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Liu L, Luo Y, Xu T, Tang Q, Yi J, Wang L, Luo S, Bi Z, Liu J, Lu J, Bi W, Peng C, Liu J. Perioperative complications of middle cerebral artery occlusion in rats alleviated by human umbilical cord mesenchymal stem cells. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024:10.1007/s00210-024-03269-3. [PMID: 38980408 DOI: 10.1007/s00210-024-03269-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 06/30/2024] [Indexed: 07/10/2024]
Abstract
For acute ischemic stroke treatment, the limitations of treatment methods and the high incidence of perioperative complications seriously affect the survival rate and postoperative recovery of patients. Human umbilical cord mesenchymal stem cells (hucMSCs) have multi-directional differentiation potential and immune regulation function, which is a potential cell therapy. The present investigation involved developing a model of cerebral ischemia-reperfusion injury by thrombectomy after middle cerebral artery occlusion (MCAO) for 90 min in rats and utilizing comprehensive multi-system evaluation methods, including the detection of brain tissue ischemia, postoperative survival rate, neurological score, anesthesia recovery monitoring, pain evaluation, stress response, and postoperative pulmonary complications, to elucidate the curative effect of tail vein injection of hucMSCs on MCAO's perioperative complications. Based on our research, it has been determined that hucMSCs treatment can reduce the volume of brain tissue ischemia, promote the recovery of neurological function, and improve the postoperative survival rate of MCAO in rats. At the same time, hucMSCs treatment can prolong the time of anesthesia recovery, relieve the occurrence of delirium during anesthesia recovery, and also have a good control effect on postoperative weight loss, facial pain expression, and lung injury. It can also reduce postoperative stress response by regulating blood glucose and serum levels of stress-related proteins including TNF-α, IL-6, CRP, NE, cortisol, β-endorphin, and IL-10, and ultimately promote the recovery of MCAO's perioperative complications.
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Affiliation(s)
- Liang Liu
- Department of Anesthesia, Changde Hospital, Xiangya School of Medicine, Central South University, Changde, 415000, Hunan, China
| | - Yating Luo
- Guangdong Chanmeng Stem Cell Technologies Co., Ltd., Foshan, 528000, Guangdong, China
| | - Tao Xu
- Department of Anesthesiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, China
| | - Qisheng Tang
- Regenerative Medicine Research Center of The First People's Hospital of Yunnan Province, Affiliated Hospital of Kunming University of Science and Technology, Xishan District, 157 Jinbi Road, Kunming, 650000, Yunnan, China
- Cell Therapy Engineering Research Center for Cardiovascular Diseases in Yunnan Province, Kunming, 650000, Yunnan, China
- Key Laboratory of Innovative Application for Traditional Chinese Medicine in Yunnan Province, Kunming, 650000, Yunnan, China
| | - Jialian Yi
- Regenerative Medicine Research Center of The First People's Hospital of Yunnan Province, Affiliated Hospital of Kunming University of Science and Technology, Xishan District, 157 Jinbi Road, Kunming, 650000, Yunnan, China
- Cell Therapy Engineering Research Center for Cardiovascular Diseases in Yunnan Province, Kunming, 650000, Yunnan, China
- Key Laboratory of Innovative Application for Traditional Chinese Medicine in Yunnan Province, Kunming, 650000, Yunnan, China
| | - Linping Wang
- Regenerative Medicine Research Center of The First People's Hospital of Yunnan Province, Affiliated Hospital of Kunming University of Science and Technology, Xishan District, 157 Jinbi Road, Kunming, 650000, Yunnan, China
- Cell Therapy Engineering Research Center for Cardiovascular Diseases in Yunnan Province, Kunming, 650000, Yunnan, China
- Key Laboratory of Innovative Application for Traditional Chinese Medicine in Yunnan Province, Kunming, 650000, Yunnan, China
| | - Shixiang Luo
- Obstetrical Department of The First People's Hospital of Yunnan Province, Affiliated Hospital of Kunming University of Science and Technology, Kunming, 650000, Yunnan, China
| | - Zhaohong Bi
- Reproductive Medicine Department of The First People's Hospital of Yunnan Province, Affiliated Hospital of Kunming University of Science and Technology, Kunming, 650000, Yunnan, China
| | - Jianlei Liu
- Cellular Immunity Laboratory of Foshan Fosun Chancheng Hospital, Foshan, 528031, Guangdong, China
| | - Jun Lu
- Cellular Immunity Laboratory of Foshan Fosun Chancheng Hospital, Foshan, 528031, Guangdong, China
| | - Weiwei Bi
- Cellular Immunity Laboratory of Foshan Fosun Chancheng Hospital, Foshan, 528031, Guangdong, China
| | - Changguo Peng
- Department of Anesthesia, Changde Hospital, Xiangya School of Medicine, Central South University, Changde, 415000, Hunan, China
| | - Jie Liu
- Regenerative Medicine Research Center of The First People's Hospital of Yunnan Province, Affiliated Hospital of Kunming University of Science and Technology, Xishan District, 157 Jinbi Road, Kunming, 650000, Yunnan, China.
- Cell Therapy Engineering Research Center for Cardiovascular Diseases in Yunnan Province, Kunming, 650000, Yunnan, China.
- Key Laboratory of Innovative Application for Traditional Chinese Medicine in Yunnan Province, Kunming, 650000, Yunnan, China.
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Li P, Gao S, Wang Y, Zhou R, Chen G, Li W, Hao X, Zhu T. Utilising intraoperative respiratory dynamic features for developing and validating an explainable machine learning model for postoperative pulmonary complications. Br J Anaesth 2024; 132:1315-1326. [PMID: 38637267 DOI: 10.1016/j.bja.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 02/20/2024] [Accepted: 02/23/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Timely detection of modifiable risk factors for postoperative pulmonary complications (PPCs) could inform ventilation strategies that attenuate lung injury. We sought to develop, validate, and internally test machine learning models that use intraoperative respiratory features to predict PPCs. METHODS We analysed perioperative data from a cohort comprising patients aged 65 yr and older at an academic medical centre from 2019 to 2023. Two linear and four nonlinear learning models were developed and compared with the current gold-standard risk assessment tool ARISCAT (Assess Respiratory Risk in Surgical Patients in Catalonia Tool). The Shapley additive explanation of artificial intelligence was utilised to interpret feature importance and interactions. RESULTS Perioperative data were obtained from 10 284 patients who underwent 10 484 operations (mean age [range] 71 [65-98] yr; 42% female). An optimised XGBoost model that used preoperative variables and intraoperative respiratory variables had area under the receiver operating characteristic curves (AUROCs) of 0.878 (0.866-0.891) and 0.881 (0.879-0.883) in the validation and prospective cohorts, respectively. These models outperformed ARISCAT (AUROC: 0.496-0.533). The intraoperative dynamic features of respiratory dynamic system compliance, mechanical power, and driving pressure were identified as key modifiable contributors to PPCs. A simplified model based on XGBoost including 20 variables generated an AUROC of 0.864 (0.852-0.875) in an internal testing cohort. This has been developed into a web-based tool for further external validation (https://aorm.wchscu.cn/). CONCLUSIONS These findings suggest that real-time identification of surgical patients' risk of postoperative pulmonary complications could help personalise intraoperative ventilatory strategies and reduce postoperative pulmonary complications.
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Affiliation(s)
- Peiyi Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; The Research Units of West China (2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Shuanliang Gao
- College of Software Engineering, Chengdu University of Information Technology, Chengdu, Sichuan, China
| | - Yaqiang Wang
- College of Software Engineering, Chengdu University of Information Technology, Chengdu, Sichuan, China; Sichuan Key Laboratory of Software Automatic Generation and Intelligent Service, Chengdu, Sichuan, China
| | - RuiHao Zhou
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; The Research Units of West China (2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Guo Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; The Research Units of West China (2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Weimin Li
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Institute of Respiratory Health, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan, China; State Key Laboratory of Respiratory Health and Multimorbidity, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
| | - Xuechao Hao
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; The Research Units of West China (2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
| | - Tao Zhu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; The Research Units of West China (2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Yuan Y, Chen L. Clinical effect of perioperative stellate ganglion block on mechanical ventilation and respiratory function of elderly patients with septic shock. Medicine (Baltimore) 2024; 103:e38166. [PMID: 38788036 PMCID: PMC11124723 DOI: 10.1097/md.0000000000038166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 04/17/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Here we investigated the effect of a stellate ganglion block on the perioperative mechanical ventilation and postoperative recovery of respiratory function of elderly patients with infectious shock. METHODS Thirty-six elderly patients with septic shock who underwent emergency general anesthesia at our hospital were randomly divided into treatment (T) and control (C) groups (n = 18 each). Group T received a preoperative stellate ganglion block, whereas group C received normal saline. Procalcitonin and C-reactive protein levels were compared preoperatively and at 1 and 7 days postoperative. Mean arterial pressure, oxygen saturation, and mean pulmonary artery pressure were measured preoperative and postoperative as well as at 1 and 7 days later. A blood gas analysis was performed preoperatively, at the end of the operation, during extubation, and at 1 and 7 days postoperative. Intubation under general anesthesia, the completion of anesthesia, and spontaneous respiratory recovery involve pulmonary dynamic compliance, plateau pressure, and mechanical ventilation. RESULTS General condition did not differ significantly between groups (P > .05). However, mean arterial pressure at the end of surgery and at 1 and 7 days postoperative were significantly higher in group T versus C (P < .05). Furthermore, mean oxygen saturation at the end of surgery and at 1 and 7 days postoperative was significantly lower in group T versus C (P < .05), while procalcitonin and C-reactive protein levels were significantly lower at 1 and 7 days postoperative. Group T had significantly better arterial partial pressure of carbon dioxide, partial pressure of oxygen, and partial pressure of oxygen/fraction of inspired oxygen than group C at the end of surgery, during extubation, and at 1 and 7 days postoperative (P < .05). CONCLUSION Group T exhibited superior inflammatory responses and respiratory function. Stellate ganglion block in elderly patients with septic shock reduces inflammation, improves mechanical ventilation perioperatively, and promotes postoperative recovery and respiratory function.
