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Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations. Br J Anaesth 2019; 123:898-913. [DOI: 10.1016/j.bja.2019.08.017] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/22/2019] [Accepted: 08/04/2019] [Indexed: 12/16/2022] Open
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Impact of Altered Airway Pressure on Intracranial Pressure, Perfusion, and Oxygenation: A Narrative Review. Crit Care Med 2019; 47:254-263. [PMID: 30653472 DOI: 10.1097/ccm.0000000000003558] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES A narrative review of the pathophysiology linking altered airway pressure and intracranial pressure and cerebral oxygenation. DATA SOURCES Online search of PubMed and manual review of articles (laboratory and patient studies) of the altered airway pressure on intracranial pressure, cerebral perfusion, or cerebral oxygenation. STUDY SELECTION Randomized trials, observational and physiologic studies. DATA EXTRACTION Our group determined by consensus which resources would best inform this review. DATA SYNTHESIS In the normal brain, positive-pressure ventilation does not significantly alter intracranial pressure, cerebral oxygenation, or perfusion. In injured brains, the impact of airway pressure on intracranial pressure is variable and determined by several factors; a cerebral venous Starling resistor explains much of the variability. Negative-pressure ventilation can improve cerebral perfusion and oxygenation and reduce intracranial pressure in experimental models, but data are limited, and mechanisms and clinical benefit remain uncertain. CONCLUSIONS The effects of airway pressure and ventilation on cerebral perfusion and oxygenation are increasingly understood, especially in the setting of brain injury. In the face of competing mechanisms and priorities, multimodal monitoring and individualized titration will increasingly be required to optimize care.
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Kim KM, Choi JJ, Lee D, Jung WS, Kim SB, Kwak HJ. Effects of ventilatory strategy on arterial oxygenation and respiratory mechanics in overweight and obese patients undergoing posterior spine surgery. Sci Rep 2019; 9:16638. [PMID: 31719658 PMCID: PMC6851094 DOI: 10.1038/s41598-019-53194-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 10/29/2019] [Indexed: 11/23/2022] Open
Abstract
Prolonged inspiratory to expiratory (I:E) ratio ventilation may improve arterial oxygenation or gas exchange and respiratory mechanics in patients with obesity. We performed a randomised study to compare the effects of the conventional ratio ventilation (CRV) of 1:2 and the equal ratio ventilation (ERV) of 1:1 on arterial oxygenation and respiratory mechanics during spine surgery in overweight and obese patients. Fifty adult patients with a body mass index of ≥25 kg/m2 were randomly allocated to receive an I:E ratio either l:2 (CRV; n = 25) or 1:1 (ERV; n = 25). Arterial oxygenation and respiratory mechanics were recorded in the supine position, and at 30 minutes and 90 minutes after placement in the prone position. The changes in partial arterial oxygen pressure (PaO2) over time did not differ between the groups. The changes in partial arterial carbon dioxide pressure over time were significantly different between the two groups (P = 0.040). The changes in mean airway pressure (Pmean) over time were significantly different between the two groups (P = 0.044). Although ERV provided a significantly higher Pmean than CRV during surgery, the changes in PaO2 did not differ between the two groups.
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Affiliation(s)
- Kyung Mi Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung Ju Choi
- Department of Anesthesiology and Pain Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Dongchul Lee
- Department of Anesthesiology and Pain Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Wol Seon Jung
- Department of Anesthesiology and Pain Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Su Bin Kim
- Department of Anesthesiology and Pain Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Hyun Jeong Kwak
- Department of Anesthesiology and Pain Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea.
