The Effects of Steep Trendelenburg Positioning on Intraocular Pressure During Robotic Radical Prostatectomy

BACKGROUND: Intraocular pressure (TOP) increases in steep Trendelenburg positioning, but the magnitude of the increase has not been quantified. In addition, the factors contributing to this increase have not been studied in robot-assisted prostatectomy cases. In this study, we sought to quantify the changes in TOP and examine perioperative factors responsible for these changes while patients are in the steep Trendelenburg position during robotic prostatectomy. METHODS: In this prospective study, we measured TOP using a Tono-pen (R) XL in 33 patients undergoing robot-assisted prostatectomy. The TOP was measured before anesthesia while supine and awake (baseline T1), anesthetized and supine (T2), anesthetized after insufflation of the abdomen with carbon dioxide (CO2) (T3), anesthetized in steep Trendelenburg (T4), anesthetized in steep Trendelenburg at the end of the procedure (T5), anesthetized supine before awakening (T6), and 1 hr after awakening in the supine position (T7). RESULTS: On average, TOP was 13.3 +/- 0.58 (mean +/- SE) mm Hg higher at the end of the period of steep Trendelenburg position (T5) compared with supine position T1 (P < 0.0001). The least square estimates for each time point in mm Hg were as follows: T1 = 15.7, T2 = 10.7, T3 = 14.6, T4 = 25.2, T5 = 29.0, T6 = 22.2, T7 = 17.0. Using univariate mixed effects models for the T1-T5 time periods, peak airway pressure, mean arterial blood pressure, ETco(2), and time were significant predictors of the TOP increase, whereas age, body mass index, blood loss, volume of IV fluid administered, mean airway pressure, and desflurane concentration were not predictive. In T4-T5, which involved no significant positional or perioperative interventions, we performed a multivariate analysis to evaluate predictors of IOP increases. Surgical duration (in minutes) and ETco(2) were the only significant variables predicting changes in TOP during stable and prolonged Trendelenburg positioning. On average, TOP increased 0.21 mm Hg per mm Hg increase in ETco(2) after adjusting for time. An increase of 0.05 mm Hg in TOP per minute Of Surgery on average was observed during this period in the Trendelenburg position after adjusting for ETco(2). CONCLUSIONS: TOP reached peak levels at the end of steep Trendelenburg position (T5), on average 13 mm Hg higher than the preanesthesia induction (T1) value. Surgical duration and ETco(2) were the only significant predictors of TOP increase in the Trendelenburg position (T4-T5). (Anesth Analg 2009;109:473-8)