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Affiliation(s)
- Yingchuan Yuan
- Department of Anesthesiology, The Second Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Lu Chen
- Department of Anesthesiology, The Second Affiliated Hospital of Xinjiang Medical University, Urumqi, China
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Bae YK, Nam SW, Oh AY, Kim BY, Koo BW, Han J, Yim S. Effect of the alveolar recruitment maneuver during laparoscopic colorectal surgery on postoperative pulmonary complications: A randomized controlled trial. PLoS One 2024; 19:e0302884. [PMID: 38722838 PMCID: PMC11081303 DOI: 10.1371/journal.pone.0302884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 04/14/2024] [Indexed: 05/13/2024] Open
Abstract
Intraoperative lung-protective ventilation, including low tidal volume and positive end-expiratory pressure, reduces postoperative pulmonary complications. However, the effect and specific alveolar recruitment maneuver method are controversial. We investigated whether the intraoperative intermittent recruitment maneuver further reduced postoperative pulmonary complications while using a lung-protective ventilation strategy. Adult patients undergoing elective laparoscopic colorectal surgery were randomly allocated to the recruitment or control groups. Intraoperative ventilation was adjusted to maintain a tidal volume of 6-8 mL kg-1 and positive end-expiratory pressure of 5 cmH2O in both groups. The alveolar recruitment maneuver was applied at three time points (at the start and end of the pneumoperitoneum, and immediately before extubation) by maintaining a continuous pressure of 30 cmH2O for 30 s in the recruitment group. Clinical and radiological evidence of postoperative pulmonary complications was investigated within 7 days postoperatively. A total of 125 patients were included in the analysis. The overall incidence of postoperative pulmonary complications was not significantly different between the recruitment and control groups (28.1% vs. 31.1%, P = 0.711), while the mean ± standard deviation intraoperative peak inspiratory pressure was significantly lower in the recruitment group (10.7 ± 3.2 vs. 13.5 ± 3.0 cmH2O at the time of CO2 gas-out, P < 0.001; 9.8 ± 2.3 vs. 12.5 ± 3.0 cmH2O at the time of recovery, P < 0.001). The alveolar recruitment maneuver with a pressure of 30 cmH2O for 30 s did not further reduce postoperative pulmonary complications when a low tidal volume and 5 cmH2O positive end-expiratory pressure were applied to patients undergoing laparoscopic colorectal surgery and was not associated with any significant adverse events. However, the alveolar recruitment maneuver significantly reduced intraoperative peak inspiratory pressure. Further study is needed to validate the beneficial effect of the alveolar recruitment maneuver in patients at increased risk of postoperative pulmonary complications. Trial registration: Clinicaltrials.gov (NCT03681236).
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Affiliation(s)
- Yu Kyung Bae
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sun Woo Nam
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong si, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University, College of Medicine, Seoul, Republic of Korea
| | - Ah-Young Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University, College of Medicine, Seoul, Republic of Korea
| | - Bo Young Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Bon-Wook Koo
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jiwon Han
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong si, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Chung-Ang University, College of Medicine, Seoul, Republic of Korea
| | - Subin Yim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University, College of Medicine, Seoul, Republic of Korea
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Dupont K, Lefrançois V, Delahaye A, Sanz M, Hestin R, Doublet T, Parienti JJ, Hanouz JL. Change in stroke volume during alveolar recruitment maneuvers through transient continuous positive airway pressure or stepwise increase in positive end expiratory pressure in anesthetized patients: a prospective randomized double-blind study. Can J Anaesth 2024; 71:224-233. [PMID: 38017197 DOI: 10.1007/s12630-023-02644-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/28/2023] [Accepted: 07/23/2023] [Indexed: 11/30/2023] Open
Abstract
PURPOSE Intraoperative alveolar recruitment maneuvers (ARM) used during protective ventilation strategy may have severe adverse hemodynamic effects, reported mainly during abrupt continuous positive airway pressure (CPAP). Stepwise increase and decrease in positive end expiratory pressure (PEEP) may be used. We compared the hemodynamic effects of these two maneuvers. METHODS We enrolled patients scheduled for intermediate to high-risk surgery with continuous arterial pressure and stroke volume (esophageal Doppler) monitoring in a prospective, single-centre, randomized, double-blind study. After induction of anesthesia, we ensured preload independence of stroke volume before an ARM was randomly performed: 30 cm H2O CPAP for 30 sec (CPAP group) or stepwise increase in PEEP from 8 to 20 cm H2O with inspiratory pressure of 10 cm H2O followed by a stepwise decrease in PEEP from 20 to 8 cm H2O (STEP group). The primary outcome was the relative variation in stroke volume. RESULTS Thirty-five patients were included in the CPAP and STEP groups. Mean (standard deviation) relative variation in stroke volume was -57 (24)% in the CPAP group and -32 (24)% in the STEP group (difference, -25; 95% confidence interval, -37 to -14; P < 0.001). Changes in systolic, mean, and diastolic arterial pressure over time were not different between groups. The ARM was stopped because of a systolic arterial pressure < 70 mm Hg in four patients in the CPAP group and in one patient in the STEP group. CONCLUSIONS Alveolar recruitment maneuvers through stepwise increase and decrease in PEEP have a better hemodynamic tolerance than transient CPAP. TRIAL REGISTRATION ClinicalTrials.gov (NCT04802421); first submitted 15 March 2021.
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Affiliation(s)
- Kevin Dupont
- Service Anesthésie Réanimation, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, 14000, Caen, France
| | - Valentin Lefrançois
- Service Anesthésie Réanimation, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, 14000, Caen, France
| | - Antoine Delahaye
- Service Anesthésie Réanimation, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, 14000, Caen, France
| | - Marine Sanz
- Service Anesthésie Réanimation, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, 14000, Caen, France
| | - Rémi Hestin
- Service Anesthésie Réanimation, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, 14000, Caen, France
| | - Théophane Doublet
- Service Anesthésie Réanimation, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, 14000, Caen, France
| | - Jean-Jacques Parienti
- Department of Clinical Research and Biostatistics, Caen University Hospital and Caen Normandy University, Caen, France
- UFR Medecine, Uiversité Caen Normandie, 2 Rue des Rochambelles, 14032 Caen Cedex 5, Caen, France
| | - Jean-Luc Hanouz
- Service Anesthésie Réanimation, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, 14000, Caen, France.
- UFR Medecine, Uiversité Caen Normandie, 2 Rue des Rochambelles, 14032 Caen Cedex 5, Caen, France.
