Brazilian Journal of Anesthesiology
Brazilian Journal of Anesthesiology
Original Investigation

The effects of positive end-expiratory pressure (PEEP) application on optic nerve sheath diameter in patients undergoing laparoscopic cholecystectomy: a randomized trial

Seher Yanatma, Reyhan Polat, Mehmet Murat Sayın, Safinaz Karabayırlı

Downloads: 0
Views: 240


Positive end-expiratory pressure (PEEP) can overcome respiratory changes that occur during pneumoperitoneum application in laparoscopic procedures, but it can also increase intracranial pressure. We investigated PEEP vs. no PEEP application on ultrasound measurement of optic nerve sheath diameter (indirect measure of increased intracranial pressure) in laparoscopic cholecystectomy.

Eighty ASA I–II patients aged between 18 and 60 years scheduled for elective laparoscopic cholecystectomy were included. The study was registered in the Australian New Zealand Clinical Trials (ACTRN12618000771257). Patients were randomly divided into either Group C (control, PEEP not applied), or Group P (PEEP applied at 10 cmH20). Optic nerve sheath diameter, hemodynamic, and respiratory parameters were recorded at six different time points. Ocular ultrasonography was used to measure optic nerve sheath diameter.

Peak pressure (PPeak) values were significantly higher in Group P after application of PEEP (p = 0.012). Mean respiratory rate was higher in Group C at all time points after application of pneumoperitoneum (p < 0.05). The mean values of optic nerve sheath diameters measured at all time points were similar between the groups (p > 0.05). The pulmonary dynamic compliance value was significantly higher in group P as long as PEEP was applied (p = 0.001).

During laparoscopic cholecystectomy, application of 10 cmH2O PEEP did not induce a significant change in optic nerve sheath diameter (indirect indicator of intracranial pressure) compared to no PEEP application. It would appear that PEEP can be used safely to correct respiratory mechanics in cases of laparoscopic cholecystectomy, with no significant effect on optic nerve sheath diameter.


Laparoscopic cholecystectomy;  Pneumoperitoneum;  Positive end-expiratory pressure;  Optic nerve sheath diameter;  Ocular ultrasonography


1 P Kundra, Y Subramani, M Ravishankar, et al. Cardiorespiratory effects of balancing PEEP with intra-abdominal pressure during laparoscopic cholecystectomy Surg Laparosc Endosc Percutan Tech, 24 (2014), pp. 232-239

2 A Russo, E Di Stasio, A Scagliusi, et al. Positive end-expiratory pressure during laparoscopy: cardiac and respiratory effects J Clin Anesth, 25 (2013), pp. 314-320

3 O Sen, Y Erdogan Doventas Effects of different levels of end expiratory pressure on hemodynamic, respiratory mechanics and systemic stress response during laparoscopic cholecystectomy Rev Bras Anestesiol, 67 (2017), pp. 28-34

4 AH You, Y Song, DH Kim, et al. Effects of positive end-expiratory pressure on intraocular pressure and optic nerve sheath diameter in robot-assisted laparoscopic radical prostatectomy: a randomized, clinical trial Medicine (Baltimore), 98 (2019), p. e15051

5 J-H Chin, W-J Kim, J Lee, et al. Effect of positive end- expiratory pressure on the sonographic optic nerve sheath diameter as a surrogate for intracranial pressure during robot-assisted laparoscopic prostatectomy: a randomized controlled trial PLoS ONE, 12 (2017), Article e0170369

6 A Mathews, S Cattamanchi, T Panneerselvam, et al. Evaluation of bedside sonographic measurement of optic nerve sheath diameter for assessment of raised intracranial pressure in adult head trauma patients J Emerg Trauma Shock, 13 (2020), pp. 190-195

7 F Dip, D Nguyen, A Rosales, et al. Impact of controlled intraabdominal pressure on the optic nerve sheath diameter during laparoscopic procedures Surg Endosc, 30 (2016), pp. 44-49

8 T Yashwashi, L Kaman, K Kajal, et al. Effects of low- and high-pressure carbon dioxide pneumoperitoneum on intracranial pressure during laparoscopic cholecystectomy Surg Endosc, 34 (2020), pp. 4369-4373

9 TH Kamine, NY Elmadhun, EM Kasper, et al. Abdominal insufflation for laparoscopy increases intracranial and intrathoracic pressure in human subjects Surg Endosc, 30 (2016), pp. 4029-4032