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Effect of prolonged inspiratory time on gas exchange during robot-assisted laparoscopic urologic surgery. Anaesthesist 2018; 67:859-867. [PMID: 30225665 DOI: 10.1007/s00101-018-0486-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 07/18/2018] [Accepted: 08/27/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Gas exchange disturbance may develop during urologic robotic laparoscopic surgery with the patient in a steep Trendelenburg position. This study investigated whether prolonged inspiratory time could mitigate gas exchange disturbances including hypercapnia. METHODS In this randomized cross-over trial, 32 patients scheduled for robot-assisted urologic surgery were randomized to receive an inspiratory to expiratory time ratio (I:E) of 1:1 for the first hour of pneumoperitoneum followed by 1:2 for last period of surgery (group A, n = 17) or I:E of 1:2 followed by 1:1 (group B, n = 15). Arterial blood gas analysis, airway pressure and hemodynamic variables were assessed at four time points (T1: 10 min after induction of general anesthesia, T2: 1 h after the initiation of pneumoperitoneum, T3: 1 h after T2 and T4: at skin closure). The carry over effect of initial I:E was also evaluated over the next hour through arterial blood gas analysis. RESULTS There was a significant decrease in partial pressure of oxygen in arterial blood (PaO2) for both groups at T2 and T3 compared to T1 but in group B the PaO2 at T4 was not decreased from the baseline. Partial pressure of carbon dioxide in arterial blood (PaCO2) increased with I:E of 1:2 but did not significantly increase with I:E of 1:1; however, there were no differences in PaO2 and PaCO2 between the groups. CONCLUSION Decreased oxygenation by pneumoperitoneum was improved and PaCO2 did not increase after 1 h of I:E of 1:1; however, the effect of equal ratio ventilation longer than 1 h remains to be determined. There was no carryover effect of the two different I:E ratios.
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Jo YY, Kwak HJ. What is the proper ventilation strategy during laparoscopic surgery? Korean J Anesthesiol 2017; 70:596-600. [PMID: 29225741 PMCID: PMC5716816 DOI: 10.4097/kjae.2017.70.6.596] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 07/14/2017] [Accepted: 07/14/2017] [Indexed: 11/26/2022] Open
Abstract
The main stream of intraabdominal surgery has changed from laparotomy to laparoscopy, but anesthetic care for laparoscopic surgery is challenging for clinicians, because pneumoperitoneum might aggravate respiratory mechanics and arterial oxygenation. The authors reviewed the literature regarding ventilation strategies that reduce deleterious pulmonary physiologic changes during pneumoperitoneum for laparoscopic surgery under general anesthesia and make appropriate recommendations.
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Affiliation(s)
- Youn Yi Jo
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hyun-Jeong Kwak
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon, Korea
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Bertran S, Debs T, Kassir R, Philippe C, Kassir R. The Effect of Ventilation Strategy on Arterial and Cerebral Oxygenation During Laparoscopic Bariatric Surgery. Obes Surg 2017; 27:2688-2689. [PMID: 28733808 DOI: 10.1007/s11695-017-2825-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - Tarek Debs
- Department of General Surgery, CHU Archet, Nice, France
| | - Rani Kassir
- Department of Pediatric Surgery, CHU Félix Guyon, La réunion, Saint Denis, France
| | | | - Radwan Kassir
- Department of General Surgery, CHU Hospital, Jean Monnet University, Avenue Albert Raimond, 42270, Saint Etienne, France.
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Xu L, Shen J, Yan M. The effect of pressure-controlled inverse ratio ventilation on lung protection in obese patients undergoing gynecological laparoscopic surgery. J Anesth 2017; 31:651-656. [DOI: 10.1007/s00540-017-2369-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 04/22/2017] [Indexed: 01/20/2023]
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Simakov SS, Roubliova XI, Ivanov AA, Kaptaeva AK, Mazitova MI, Mynbaev OA. Respiratory acidosis in obese gynecological patients undergoing laparoscopic surgery independently of the type of ventilation. ACTA ACUST UNITED AC 2016; 54:131-133. [PMID: 28024717 DOI: 10.1016/j.aat.2016.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 11/23/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Sergey S Simakov
- Moscow Institute of Physics and Technology (State University), Dolgoprudny, Moscow Region, Russia
| | - Xenia I Roubliova
- Moscow Institute of Physics and Technology (State University), Dolgoprudny, Moscow Region, Russia
| | - Alexey A Ivanov
- The Russian National Research Medical University named after N.I. Pirogov, Moscow, Russia
| | - Anar K Kaptaeva
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - Ospan A Mynbaev
- Moscow Institute of Physics and Technology (State University), Dolgoprudny, Moscow Region, Russia; The Russian National Research Medical University named after N.I. Pirogov, Moscow, Russia.