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Edmark L, Englund EK, Jonsson AS, Zilic AT, Cajander P, Östberg E. Pressure-controlled versus manual facemask ventilation for anaesthetic induction in adults: A randomised controlled non-inferiority trial. Acta Anaesthesiol Scand 2023; 67:1356-1362. [PMID: 37476919 DOI: 10.1111/aas.14308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/06/2023] [Accepted: 07/03/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Pressure-controlled face mask ventilation (PC-FMV) with positive end-expiratory pressure (PEEP) after apnoea following induction of general anaesthesia prolongs safe apnoea time and reduces atelectasis formation. However, depending on the set inspiratory pressure, a delayed confirmation of a patent airway might occur. We hypothesised that by lowering the peak inspiratory pressure (PIP) when using PC-FMV with PEEP, confirmation of a patent airway would not be delayed as studied by the first return of CO2 , compared with manual face mask ventilation (Manual FMV). METHODS This was a single-centre, randomised controlled non-inferiority trial. Seventy adult patients scheduled for elective day-case surgery under general anaesthesia with body mass index between 18.5 and 29.9 kg m-2 , American Society of Anesthesiologists (ASA) classes I-III, and without anticipated difficult FMV, were included. Before the start of pre-oxygenation and induction of general anaesthesia, participants were randomly allocated to receive ventilation with either PC-FMV with PEEP, at a PIP of 11 and a PEEP of 6 cmH2 O or Manual FMV, with the adjustable pressure-limiting valve set at 11 cmH2 O. The primary outcome variable was the number of ventilatory attempts needed until confirmation of a patent airway, defined as the return of at least 1.3 kPa CO2 . RESULTS The return of ≥1.3 kPa CO2 on the capnography curve was observed after mean ± SD, 3.6 ± 4.2 and 2.5 ± 1.9 ventilatory attempts/breaths with PC-FMV with PEEP and Manual FMV, respectively. The difference in means (1.1 ventilatory attempts/breaths) had a 99% CI of -1.0 to 3.1, within the accepted upper margin of four breaths for non-inferiority. CONCLUSION Following induction of general anaesthesia, PC-FMV with PEEP was used without delaying a patent airway as confirmed with capnography, if moderate pressures were used.
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Affiliation(s)
- Lennart Edmark
- Department of Anaesthesia and Intensive Care, Västmanland Hospital Köping, Köping, Sweden
- Region Västmanland-Uppsala University, Centre for Clinical Research, Västmanland Hospital Västerås, Västerås, Sweden
| | - Emma-Karin Englund
- Department of Anaesthesia and Intensive Care, Västmanland Hospital Köping, Köping, Sweden
| | | | | | - Per Cajander
- Department of Anaesthesia and Intensive Care, Örebro University Hospital, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Erland Östberg
- Department of Anaesthesia and Intensive Care, Västmanland Hospital Köping, Köping, Sweden
- Region Västmanland-Uppsala University, Centre for Clinical Research, Västmanland Hospital Västerås, Västerås, Sweden
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Wu L, Yang Y, Yin Y, Yang L, Sun X, Zhang J. Lung ultrasound for evaluating perioperative atelectasis and aeration in the post-anesthesia care unit. J Clin Monit Comput 2023; 37:1295-1302. [PMID: 36961634 DOI: 10.1007/s10877-023-00994-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/07/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE Lung ultrasound is widely accepted as a reliable, noninvasive tool for evaluating lung status at the bedside. We assessed the impact of perioperative variables on atelectasis and lung aeration using lung ultrasound, and their correlation with postoperative oxygenation in patients undergoing general anesthesia. METHODS This prospective observational study evaluated 93 consecutive patients scheduled to undergo elective non-cardiothoracic surgery under general anesthesia. Lung ultrasound was performed 5 min after admission to the post-anesthesia care unit (PACU). Twelve pulmonary quadrants were selected for each ultrasound examination. The lung ultrasound scores and atelectasis status were calculated. The oxygenation assessment was obtained by arterial blood gas analysis before discharge from the PACU. RESULTS Thirty-two patients (34%) had atelectasis in at least one of the 12 evaluated segments, whereas 12 patients (13%) had atelectasis in at least three segments. The proportion of B-lines (≥ 3) and atelectasis in the inferolateral and posterior regions was significantly higher than in other regions. Patients with lung ultrasound scores ≥ 5 had a higher body mass index and lower PaO2 before discharge from the PACU than those with scores < 5. Patients with atelectasis had higher body mass indices and lung ultrasound scores. The presence of ≥ 2 regions of atelectasis was associated with lower PaO2. Using multivariate analysis, body mass index, intraoperative body position, and sex independently correlated with lung ultrasound scores. Age and lung ultrasound scores independently correlated with hypoxemia. CONCLUSION Lung ultrasound enables early postoperative evaluation of atelectasis and lung aeration, which are closely associated with postoperative oxygenation.
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Affiliation(s)
- Lei Wu
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Yanyan Yang
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Yuehao Yin
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Li Yang
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Xia Sun
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China.
| | - Jun Zhang
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China.
- Department of Oncology, Shanghai Medical College, Fudan University, No. 270, Dong'an Road, 200032, Xuhui, Shanghai, China.
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De Meyer GRA, Morrison SG, Saldien V, Jorens PG, Schepens T. Minimizing Lung Injury During Laparoscopy in Head-Down Tilt: A Physiological Cohort Study. Anesth Analg 2023; 137:841-849. [PMID: 36729514 DOI: 10.1213/ane.0000000000006325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Increased intra-abdominal pressure during laparoscopy induces atelectasis. Positive end-expiratory pressure (PEEP) can alleviate atelectasis but may cause hyperinflation. Cyclic opening of collapsed alveoli and hyperinflation can lead to ventilator-induced lung injury and postoperative pulmonary complications. We aimed to study the effect of PEEP on atelectasis, lung stress, and hyperinflation during laparoscopy in the head-down (Trendelenburg) position. METHODS An open-label, repeated-measures, interventional, physiological cohort trial was designed. All participants were recruited from a single tertiary Belgian university hospital. Twenty-three nonobese patients scheduled for laparoscopy in the Trendelenburg position were recruited.We applied a decremental PEEP protocol: 15 (high), 10 and 5 (low) cm H 2 O. Atelectasis was studied with the lung ultrasound score, the end-expiratory transpulmonary pressure, the arterial oxygen partial pressure to fraction of inspired oxygen concentration (P ao2 /Fi o2 ) ratio, and the dynamic respiratory system compliance. Global hyperinflation was evaluated by dead space volume, and regional ventilation was evaluated by lung ultrasound. Lung stress was estimated using the transpulmonary driving pressure and dynamic compliance. Data are reported as medians (25th-75th percentile). RESULTS At 15, 10, and 5 cm H 2 O PEEP, the respective measurements were: lung ultrasound scores (%) 11 (0-22), 27 (11-39), and 53 (42-61) ( P < .001); end-expiratory transpulmonary pressures (cm H 2 O) 0.9 (-0.6 to 1.7), -0.3 (-2.0 to 0.7), and -1.9 (-4.6 to -0.9) ( P < .001); P ao2 /Fi o2 ratios (mm Hg) 471 (435-538), 458 (410-537), and 431 (358-492) ( P < .001); dynamic respiratory system compliances (mL/cm H 2 O) 32 (26-36), 30 (25-34), and 27 (22-30) ( P < .001); driving pressures (cm H 2 O) 8.2 (7.5-9.5), 9.3 (8.5-11.1), and 11.0 (10.3-12.2) ( P < .001); and alveolar dead space ventilation fractions (%) 10 (9-12), 10 (9-12), and 9 (8-12) ( P = .23). The lung ultrasound score was similar between apical and basal lung regions at each PEEP level ( P = .76, .37, and .76, respectively). CONCLUSIONS Higher PEEP levels during laparoscopy in the head-down position facilitate lung-protective ventilation. Atelectasis and lung stress are reduced in the absence of global alveolar hyperinflation.