10 A Battisti-Charbonney, J Fisher, J. Duffin The cerebrovascular response to carbon dioxide in humans J Physiol, 589 (Pt 12) (2011), pp. 3039-3048

11 LA Van der Kleij, JB De Vis, J de Bresser, et al. Arterial CO(2) pressure changes during hypercapnia are associated with changes in brain parenchymal volume Eur Radiol Exp, 4 (2020), p. 17

12 M Hiler, M Czosnyka, P Hutchinson, et al. Predictive value of initial computerized tomography scan, intracranial pressure, and state of autoregulation in patients with traumatic brain injury J Neurosurg, 104 (2006), pp. 731-737

13 B Schmidt, M Czosnyka, A Raabe, et al. Adaptive noninvasive assessment of intracranial pressure and cerebral autoregulation Stroke, 34 (2003), pp. 84-89

14 HH Kimberly, S Shah, K Marill, et al. Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure Acad Emerg Med, 15 (2008), pp. 201-204

15 J Dubourg, E Javouhey, T Geeraerts, et al. Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure: a systematic review and metaanalysis Intensive Care Med, 37 (2011), pp. 1059-1068

16 K Helmke, HC. Hansen Fundamentals of transorbital sonographic evaluation of optic nerve sheath expansion under intracranial hypertension I. Experimental study Pediatr Radiol, 26 (1996), pp. 701-705

17 C Robba, NL Bragazzi, A Bertuccio, et al. Effects of prone position on positive end expiratory pressure on non-invasive estimators of ICP: a pilot study J Neurosurg Anesthesiol, 29 (2017), pp. 243-250

18 N Bedirli, G Emmez, Y Ünal, et al. Effects of positive end-expiratory pressure on intracranial pressure during pneumoperitoneum and Trendelenburg position in a porcine mode Turk J Med Sci, 147 (2017), pp. 1610-1615

19 P Verdonck, AF Kalmar, K Suy, et al. Optic nerve sheath diameter remains constant during robot-assisted laparoscopic radical prostatectomy PLoS One, 9 (2014), Article e111916

20 JH Chin, H Seo, EH Lee, et al. Sonographic optic nerve sheath diameter as a surrogate measure for intracranial pressure in anesthetized patients in the Trendelenburg position BMC Anesthesiol, 15 (2015), pp. 43-49

21 JR Whiteley, J Taylor, M Henry, et al. Detection of elevated intracranial pressure in robot-assisted laparoscopic radical prostatectomy using ultrasonography of optic nerve sheath diameter J Neurosurg Anesthesiol, 27 (2015), pp. 155-159

22 C Robba, D Cardim, J Donnelly, et al. Effects of pneumoperitoneum and Trendelenburg position on intracranial pressure assessed using different non-invasive methods Br J Anaesth, 117 (2016), pp. 783-791

23 K Chen, L Wang, Q Wang, et al. Effects of pneumoperitoneum and steep Trendelenburg position on cerebral hemodynamics during robotic-assisted laparoscopic radical prostatectomy: a randomized controlled study Medicine, 98 (2019), p. e15794

24 AF Kalmar, L Foubert, JF Hendrickx, et al. Influence of steep Trendelenburg position and CO2 pneumoperitoneum on cardiovascular, cerebrovascular, and respiratory homeostasis during robotic prostatectomy Br J Anaesth, 104 (2010), pp. 433-439

25 S Haas, A Haese, AE Goetz, et al. Haemodynamics and cardiac function during robotic-assisted laparoscopic prostatectomy in steep Trendelenburg position Int J Med Robot, 7 (2011), pp. 408-413

26 HJ Kwak, SK Park, KC. Lee High positive end-expiratory pressure preserves cerebral oxygen saturation during laparoscopic cholecystectomy under propofol anesthesia Surg Endosc, 27 (2013), pp. 415-420

27 A Caricato, G Conti, F Della Corte Effects of PEEP on the intracranial system of patients with head injury and subarachnoid hemorrhage: the role of respiratory system compliance J Trauma, 58 (2005), pp. 571-576

28 RR Maude, MA Hossain, MU Hassan, et al. Transorbital sonographic evaluation of normal optic nerve sheath diameter in healthy volunteers in Bangladesh PLoS One, 8 (2013), p. e81013

626fe5daa953951b823ab485 rba Articles
Links & Downloads

Braz J Anesthesiol

Share this page
Page Sections