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Yu P, Wang H, Mu L, Ding X, Ding W. Effect of general anesthesia on serum β-amyloid protein and regional cerebral oxygen saturation of elderly patients after subtotal gastrectomy. Exp Ther Med 2016; 12:3561-3566. [PMID: 28101151 PMCID: PMC5228211 DOI: 10.3892/etm.2016.3814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 09/28/2016] [Indexed: 12/14/2022] Open
Abstract
The aim of the present study was to investigate the influence of general anesthesia on serum β-amyloid protein (Aβ) and regional cerebral oxygen saturation (rSO2) of elderly patients after subtotal gastrectomy. From June, 2014 to December, 2015, among 168 patients undergoing subtotal gastrectomy, the Mini-Mental State Examination and Montreal Cognitive Assessment was administered the day prior to surgery and the second and ninth days after the operation. In addition, we administered the tests to 168 healthy adult volunteers (healthy controls) who were treated in our hospital medical center in the same period. Near-infrared spectroscopy technology was used for continuous monitoring of the intraoperative rSO2, and the mean of intraoperative rSO2 was then calculated. Of the 168 patients, 28 developed postoperative cognitive dysfunction (POCD) and the remaining 140 patients were normal (control). The ELISA method was used to test the expression levels of serum Aβ in the three groups and statistical analyses were conducted. Serum Aβ level in the POCD group was significantly higher than that in the control and healthy control groups, and the difference was statistically significant (P<0.05). The rSO2 level in the patients with POCD was significantly lower than the control group (P<0.05). The correlation analysis with Aβ as an independent variable and other factors as dependent variables revealed that the serum Aβ level negatively correlated with rSO2 (r=-1.6749, P<0.05). The combined Aβ and rSO2 may be useful for the diagnosis and prevention of POCD after subtotal gastrectomy under general anesthesia.
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Affiliation(s)
- Peng Yu
- Department of Anesthesiology, Traditional Chinese Medical Hospital of Rizhao, Rizhao, Shandong 276800, P.R. China
| | - Hua Wang
- Department of Otolaryngology, People's Hospital of Rizhao, Rizhao, Shandong 276800, P.R. China
| | - Lei Mu
- Department of Neurology, Traditional Chinese Medical Hospital of Rizhao, Rizhao, Shandong 276800, P.R. China
| | - Xuemei Ding
- Department of Surgery, Traditional Chinese Medical Hospital of Rizhao, Rizhao, Shandong 276800, P.R. China
| | - Wei Ding
- Department of Neurosurgery, Traditional Chinese Medical Hospital of Rizhao, Rizhao, Shandong 276800, P.R. China
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Mynbaev OA, Gerntke I, Tinelli A, Malvasi A, Benhidjeb T. Letter to the Editor: The Effect of Ventilation Strategy on Arterial and Cerebral Oxygenation During Laparoscopic Bariatric Surgery. Obes Surg 2016; 26:1599-600. [PMID: 27132245 DOI: 10.1007/s11695-016-2194-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Ospan A Mynbaev
- Laboratory of Human Physiology, Moscow Institute of Physics and Technology (State University), 9 Institutskiy per., Dolgoprudny, Moscow Region, 141700, Russian Federation. .,Institute of Numerical Mathematics, Moscow, Russia.