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Affiliation(s)
- Gregory R A De Meyer
- From the Department of Anesthesia, Antwerp University Hospital, Edegem, Belgium
- Department of Critical Care Medicine, Antwerp University Hospital, Edegem, Belgium
- Laboratory of Experimental Medicine and Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Stuart G Morrison
- From the Department of Anesthesia, Antwerp University Hospital, Edegem, Belgium
| | - Vera Saldien
- From the Department of Anesthesia, Antwerp University Hospital, Edegem, Belgium
- Antwerp Surgical Training, Anatomy and Research Centre, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Philippe G Jorens
- Department of Critical Care Medicine, Antwerp University Hospital, Edegem, Belgium
- Laboratory of Experimental Medicine and Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Tom Schepens
- Department of Critical Care Medicine, Antwerp University Hospital, Edegem, Belgium
- Laboratory of Experimental Medicine and Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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Giannakoulis VG, Papoutsi E, Kaldis V, Tsirogianni A, Kotanidou A, Siempos II. Postoperative acute respiratory distress syndrome in randomized controlled trials. Surgery 2023; 174:1050-1055. [PMID: 37481422 DOI: 10.1016/j.surg.2023.06.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/05/2023] [Accepted: 06/18/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Acute respiratory distress syndrome is a potentially fatal postoperative complication. We aimed to estimate temporal trends of the representation of patients with postoperative acute respiratory distress syndrome in clinical trials, determine their distinct clinical features, and identify predictors of mortality. METHODS This is a secondary analysis of 7 randomized controlled clinical trials conducted by the Acute Respiratory Distress Syndrome Network and the Clinical Trials Network for the Prevention and Early Treatment of Acute Lung Injury. Patients with acute respiratory distress syndrome were classified into a postoperative acute respiratory distress syndrome group (ie, patients who had undergone elective surgery in the immediate period before trial enrollment) and a non-postoperative acute respiratory distress syndrome group. RESULTS Out of 5,316 patients with acute respiratory distress syndrome, 256 (4.8%) had postoperative acute respiratory distress syndrome. Representation of postoperative acute respiratory distress syndrome in trials gradually declined from 2000 to 2011, but it remained stable afterward at 2.7%. Postoperative acute respiratory distress syndrome was associated with lower 90-day mortality (24.6% vs 30.9%, P = .032) than non-postoperative acute respiratory distress syndrome, even after adjusting for age, acute respiratory distress syndrome severity, usage of vasopressors at baseline, and the study publication year (hazard ratio 0.63, 95% confidence interval 0.49-0.82). Age (odds ratio 1.07, 95% confidence interval 1.04-1.09), immunosuppression (odds ratio 4.12, 95% confidence interval 1.43-11.86), and positive fluid balance (odds ratio 1.09, 95% confidence interval 1.04-1.14) were associated with 90-day mortality among patients with postoperative acute respiratory distress syndrome. CONCLUSION Representation of postoperative acute respiratory distress syndrome in trials of the Acute Respiratory Distress Syndrome Network and the Clinical Trials Network for the Prevention and Early Treatment of Acute Lung Injury gradually declined from 2000 to 2011 but remained stable afterward. Postoperative acute respiratory distress syndrome was associated with lower mortality than non-postoperative acute respiratory distress syndrome. These findings may put both temporal trends and the prognosis of postoperative acute respiratory distress syndrome in perspective. Also, positive fluid balance was associated with the mortality of patients with postoperative acute respiratory distress syndrome.
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Affiliation(s)
- Vassilis G Giannakoulis
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Greece
| | - Eleni Papoutsi
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Greece
| | - Vassileios Kaldis
- Department of Emergency Medicine, KAT General Hospital, Athens, Greece
| | | | - Anastasia Kotanidou
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Greece
| | - Ilias I Siempos
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Greece; Department of Medicine, Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY.
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10
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Oh EJ, Kim J, Kim BG, Han S, Ko JS, Gwak MS, Kim GS, Choi EA, Kang J, Park HY. Intraoperative Factors Modifying the Risk of Postoperative Pulmonary Complications After Living Donor Liver Transplantation. Transplantation 2023; 107:1748-1755. [PMID: 36959123 DOI: 10.1097/tp.0000000000004544] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
BACKGROUND The relationship between intraoperative anesthetic management and postoperative pulmonary complications (PPCs) after liver transplantation is not fully understood. We aimed to determine the intraoperative contributors to PPC. METHODS The retrospectively collected cohort included 605 patients who underwent living donor liver transplantation. PPCs comprised respiratory failure, respiratory infection, pulmonary edema, atelectasis (at least moderate degree), pneumothorax, and pleural effusion (at least moderate degree). The presence and type of PPC were evaluated by 2 pulmonary physicians. Logistic regression analysis was performed to determine the association between perioperative variables and PPC risk. RESULTS Of the 605 patients, 318 patients (52.6%) developed 486 PPCs. Multivariable analysis demonstrated that PPC risk decreased with low tidal volume ventilation (odds ratio [OR] 0.62 [0.41-0.94], P = 0.023) and increased with greater driving pressure at the end of surgery (OR 1.08 [1.01-1.14], P = 0.018), prolonged hypotension (OR 1.85 [1.27-2.70], P = 0.001), and blood albumin level ≤3.0 g/dL at the end of surgery (OR 2.43 [1.51-3.92], P < 0.001). Survival probability at 3, 6, and 12 mo after transplantation was 91.2%, 89.6%, and 86.5%, respectively, in patients with PPCs and 98.3%, 96.5%, and 93.4%, respectively, in patients without PPCs (hazard ratio 2.2 [1.3-3.6], P = 0.004). Graft survival probability at 3, 6, and 12 mo after transplantation was 89.3%, 87.1%, and 84.3%, respectively, in patients with PPCs and 97.6%, 95.8%, and 92.7%, respectively, in patients without PPCs (hazard ratio 2.3 [1.4-3.7], P = 0.001). CONCLUSIONS We found that tidal volume, driving pressure, hypotension, and albumin level during living donor liver transplantation were significantly associated with PPC risk. These data may help determine patients at risk of PPC or develop an intraoperative lung-protective strategy for liver transplant recipients.
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Affiliation(s)
- Eun Jung Oh
- Department of Anesthesiology and Pain Medicine, Gwangmyeong Hospital, Chung-Ang University School of Medicine, Gwangmyeong, Korea
| | - Jeayoun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Bo-Guen Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sangbin Han
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Justin S Ko
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mi Sook Gwak
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gaab Soo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Ah Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jiyeon Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Hye Yun Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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11
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Sun M, Jia R, Wang L, Sun D, Wei M, Wang T, Jiang L, Wang Y, Yang B. Effect of protective lung ventilation on pulmonary complications after laparoscopic surgery: a meta-analysis of randomized controlled trials. Front Med (Lausanne) 2023; 10:1171760. [PMID: 37305134 PMCID: PMC10248173 DOI: 10.3389/fmed.2023.1171760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/05/2023] [Indexed: 06/13/2023] Open
Abstract
Introduction Compared with traditional open surgery, laparoscopic surgery is widely used in surgery, with the advantages of being minimally invasive, having good cosmetic effects, and having short hospital stays, but in laparoscopic surgery, pneumoperitoneum and the Trendelenburg position can cause complications, such as atelectasis. Recently, several studies have shown that protective lung ventilation strategies are protective for abdominal surgery, reducing the incidence of postoperative pulmonary complications (PPCs). Ventilator-associated lung injury can be reduced by protective lung ventilation, which includes microtidal volume (4-8 mL/kg) ventilation and positive end-expiratory pressure (PEEP). Therefore, we used randomized, controlled trials (RCTs) to assess the results on this topic, and RCTs were used for meta-analysis to further evaluate the effect of protective lung ventilation on pulmonary complications in patients undergoing laparoscopic surgery. Methods In this meta-analysis, we searched the relevant literature contained in six major databases-CNKI, CBM, Wanfang Medical, Cochrane, PubMed, and Web of Science-from their inception to October 15, 2022. After screening the eligible literature, a randomized, controlled method was used to compare the occurrence of postoperative pulmonary complications when a protective lung ventilation strategy and conventional lung ventilation strategy were applied to laparoscopic surgery. After statistical analysis, the results were verified to be statistically significant. Results Twenty-three trials were included. Patients receiving protective lung ventilation were 1.17 times less likely to develop pulmonary complications after surgery than those receiving conventional lung ventilation (hazard ratio [RR] 0.18, 95% confidence interval [CI] 1.13-1.22; I2 = 0%). When tested for bias (P = 0.36), the result was statistically significant. Patients with protective lung ventilation were less likely to develop pulmonary complications after laparoscopic surgery. Conclusion Compared with conventional mechanical ventilation, protective lung ventilation reduces the incidence of postoperative pulmonary complications. For patients undergoing laparoscopic surgery, we suggest the use of protective lung ventilation, which is effective in reducing the incidence of lung injury and pulmonary infection. Implementation of a low tidal volume plus moderate positive end-expiratory pressure strategy reduces the risk of postoperative pulmonary complications.
