Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 7  |  Issue : 3  |  Page : 367-369

The effect of the cytoreductive surgery and hyperthermic intraperitoneal chemotherapy procedure on endotracheal tube cuff pressure


Department of Anesthesia, ICU and Pain Relief, National Cancer Institute, Cairo University, Cairo, Egypt

Date of Submission27-Aug-2014
Date of Acceptance27-Aug-2014
Date of Web Publication27-Aug-2014

Correspondence Address:
Essam Mahran
Department of Anesthesia, ICU and Pain Relief, National Cancer Institute, Cairo University, Cairo 11553
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.139568

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  Abstract 

Objective
The cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) procedure is a relatively new modality in treatment that can benefit many abdominal cancer patients. This lengthy procedure has many steps with many anesthesia challenges. One of the challenges that we studied is the effect of this procedure on endotracheal tube (ETT) cuff pressure.
Patients and methods
After obtaining ethical approval, 25 patients of both sexes, ASA I and II, Mallampati I and II, who had undergone this surgery in our institute from 1 June 2013 to 1 October 2013 were enrolled in this study. In each patient, we measured the ETT cuff pressure five times, at the following time points: (a) immediately after intubation; (b) at the end of cytoreduction before the start of HIPEC; (c) at the end of HIPEC; (d) immediately before transfer to ICU; and (e) in the ICU immediately before extubation. Everytime, we reduced the cuff pressure (if higher) to 35 cmH 2 O using a Portex manometer. Statistical analyses were performed using SPSS version 17. Continuous variables were analyzed as mean ± SD or median (range) as appropriate. Rates and proportions were calculated for categorical data. Differences among the pressure of the ETT cuff over time were analyzed by analysis of variance test using the generalized linear model methodology, whereas a pairwise comparison was performed by the Bonferroni post-hoc test adjusted for multiplicity. P values less than or equal to 0.05 were considered significant.
Results
Pairwise comparisons between the ETT cuff pressure performed by the Bonferroni post-hoc test showed a significant difference between the ETT cuff pressure at all measured time points (P < 0.005).
Conclusion
The cytoreductive surgery and HIPEC procedure has a significant effect on the ETT cuff pressure. We recommend close and frequent monitoring of the ETT cuff pressure during the steps of this major procedure.

Keywords: cuff pressure, cytoreductive surgery, endotracheal tube, hyperthermic intraperitoneal chemotherapy


How to cite this article:
Mahran E, Elsaid M. The effect of the cytoreductive surgery and hyperthermic intraperitoneal chemotherapy procedure on endotracheal tube cuff pressure. Ain-Shams J Anaesthesiol 2014;7:367-9

How to cite this URL:
Mahran E, Elsaid M. The effect of the cytoreductive surgery and hyperthermic intraperitoneal chemotherapy procedure on endotracheal tube cuff pressure. Ain-Shams J Anaesthesiol [serial online] 2014 [cited 2021 Apr 23];7:367-9. Available from: http://www.asja.eg.net/text.asp?2014/7/3/367/139568


  Introduction Top


The cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) procedure is a relatively new modality in abdominal cancer treatment that has been used since 1980 by Spratt et al. [1]. Many cancer patients can benefit from this modality of treatment, especially appendicular cancer, colon cancer, gastric cancer with peritoneal carcinomatosis, and recurrent ovarian cancer [2]. This lengthy procedure has many steps: the first of them after induction of anesthesia and intubation is cytoreduction, followed by the HIPEC procedure, which takes around 2 h, and then closure of the abdominal wall, and finally optimization of acid base and electrolytes in the ICU before extubation. This extensive procedure poses many challenges to the anesthesia team [3]. One of these challenges is the maintenance of the endotracheal tube (ETT) cuff pressure within an acceptable range to prevent aspiration without interference with the tracheal blood supply [4]. The acceptable range of pressure in the ETT cuff is from 20 to 35 cmH 2 O to avoid pressure necrosis of the tracheal mucosa with adequate prevention of aspiration [5].

In our National Cancer Institute, we have a protocol for anesthetic management of these extensive surgeries that includes delayed postoperative extubation of these patients in the ICU after assurance of hemodynamic stability and exclusion of any blood gas abnormalities or electrolyte disturbances.

The objective of the study was to monitor the effect of this major lengthy procedure on the ETT cuff pressure.


  Patients and methods Top


We obtained the approval of the ethics committee of the National Cancer Institute. Then, this prospective study was conducted on all patients undergoing the cytoreductive surgery and HIPEC procedure during the period from 1 June 2013 to 1 October 2013 in the National Cancer Institute, Cairo, Egypt. Informed consent was obtained from each patient before induction of anesthesia, and patients who refused to give informed consent were excluded. Inclusion criteria also included age 30-70 years, ASA I and II, and easily intubated patients (Mallampati scores I and II). The total number of accepted patients enrolled in this study was 25. Balanced anesthesia (midazolam, fentanyl, cisatracurium, propofol, and sevoflurane) was induced using high-volume low-pressure ETT, avoiding the use of nitrous oxide (only oxygen/air mixture). The ETT cuff pressure was measured using a Portex manometer (Portex Limited, Kent, United Kingdom) (Image 1) five times in each patient; each time, the pressure, if higher, was reduced to 35 mmHg. The ETT cuff pressure was measured at the following time points.

(1) Immediately after intubation.

(2) At the end of the cytoreductive surgery immediately before the start of HIPEC.

(3) At the end of HIPEC.