| | - Isabel Gerntke
- Laboratory of Human Physiology, Moscow Institute of Physics and Technology (State University), 9 Institutskiy per., Dolgoprudny, Moscow Region, 141700, Russian Federation.,Burjeel Hospital, Abu Dhabi, United Arab Emirates
| | - Andrea Tinelli
- Laboratory of Human Physiology, Moscow Institute of Physics and Technology (State University), 9 Institutskiy per., Dolgoprudny, Moscow Region, 141700, Russian Federation.,Department of Obstetrics and Gynecology, Division of Experimental Endoscopic Surgery, Imaging, Technology and Minimally Invasive Therapy, Vito Fazzi Hospital, Lecce, Italy
| | - Antonio Malvasi
- Laboratory of Human Physiology, Moscow Institute of Physics and Technology (State University), 9 Institutskiy per., Dolgoprudny, Moscow Region, 141700, Russian Federation.,Department of Obstetrics & Gynecology, Santa Maria Hospital, Bari, Italy
| | - Tahar Benhidjeb
- Laboratory of Human Physiology, Moscow Institute of Physics and Technology (State University), 9 Institutskiy per., Dolgoprudny, Moscow Region, 141700, Russian Federation.,Burjeel Hospital, Abu Dhabi, United Arab Emirates
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Park JH, Lee JS, Lee JH, Shin S, Min NH, Kim MS. Effect of the Prolonged Inspiratory to Expiratory Ratio on Oxygenation and Respiratory Mechanics During Surgical Procedures. Medicine (Baltimore) 2016; 95:e3269. [PMID: 27043700 PMCID: PMC4998561 DOI: 10.1097/md.0000000000003269] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Prolonged inspiratory to expiratory (I:E) ratio ventilation has been researched to reduce lung injury and improve oxygenation in surgical patients with one-lung ventilation (OLV) or carbon dioxide (CO2) pneumoperitoneum. We aimed to confirm the efficacy of the 1:1 equal ratio ventilation (ERV) compared with the 1:2 conventional ratio ventilation (CRV) during surgical procedures. Electronic databases, including PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Google Scholar were searched.Prospective interventional trials that assessed the effects of prolonged I:E ratio of 1:1 during surgical procedures. Adult patients undergoing OLV or CO2 pneumoperitoneum as specific interventions depending on surgical procedures. The included studies were examined with the Cochrane Collaboration's tool. The data regarding intraoperative oxygenation and respiratory mechanics were extracted, and then pooled with standardized mean difference (SMD) using the method of Hedges. Seven trials (498 total patients, 274 with ERV) were included. From overall analysis, ERV did not improve oxygenation at 20 or 30 minutes after specific interventions (SMD 0.193, 95% confidence interval (CI): -0.094 to 0.481, P = 0.188). From subgroup analyses, ERV provided significantly improved oxygenation only with laparoscopy (SMD 0.425, 95% CI: 0.167-0.682, P = 0.001). At 60 minutes after the specific interventions, ERV improved oxygenation significantly in the overall analysis (SMD 0.447, 95% CI: 0.209-0.685, P < 0.001) as well as in the subgroup analyses with OLV (SMD 0.328, 95% CI: 0.011-0.644, P = 0.042) and laparoscopy (SMD 0.668, 95% CI: 0.052-1.285, P = 0.034). ERV provided lower peak airway pressure (Ppeak) and plateau airway pressure (Pplat) than CRV, regardless of the type of intervention. The relatively small number of the included articles and their heterogeneity could be the main limitations. ERV improved oxygenation at all of the assessment points during laparoscopy. In OLV, oxygenation improvement with ERV was observed 1 hour after application. ERV could be beneficial to reduce the Ppeak and Pplat.
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Affiliation(s)
- Jin Ha Park
- From the Department of Anesthesiology and Pain Medicine (JHP, JSL, JHL, SS, NHM, M-SK); Anesthesia and Pain Research Institute (JHP, JSL, JHL, SS, MSK), Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
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