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Affiliation(s)
- Menglin Sun
- Department of Anesthesiology, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ruolin Jia
- Department of Obstetrics and Gynecology, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lijuan Wang
- Department of Anesthesiology, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Daqi Sun
- Department of Anesthesiology, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mingqian Wei
- Department of Anesthesiology, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tao Wang
- Department of Anesthesiology, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lihua Jiang
- Department of Anesthesiology, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuxia Wang
- Department of Anesthesiology, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Bo Yang
- Department of Anesthesiology, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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12
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Postoperative Pulmonary Complications in the ENIGMA II Trial: A Post Hoc Analysis. Anesthesiology 2023; 138:354-363. [PMID: 36645804 DOI: 10.1097/aln.0000000000004497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Nitrous oxide promotes absorption atelectasis in poorly ventilated lung segments at high inspired concentrations. The Evaluation of Nitrous oxide In the Gas Mixture for Anesthesia (ENIGMA) trial found a higher incidence of postoperative pulmonary complications and wound sepsis with nitrous oxide anesthesia in major surgery compared to a fraction of inspired oxygen of 0.8 without nitrous oxide. The larger ENIGMA II trial randomized patients to nitrous oxide or air at a fraction of inspired oxygen of 0.3 but found no effect on wound infection or sepsis. However, postoperative pulmonary complications were not measured. In the current study, post hoc data were collected to determine whether atelectasis and pneumonia incidences were higher with nitrous oxide in patients who were recruited to the Australian cohort of ENIGMA II. METHODS Digital health records of patients who participated in the trial at 10 Australian hospitals were examined blinded to trial treatment allocation. The primary endpoint was the incidence of atelectasis, defined as lung atelectasis or collapse reported on chest radiology. Pneumonia, as a secondary endpoint, required a diagnostic chest radiology report with fever, leukocytosis, or positive sputum culture. Comparison of the nitrous oxide and nitrous oxide-free groups was done according to intention to treat using chi-square tests. RESULTS Data from 2,328 randomized patients were included in the final data set. The two treatment groups were similar in surgical type and duration, risk factors, and perioperative management recorded for ENIGMA II. There was a 19.3% lower incidence of atelectasis with nitrous oxide (171 of 1,169 [14.6%] vs. 210 of 1,159 [18.1%]; odds ratio, 0.77; 95% CI, 0.62 to 0.97; P = 0.023). There was no difference in pneumonia incidence (60 of 1,169 [5.1%] vs. 52 of 1159 [4.5%]; odds ratio, 1.15; 95% CI, 0.77 to 1.72; P = 0.467) or combined pulmonary complications (odds ratio, 0.84; 95% CI, 0.69 to 1.03; P = 0.093). CONCLUSIONS In contrast to the earlier ENIGMA trial, nitrous oxide anesthesia in the ENIGMA II trial was associated with a lower incidence of lung atelectasis, but not pneumonia, after major surgery. EDITOR’S PERSPECTIVE
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13
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Henricks EM, Pfeifer KJ. Pulmonary assessment and optimization for older surgical patients. Int Anesthesiol Clin 2023; 61:8-15. [PMID: 36794803 DOI: 10.1097/aia.0000000000000398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Affiliation(s)
- Evan M Henricks
- Division of Geriatric and Palliative Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kurt J Pfeifer
- Department of Medicine, Section of Perioperative & Consultative Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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14
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Low tidal volume ventilation for patients undergoing laparoscopic surgery: a secondary analysis of a randomised clinical trial. BMC Anesthesiol 2023; 23:71. [PMID: 36882701 PMCID: PMC9990198 DOI: 10.1186/s12871-023-01998-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 01/30/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND We recently reported the results for a large randomized controlled trial of low tidal volume ventilation (LTVV) versus conventional tidal volume (CTVV) during major surgery when positive end expiratory pressure (PEEP) was equal between groups. We found no difference in postoperative pulmonary complications (PPCs) in patients who received LTVV. However, in the subgroup of patients undergoing laparoscopic surgery, LTVV was associated with a numerically lower rate of PPCs after surgery. We aimed to further assess the relationship between LTVV versus CTVV during laparoscopic surgery. METHODS We conducted a post-hoc analysis of this pre-specified subgroup. All patients received volume-controlled ventilation with an applied PEEP of 5 cmH2O and either LTVV (6 mL/kg predicted body weight [PBW]) or CTVV (10 mL/kg PBW). The primary outcome was the incidence of a composite of PPCs within seven days. RESULTS Three hundred twenty-eight patients (27.2%) underwent laparoscopic surgeries, with 158 (48.2%) randomised to LTVV. Fifty two of 157 patients (33.1%) assigned to LTVV and 72 of 169 (42.6%) assigned to conventional tidal volume developed PPCs within 7 days (unadjusted absolute difference, - 9.48 [95% CI, - 19.86 to 1.05]; p = 0.076). After adjusting for pre-specified confounders, the LTVV group had a lower incidence of the primary outcome than patients receiving CTVV (adjusted absolute difference, - 10.36 [95% CI, - 20.52 to - 0.20]; p = 0.046). CONCLUSION In this post-hoc analysis of a large, randomised trial of LTVV we found that during laparoscopic surgeries, LTVV was associated with a significantly reduced PPCs compared to CTVV when PEEP was applied equally between both groups. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry no: 12614000790640.
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15
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Jin F, Liu W, Qiao X, Shi J, Xin R, Jia HQ. Nomogram prediction model of postoperative pneumonia in patients with lung cancer: A retrospective cohort study. Front Oncol 2023; 13:1114302. [PMID: 36910602 PMCID: PMC9996165 DOI: 10.3389/fonc.2023.1114302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/06/2023] [Indexed: 02/25/2023] Open
Abstract
Background The prediction model of postoperative pneumonia (POP) after lung cancer surgery is still scarce. Methods Retrospective analysis of patients with lung cancer who underwent surgery at The Fourth Hospital of Hebei Medical University from September 2019 to March 2020 was performed. All patients were randomly divided into two groups, training cohort and validation cohort at the ratio of 7:3. The nomogram was formulated based on the results of multivariable logistic regression analysis and clinically important factors associated with POP. Concordance index (C-index), receiver operating characteristic (ROC) curve, calibration curve, Hosmer-Lemeshow goodness-of-fit test and decision curve analysis (DCA) were used to evaluate the predictive performance of the nomogram. Results A total of 1252 patients with lung cancer was enrolled, including 877 cases in the training cohort and 375 cases in the validation cohort. POP was found in 201 of 877 patients (22.9%) and 89 of 375 patients (23.7%) in the training and validation cohorts, respectively. The model consisted of six variables, including smoking, diabetes mellitus, history of preoperative chemotherapy, thoracotomy, ASA grade and surgery time. The C-index from AUC was 0.717 (95%CI:0.677-0.758) in the training cohort and 0.726 (95%CI:0.661-0.790) in the validation cohort. The calibration curves showed the model had good agreement. The result of DCA showed that the model had good clinical benefits. Conclusion This proposed nomogram could predict the risk of POP in patients with lung cancer surgery in advance, which can help clinician make reasonable preventive and treatment measures.
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Affiliation(s)
- Fan Jin
- Department of Anesthesiology, The Fourth hospital of Hebei Medical University, Shijiazhuang, Hebei, China.,Department of Anesthesiology, Zhuji People's Hospital, Shaoxing, Zhejiang, China
| | - Wei Liu
- Department of Anesthesiology, The Fourth hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xi Qiao
- Department of Anesthesiology, The Fourth hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jingpu Shi
- Department of Anesthesiology, The Fourth hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Rui Xin
- Department of Anesthesiology, The Fourth hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Hui-Qun Jia
- Department of Anesthesiology, The Fourth hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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16
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The association between initial calculated driving pressure at the induction of general anesthesia and composite postoperative oxygen support. BMC Anesthesiol 2022; 22:411. [PMID: 36581842 PMCID: PMC9798593 DOI: 10.1186/s12871-022-01959-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 12/27/2022] [Indexed: 12/30/2022] Open
Abstract
PURPOSE Early discontinuation of postoperative oxygen support (POS) would partially depend on the innate pulmonary physics. We aimed to examine if the initial driving pressure (dP) at the induction of general anesthesia (GA) predicted POS prolongation. METHODS We conducted a single-center retrospective study using the facility's database. Consecutive subjects over 2 years were studied to determine the change in odds ratio (OR) for POS prolongation of different dP classes at GA induction. The dP (cmH2O) was calculated as the ratio of tidal volume (mL) over dynamic Crs (mL/cmH2O) regardless of the respiratory mode. The adjusted OR was calculated using the logistic regression model of multivariate analysis. Moreover, we performed a secondary subgroup analysis of age and the duration of GA. RESULTS We included 5,607 miscellaneous subjects. Old age, high scores of American Society of Anesthesiologist physical status, initial dP, and long GA duration were associated with prolonged POS. The dP at the induction of GA (7.78 [6.48, 9.45] in median [interquartile range]) was categorized into five classes. With the dP group of 6.5-8.3 cmH2O as the reference, high dPs of 10.3-13 cmH2O and ≥ 13 cmH2O were associated with significant prolongation of POS (adjusted OR, 1.62 [1.19, 2.20], p = 0.002 and 1.92 [1.20, 3.05], p = 0.006, respectively). The subgroup analysis revealed that the OR for prolonged POS of high dPs disappeared in the aged and ≥ 6 h anesthesia time subgroup. CONCLUSIONS High initial dPs ≥ 10 cmH2O at GA induction predicted longer POS than those of approximately 7 cmH2O. High initial dPs were, however, a secondary factor for prolongation of postoperative hypoxemia in old age and prolonged surgery.
