010

  34. Ventilation improvement only in difficult to ventilate patients Physiology APVR and impact on ITE? 12 jan 2010

  35. Who is at risk ? • Patients with large E • Never pregnant, never laparatomy, never laparoscopy, sport • Android obese person • Patients with high PV0 • Intra abdominal fat, hepatomegaly • Android obese person Physiology APVR and impact on ITE? 12 jan 2010

  36. How to measure E on ICU: Vol change is needed • Urine bladder compliance • Bladder has its own compliance • Stomach volume change • Leak – balloon insertion? • Ventilatory measured abdominal compliance • Not accurate enough! • Echo abd • Hepatomegalie? • CT abdomen • ellips or circle! • Android central fat in obesity. Physiology APVR and impact on ITE? 12 jan 2010

  37. Physiology APVR and impact on ITE? 12 jan 2010

  38. Physiology APVR and impact on ITE? 12 jan 2010

  39. Become member of ESPCOP today Everyone has obese patients in the future Physiology APVR and impact on ITE? 12 jan 2010

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