(4) Immediately before transfer to the ICU.

(5) In the ICU immediately before extubation.

Our aim was to keep the ETT cuff pressure at 20-35 cmH 2 O (a safe area before the red dangerous area in the Portex manometer as shown in Image 2), and to compare the ETT cuff pressure value in these different intervals to test the effect of HIPEC.



Statistical analysis

Statistical analyses were performed using SPSS version 17.0 for Windows. Continuous variables were analyzed as mean ± SD or median (range) as appropriate. Rates and proportions were calculated for categorical data. Differences among pressures of the ETT cuff over time were analyzed by analysis of variance for repeated measures using the generalized linear model methodology, whereas the pairwise comparison was performed by the Bonferroni post-hoc test adjusted for multiplicity. P values less than or equal to 0.05 were considered significant.


  Results Top


Criteria of patients included in the study are described in [Table 1].
Figure 1: Changes in ETT cuff pressure over stages of the procedure. ETT, endotracheal tube.

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Changes in the ETT cuff pressure are shown in [Table 2] and [Figure 1].
Table 1 Patient criteria (mean ± SD)

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Table 2 Changes in the endotracheal tube cuff pressure

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A pairwise comparison was performed by the Bonferroni post-hoc test adjusted for multiplicity. Pairwise comparisons between the ETT cuff pressure showed a significant difference between the cuff pressure at all measured time points: that is, a significant difference between the cuff pressure immediately after intubation and at each of the other four times, with P value less than 0.001; a significant difference between the cuff pressure at the end of cytoreduction immediately before HIPEC and at each of the three times thereafter, with P value less than 0.005; a significant difference between the cuff pressure at the end of HIPEC and at each of the two times thereafter, with P value less than 0.001; and a significant difference between the cuff pressure immediately before ICU and that immediately before extubation with P value less than 0.001.

Differences in the pressure of the ETT cuff at different stages of the procedure were analyzed by analysis of variance for repeated measures using the generalized linear model methodology, and these changes in the cuff pressure are shown in [Figure 1].


  Discussion Top


The cytoreductive surgery and HIPEC procedure is a major procedure that has many effects on different body systems. One of these effects is the effect on airway management and different airway pressures [6]. In this study, we studied the effect of this major procedure on the pressure of the ETT cuff. We applied this study on a homogenous group of 25 patients of both sexes as shown in [Table 1].

We found that the ETT cuff pressure was changed (increased) significantly in all five surgical steps of cytoreduction and HIPEC, with maximal increase at the end of the HIPEC procedure itself.

The ETT cuff pressure was found to be increased with some surgical procedures close to the upper airway such as the anterior approach of cervical discectomy [7,8]; however, in our study, the surgical site was relatively far from the site of the cuff.

The results of our study coincide with the general rule put forth by Georgi et al. [9], who stated that the ETT cuff pressure increases with lengthy procedures.


  Conclusion Top


The cytoreductive surgery and HIPEC procedure has a significant effect on the ETT cuff pressure. This effect should be taken into consideration during anesthesia in this major surgical procedure. We recommend close frequent monitoring of the ETT cuff pressure with a specific manometer during the steps of this major procedure.


  Acknowledgements Top


 
  References Top

1.Spratt JS, Adcock RA, Muskovin M, et al. Clinical delivery system for intraperitoneal hyperthermic chemotherapy. Cancer Res 1980; 40:256-260.  Back to cited text no. 1
[PUBMED]    
2.Esquivel J, Sticca R, Sugarbaker P, et al. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of peritoneal surface malignancies of colonic origin: a consensus statement. Ann Surg Oncol 2007; 14:128-133.  Back to cited text no. 2
    
3.González-Moreno S, González-Bayón LA, Ortega-Pérez G. Hyperthermic intraperitoneal chemotherapy: rationale and technique. World J Gastrointest Oncol 2010; 2:68-75.  Back to cited text no. 3
    
4.Stewart SL, Secrest JA, Norwood BR, Zachary R. A comparison of endotracheal tube cuff pressures using estimation techniques and direct intracuff measurement. AANA J 2003; 71:6.  Back to cited text no. 4
    
5.Dorsch JA, Dorsch SE. Tracheal tubes and associated equipment. Understanding anesthesia equipment. 5 th ed. Philadelphia: Lippincott Williams & Wilkins; 2008.  Back to cited text no. 5
    
6.Ahmed S, Oropello JM. Critical care issues in oncological surgery patients. Crit Care Clin 2010; 26:93-106.  Back to cited text no. 6
    
7.Garg R, Rath GP, Bithal PK, Prabhakar H, Marda MK. Effects of retractor application on cuff pressure and vocal cord function in patients undergoing anterior cervical discectomy and fusion. Indian J Anaesth 2010; 54:292-295.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.Arts MP, Rettig TCD, Vries J de, Wolfs JFC, Veld BA iñt. Maintaining endotracheal tube cuff pressure at 20 mm Hg to prevent dysphagia after anterior cervical spine surgery; protocol of a double-blind randomised controlled trial. BMC Musculoskelet Disord 2013; 14:280.  Back to cited text no. 8
    
9.Georgi R, Hagberg C, Krier C. Complications of managing the airway. Best Pract Res Clin Anaesthesiol. 2005; 19:641-659.  Back to cited text no. 9
    


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    Tables

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  In this article
   Abstract
  Introduction
  Patients and methods
  Results
  Discussion
  Conclusion
  Acknowledgements
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