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Reliability of stroke volume or pulse pressure variation as dynamic predictors of fluid responsiveness in laparoscopic surgery: a systematic review. J Clin Monit Comput 2022; 37:379-387. [PMID: 36399217 DOI: 10.1007/s10877-022-00939-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/25/2022] [Indexed: 11/19/2022]
Abstract
The reliability of stroke volume variation (SVV) and pulse pressure variation (PPV) in predicting fluid responsiveness during laparoscopic surgery remains unclear. We conducted the present systematic review to summarize the current evidence. We reviewed studies that investigated the reliability of SVV and PPV in laparoscopic surgery. Seven studies were included in the final analysis. Two studies demonstrated that the area under the receiver operating characteristic curve (AUROC) for SVV was less than 0.8, and five studies reported that the AUROC was > 0.8. The pooled AUROC for SVV and PPV was more than 0.8 with high heterogeneities between the included studies. Most individual studies have suggested that SVV and PPV are sufficiently reliable for predicting fluid responsiveness during laparoscopic surgery. However, the limited number of patients, varied apparatus used to define fluid responsiveness, diverse definitions of fluid responsiveness, and different fluids used to perform fluid challenges in the included studies render firm conclusions about SVV's and PPV's reliability impossible.
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18
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Cheng M, Ni L, Huang L, Zhou Y, Wang K. Effect of positive end-expiratory pressure on pulmonary compliance and pulmonary complications in patients undergoing robot-assisted laparoscopic radical prostatectomy: a randomized control trial. BMC Anesthesiol 2022; 22:347. [DOI: 10.1186/s12871-022-01869-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 10/18/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
To observe the effects of different positive end-expiratory pressure (PEEP) ventilation strategies on pulmonary compliance and complications in patients undergoing robotic-assisted laparoscopic prostate surgery.
Methods
A total of 120 patients with the American Society of Anesthesiologists Physical Status Class I or II who underwent elective robotic-assisted laparoscopic prostatectomy were enrolled. We randomized the patients divided into divided into three groups of 40 patients each: PEEP0, PEEP5, or PEEP10. Master Anesthetist used volume control ventilation intraoperatively with an intraoperative deep muscle relaxation strategy. Respiratory mechanics indexes were recorded at six time-points: 10 mimuts after anaesthesia induction, immediately after pneumoperitoneum establishment, 30 min, 60 min, 90 min, and at the end of pneumoperitoneum. Arterial blood gas analysis and oxygenation index calculation were performed 10 mimuts after anaesthesia induction, 60 mimuts after pneumoperitoneum, and after tracheal extubation. Postoperative pulmonary complications were also recorded.
Results
After pneumoperitoneum, peak inspiratory pressure (Ppeak), plateau pressure (Pplat), mean pressure (Pmean), driving pressure (ΔP), and airway resistance (Raw) increased significantly, and pulmonary compliance (Crs) decreased, persisting during pneumoperitoneum in all groups. Between immediately after pneumoperitoneum establishment, 30 min, 60 min, and 90 min, pulmonary compliance in the 10cmH2OPEEP group was higher than in the 5cmH2OPEEP (P < 0.05) and 0cmH2OPEEP groups(P < 0.05). The driving pressure (ΔP) immediately after pneumoperitoneum establishment, at 30 min, 60 min, and 90 min in the 10cmH2OPEEP group was lower than in the 5cmH2OPEEP (P < 0.05) and 0cmH2OPEEP groups (P < 0.05). Sixty min after pneumoperitoneum and tracheal extubation, the PaCO2 did not differ significantly among the three groups (P > 0.05). The oxygenation index (PaO2/FiO2) was higher in the PEEP5 group than in the PEEP0 and PEEP10 groups 60 min after pneumoperitoneum and after tracheal extubation, with a statistically significant difference (P < 0.05). In postoperative pulmonary complications, the incidence of atelectasis was higher in the PEEP0 group than in the PEEP5 and PEEP10 groups, with a statistically significant difference (p < 0.05).
Conclusion
The use of PEEP at 5cmH2O during RARP increases lung compliance, improves intraoperative oxygenation index and reduces postoperative atelectasis.
Trial registration
This study was registered in the China Clinical Trials Registry on May 30, 2020 (Registration No. ChiCTR2000033380).
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19
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Bolther M, Henriksen J, Holmberg MJ, Jessen MK, Vallentin MF, Hansen FB, Holst JM, Magnussen A, Hansen NS, Johannsen CM, Enevoldsen J, Jensen TH, Roessler LL, Carøe Lind P, Klitholm MP, Eggertsen MA, Caap P, Boye C, Dabrowski KM, Vormfenne L, Høybye M, Karlsson M, Balleby IR, Rasmussen MS, Pælestik K, Granfeldt A, Andersen LW. Ventilation Strategies During General Anesthesia for Noncardiac Surgery: A Systematic Review and Meta-Analysis. Anesth Analg 2022; 135:971-985. [PMID: 35703253 DOI: 10.1213/ane.0000000000006106] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The optimal ventilation strategy during general anesthesia is unclear. This systematic review investigated the relationship between ventilation targets or strategies (eg, positive end-expiratory pressure [PEEP], tidal volume, and recruitment maneuvers) and postoperative outcomes. METHODS PubMed and Embase were searched on March 8, 2021, for randomized trials investigating the effect of different respiratory targets or strategies on adults undergoing noncardiac surgery. Two investigators reviewed trials for relevance, extracted data, and assessed risk of bias. Meta-analyses were performed for relevant outcomes, and several subgroup analyses were conducted. The certainty of evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS This review included 63 trials with 65 comparisons. Risk of bias was intermediate for all trials. In the meta-analyses, lung-protective ventilation (ie, low tidal volume with PEEP) reduced the risk of combined pulmonary complications (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.28-0.49; 9 trials; 1106 patients), atelectasis (OR, 0.39; 95% CI, 0.25-0.60; 8 trials; 895 patients), and need for postoperative mechanical ventilation (OR, 0.36; 95% CI, 0.13-1.00; 5 trials; 636 patients). Recruitment maneuvers reduced the risk of atelectasis (OR, 0.44; 95% CI, 0.21-0.92; 5 trials; 328 patients). We found no clear effect of tidal volume, higher versus lower PEEP, or recruitment maneuvers on postoperative pulmonary complications when evaluated individually. For all comparisons across targets, no effect was found on mortality or hospital length of stay. No effect measure modifiers were found in subgroup analyses. The certainty of evidence was rated as very low, low, or moderate depending on the intervention and outcome. CONCLUSIONS Although lung-protective ventilation results in a decrease in pulmonary complications, randomized clinical trials provide only limited evidence to guide specific ventilation strategies during general anesthesia for adults undergoing noncardiac surgery.
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Affiliation(s)
- Maria Bolther
- From the Department of Anesthesiology and Intensive Care
| | | | - Mathias J Holmberg
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Cardiology, Viborg Regional Hospital, Viborg, Denmark
| | - Marie K Jessen
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mikael F Vallentin
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
| | | | | | | | | | | | | | - Thomas H Jensen
- Department of Internal Medicine, University Hospital of North Norway, Narvik, Norway
| | - Lara L Roessler
- Department of Emergency Medicine, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | | | - Mark A Eggertsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Philip Caap
- From the Department of Anesthesiology and Intensive Care
| | - Caroline Boye
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Lasse Vormfenne
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Maria Høybye
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Mathias Karlsson
- Anesthesiology and Intensive Care, Aalborg University Hospital, Denmark
| | - Ida R Balleby
- National Hospital of the Faroe Islands, Torshavn, Faroe Islands
| | - Marie S Rasmussen
- Anesthesiology and Intensive Care, Aalborg University Hospital, Denmark
| | - Kim Pælestik
- Department of Anesthesiology and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
| | - Asger Granfeldt
- From the Department of Anesthesiology and Intensive Care.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lars W Andersen
- From the Department of Anesthesiology and Intensive Care.,Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
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20
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Duff AM, Lambe G, Donlon NE, Donohoe CL, Brady AM, Reynolds JV. Interventions targeting postoperative pulmonary complications (PPCs) in patients undergoing esophageal cancer surgery: a systematic review of randomized clinical trials and narrative discussion. Dis Esophagus 2022; 35:6565163. [PMID: 35393612 DOI: 10.1093/dote/doac017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/06/2022] [Indexed: 12/11/2022]
Abstract
Postoperative pulmonary complications (PPCs) represent the most common complications after esophageal cancer surgery. The lack of a uniform reporting nomenclature and a severity classification has hampered consistency of research in this area, including the study of interventions targeting prevention and treatment of PPCs. This systematic review focused on RCTs of clinical interventions used to minimize the impact of PPCs. Searches were conducted up to 08/02/2021 on MEDLINE (OVID), CINAHL, Embase, Web of Science, and the COCHRANE library for RCTs and reported in accordance with PRISMA guidelines. A total of 339 citations, with a pooled dataset of 1,369 patients and 14 RCTs, were included. Heterogeneity of study design and outcomes prevented meta-analysis. PPCs are multi-faceted and not fully understood with respect to etiology. The review highlights the paucity of high-quality evidence for best practice in the management of PPCs. Further research in the area of intraoperative interventions and early postoperative ERAS standards is required. A consistent uniform for definition of pneumonia after esophagectomy and the development of a severity scale appears warranted to inform further RCTs and guidelines.
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Affiliation(s)
- Ann-Marie Duff
- National Esophageal and Gastric Centre, St James's Hospital Dublin 8 and Trinity St. James's Cancer Institute, Dublin, Ireland.,Trinity Centre for Practice & Health Care Innovation, School of Nursing & Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Gerard Lambe
- Department of Radiology, St. James's Hospital, Dublin 8 & University College Dublin, Dublin, Ireland
| | - Noel E Donlon
- National Esophageal and Gastric Centre, St James's Hospital Dublin 8 and Trinity St. James's Cancer Institute, Dublin, Ireland
| | - Claire L Donohoe
- National Esophageal and Gastric Centre, St James's Hospital Dublin 8 and Trinity St. James's Cancer Institute, Dublin, Ireland
| | - Anne-Marie Brady
- Trinity Centre for Practice & Health Care Innovation, School of Nursing & Midwifery, Trinity College Dublin, Dublin, Ireland
| | - John V Reynolds
- National Esophageal and Gastric Centre, St James's Hospital Dublin 8 and Trinity St. James's Cancer Institute, Dublin, Ireland
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21
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Suleiman A, Costa E, Santer P, Tartler TM, Wachtendorf LJ, Teja B, Chen G, Baedorf-Kassis E, Nagrebetsky A, Vidal Melo MF, Eikermann M, Schaefer MS. Association between intraoperative tidal volume and postoperative respiratory complications is dependent on respiratory elastance: a retrospective, multicentre cohort study. Br J Anaesth 2022; 129:263-272. [PMID: 35690489 PMCID: PMC9837741 DOI: 10.1016/j.bja.2022.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 02/18/2022] [Accepted: 05/05/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The impact of high vs low intraoperative tidal volumes on postoperative respiratory complications remains unclear. We hypothesised that the effect of intraoperative tidal volume on postoperative respiratory complications is dependent on respiratory system elastance. METHODS We retrospectively recorded tidal volume (Vt; ml kg-1 ideal body weight [IBW]) in patients undergoing elective, non-cardiothoracic surgery from hospital registry data. The primary outcome was respiratory failure (requiring reintubation within 7 days of surgery, desaturation after extubation, or both). The primary exposure was defined as the interaction between Vt and standardised respiratory system elastance (driving pressure divided by Vt; cm H2O/[ml kg-1]). Multivariable logistic regression models, with and without interaction terms (which categorised Vt as low [Vt ≤8 ml kg-1] or high [Vt >8 ml kg-1]), were adjusted for potential confounders. Additional analyses included path mediation analysis and fractional polynomial modelling. RESULTS Overall, 10 821/197 474 (5.5%) patients sustained postoperative respiratory complications. Higher Vt was associated with greater risk of postoperative respiratory complications (adjusted odds ratio=1.42 per ml kg-1; 95% confidence interval [CI], 1.35-1.50]; P<0.001). This association was modified by respiratory system elastance (P<0.001); in patients with low compliance (<42.4 ml cm H2O-1), higher Vt was associated with greater risk of postoperative respiratory complications (adjusted risk difference=0.3% [95% CI, 0.0-0.5] at 41.2 ml cm H2O-1 compliance, compared with 5.8% [95% CI, 3.8-7.8] at 14 ml cm H2O-1 compliance). This association was absent when compliance exceeded 41.2 ml cm H2O-1. Adverse effects associated with high Vt were entirely mediated by driving pressures (P<0.001). CONCLUSIONS The association of harm with higher tidal volumes during intraoperative mechanical ventilation is modified by respiratory system elastance. These data suggest that respiratory elastance should inform the design of perioperative trials testing intraoperative ventilatory strategies.
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Affiliation(s)
- Aiman Suleiman
- Department of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Boston, MA, USA,Center for Anaesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Centre, Boston, MA, USA,Department of Anaesthesia and Intensive Care, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Eduardo Costa
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil,Research and Education Institute, Hospital Sírio-Libanes, Sao Paulo, Brazil
| | - Peter Santer
- Department of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Tim M. Tartler
- Department of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Boston, MA, USA,Center for Anaesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Luca J. Wachtendorf
- Department of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Boston, MA, USA,Center for Anaesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Centre, Boston, MA, USA,Department of Anaesthesiology, Montefiore Medical Centre and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Bijan Teja
- Department of Anaesthesiology and Pain Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Guanqing Chen
- Center for Anaesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Elias Baedorf-Kassis
- Department of Pulmonary, Critical Care & Sleep Medicine, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Alexander Nagrebetsky
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Marcos F. Vidal Melo
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, USA,Corresponding authors.
| | - Matthias Eikermann
- Department of Anaesthesiology, Montefiore Medical Centre and Albert Einstein College of Medicine, Bronx, NY, USA,Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany
| | - Maximilian S. Schaefer
- Department of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Boston, MA, USA,Center for Anaesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Centre, Boston, MA, USA,Department of Anaesthesiology, Düsseldorf University Hospital, Dusseldorf, Germany,Corresponding authors.
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22
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Wang ZY, Ye SS, Fan Y, Shi CY, Wu HF, Miao CH, Zhou D. Individualized positive end-expiratory pressure with and without recruitment maneuvers in obese patients during bariatric surgery. Kaohsiung J Med Sci 2022; 38:858-868. [PMID: 35866347 DOI: 10.1002/kjm2.12576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 05/26/2022] [Accepted: 06/22/2022] [Indexed: 11/10/2022] Open
Abstract
This study aimed to determine whether regular recruitment maneuvers (RMs) are essential for obese patients (OPs) undergoing elective laparoscopic bariatric surgery (LBS) during intraoperative ventilation with individualized positive end-expiratory pressure (PEEP). Patients were randomly assigned to two arms: the RM + PEEP-EIT arm consisted of individualized PEEP titrated by electrical impedance tomography (EIT) with two regular RMs and the PEEP-EIT arm consisted of individualized PEEP titrated by EIT without additional RMs. For these two arms together, EIT-guided PEEP varied among individuals. The partial pressure of oxygen in arterial blood to fractional inspired oxygen (PaO2 /FiO2 ) ratio in the RM + PEEP-EIT arm was higher than that in the PEEP-EIT arm at 1 h after pneumoperitoneum (p = 0.024) and at the end of surgery (p = 0.035). There was no great difference in the PaO2 /FiO2 ratio between these two arms when measured 5 min prior to postanesthesia care unit (PACU) departure and on postoperative day 1. Compared with the PEEP-EIT arm, patients in the RM + PEEP-EIT arm had significantly higher intraoperative dynamic respiratory system compliance (p < 0.001) but consumed more vasopressors (p = 0.036). Postoperative pulmonary complications occurred in 1 of 29 patients in the RM + PEEP-EIT arm compared with 2 of 31 patients in the PEEP-EIT arm. Regular lung RMs can improve intraoperative oxygenation and respiratory system compliance among OPs undergoing LBS with EIT-guided individual PEEP. However, the improvement might disappear before leaving the PACU, and regular RMs resulted in more vasopressor consumption.
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Affiliation(s)
- Zhi-Yao Wang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shan-Shan Ye
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yu Fan
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Cheng-Ye Shi
- Department of Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hai-Fu Wu
- Department of Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chang-Hong Miao
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Di Zhou
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
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23
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Shang K, Xia Z, Ye X, Li Z, Gong C. Positive end-expiratory pressure and risk of postoperative pulmonary complications in patients living at high altitudes and undergoing surgery at low altitudes: a single-centre, retrospective observational study in China. BMJ Open 2022; 12:e057698. [PMID: 35701068 PMCID: PMC9198711 DOI: 10.1136/bmjopen-2021-057698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES To examine whether a high positive end-expiratory pressure (PEEP ≥5 cmH2O) has a protective effect on the risk of postoperative pulmonary complications (PPCs) in a cohort of patients living at high altitudes and undergoing general anaesthesia. DESIGN Retrospective, observational study. SETTING A tertiary hospital in China. PARTICIPANTS Adult Tibetan patients living at high altitudes (≥3000 m) and who went to the low-altitude plain to undergo non-cardiothoracic surgery under general anaesthesia, from January 2018 to April 2020. MEASUREMENTS This study included 1905 patients who were divided according to the application of an intraoperative PEEP: low PEEP (<5 cmH2O, including 0 cmH2O) or high PEEP (≥5 cmH2O). The primary outcome was a composite of PPCs within the first 7 postoperative days. The secondary outcomes included reintubation and unplanned intensive care unit (ICU) admission within the first 7 postoperative days and total hospital stays (day). RESULTS The study included 1032 patients in the low PEEP group and 873 in the high PEEP group. There were no differences in the incidence of PPCs between the high and low PEEP groups (relative risk (RR) 0.913; 95% CI 0.716 to 1.165; p=0.465). After propensity score matching, 643 patients remained in each group, and the incidence of PPCs in the low PEEP group (18.0%) was higher than in the high PEEP group (13.7%; RR 0.720; 95% CI 0.533 to 0.974; p=0.033). There were no differences in the incidence of reintubation, unplanned ICU admission or hospital stays. The risk factors of PPCs derived from multiple regression showed that the application of >5 cmH2O PEEP during intraoperative mechanical ventilation was associated with a significantly lower risk of PPCs in patients from a high altitude (OR=0.725, 95% CI 0.530 to 0.992; p=0.044). CONCLUSIONS The application of PEEP ≥5 cmH2O during intraoperative mechanical ventilation in patients living at high altitudes and undergoing surgery at low altitudes may be associated with a lower risk of PPCs. Prospective longitudinal studies are needed to further investigate perioperative lung protection ventilation strategies for patients from high altitudes. TRIAL REGISTRATION NUMBER Chinese Clinical Trial Registry (ChiCTR2100044260).
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Affiliation(s)
- Kaixi Shang
- Department of Anesthesiology, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (West China Hospital Sichuan University Tibet Chengdu Branch Hospital), Chengdu, China
| | - Zongjing Xia
- Department of Anesthesiology, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (West China Hospital Sichuan University Tibet Chengdu Branch Hospital), Chengdu, China
| | - Xiaoli Ye
- Department of Anesthesiology, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (West China Hospital Sichuan University Tibet Chengdu Branch Hospital), Chengdu, China
| | - Zhuoning Li
- Department of Anesthesiology, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (West China Hospital Sichuan University Tibet Chengdu Branch Hospital), Chengdu, China
| | - Chongcong Gong
- Department of Anesthesiology, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (West China Hospital Sichuan University Tibet Chengdu Branch Hospital), Chengdu, China
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24
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Cylwik J, Buda N. The impact of ultrasound-guided recruitment maneuvers on the risk of postoperative pulmonary complications in patients undergoing general anesthesia. J Ultrason 2022; 22:e6-e11. [PMID: 35449694 PMCID: PMC9009342 DOI: 10.15557/jou.2022.0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 11/17/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction Postoperative pulmonary complications are among the most frequent problems in perioperative care. The risk of their development depends not only on the parameters associated with the patient’s initial clinical condition, but also on the employed anesthesia technique, the method of mechanical ventilation, and the type and technique of the surgical procedure. Atelectasis is the most common complication, affecting nearly 90% of the patients undergoing general anesthesia. Aim The aim of this study was to determine whether it was possible to positively impact the postoperative period and reduce the frequency of postoperative pulmonary complications via patient-based intraoperative ultrasound-guided recruitment maneuvers. Methodology The course of the postoperative period was analyzed in two groups of patients. One of them comprised 100 patients in whom no recruitment maneuvers were performed during general anesthesia. The other group (100 patients) consisted of patients in whom patient-based ultrasound-guided pulmonary recruitment maneuvers were performed. Results In the recruitment group, the postoperative hospitalization was statistically significantly shorter (p = 0.003) and the risk of intensive care treatment significantly lower. Additionally, the need for prolonged postoperative mechanical ventilation was reduced, as was the risk of respiratory tract infections. Conclusions Intraoperative ultrasound-guided recruitment maneuvers reduce the frequency of postoperative pulmonary complications.
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Affiliation(s)
- Jolanta Cylwik
- Anesthesiology and Intensive Care Unit, Mazovia Regional Hospital in Siedlce, Poland
| | - Natalia Buda
- Department of Internal Medicine, Connective Tissue Diseases and Geriatrics, Medical University of Gdansk, Poland
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25
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Prophylactic Penehyclidine Inhalation for Prevention of Postoperative Pulmonary Complications in High-risk Patients: A Double-blind Randomized Trial. Anesthesiology 2022; 136:551-566. [PMID: 35226725 DOI: 10.1097/aln.0000000000004159] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Postoperative pulmonary complications are common. Aging and respiratory disease provoke airway hyperresponsiveness, high-risk surgery induces diaphragmatic dysfunction, and general anesthesia contributes to atelectasis and peripheral airway injury. This study therefore tested the hypothesis that inhalation of penehyclidine, a long-acting muscarinic antagonist, reduces the incidence of pulmonary complications in high-risk patients over the initial 30 postoperative days. METHODS This single-center double-blind trial enrolled 864 patients age over 50 yr who were scheduled for major upper-abdominal or noncardiac thoracic surgery lasting 2 h or more and who had an Assess Respiratory Risk in Surgical Patients in Catalonia score of 45 or higher. The patients were randomly assigned to placebo or prophylactic penehyclidine inhalation from the night before surgery through postoperative day 2 at 12-h intervals. The primary outcome was the incidence of a composite of pulmonary complications within 30 postoperative days, including respiratory infection, respiratory failure, pleural effusion, atelectasis, pneumothorax, bronchospasm, and aspiration pneumonitis. RESULTS A total of 826 patients (mean age, 64 yr; 63% male) were included in the intention-to-treat analysis. A composite of pulmonary complications was less common in patients assigned to penehyclidine (18.9% [79 of 417]) than those receiving the placebo (26.4% [108 of 409]; relative risk, 0.72; 95% CI, 0.56 to 0.93; P = 0.010; number needed to treat, 13). Bronchospasm was less common in penehyclidine than placebo patients: 1.4% (6 of 417) versus 4.4% (18 of 409; relative risk, 0.327; 95% CI, 0.131 to 0.82; P = 0.011). None of the other individual pulmonary complications differed significantly. Peak airway pressures greater than 40 cm H2O were also less common in patients given penehyclidine: 1.9% (8 of 432) versus 4.9% (21 of 432; relative risk, 0.381; 95% CI, 0.171 to 0.85; P = 0.014). The incidence of other adverse events, including dry mouth and delirium, that were potentially related to penehyclidine inhalation did not differ between the groups. CONCLUSIONS In high-risk patients having major upper-abdominal or noncardiac thoracic surgery, prophylactic penehyclidine inhalation reduced the incidence of pulmonary complications without provoking complications. EDITOR’S PERSPECTIVE
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26
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Yang J, Cheng D, Hofer I, Nguyen-Buckley C, Disque A, Wray C, Xia VW. Intraoperative High Tidal Volume Ventilation and Postoperative Acute Respiratory Distress Syndrome in Liver Transplant. Transplant Proc 2022; 54:719-725. [PMID: 35219521 PMCID: PMC9699994 DOI: 10.1016/j.transproceed.2021.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/04/2021] [Accepted: 10/08/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Mechanical ventilation plays an important role in perioperative management and patient outcomes. Although mechanical ventilation with high tidal volume (HTV) is injurious in patients in the intensive care unit, the effects of HTV ventilation in patients undergoing liver transplant (LT) has not been reported. The aim of this study was to determine if intraoperative HTV ventilation was associated with the development of acute respiratory distress syndrome (ARDS). METHODS Patients undergoing LT between 2013 and 2018 at a tertiary medical center were reviewed. The tidal volume was recorded at 3 time points: after anesthesia induction, before liver reperfusion, and at the end of surgery. Patients were divided into 2 groups: HTV (>10 mL/kg predicted body weight [pBW]) and non-HTV (≤10 mL/kg pBW). The 2 groups were compared. Independent risk factors were identified by multivariable logistic models. RESULTS Of 780 LT patients, 85 (10.9%) received HTV ventilation. Female sex and greater difference between actual body weight and pBW were independent risk factors for HTV ventilation. Patients who received HTV ventilation had a significantly higher incidence of ARDS (10.3% vs 3.9%; P = .01) than those who received non-HTV ventilation. CONCLUSIONS In this retrospective study, we showed that HTV ventilation during LT was common and was associated with a higher incidence of ARDS. Therefore, tidal volume should be carefully selected during LT surgery. More studies using a prospective randomized controlled design are needed.
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Affiliation(s)
- Jun Yang
- Department of Critical Care Medicine, Yantaishan Hospital, Yantai, Shandong, P. R. China; Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Drew Cheng
- Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Ira Hofer
- Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Christine Nguyen-Buckley
- Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Andrew Disque
- Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Christopher Wray
- Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Victor W Xia
- Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
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Nakazawa K, Kodaira A, Matsumoto R, Matsushita T, Yoshikawa R, Ishida Y, Uchino H. Positive end-expiratory pressure setting based on transpulmonary pressure during robot-assisted laparoscopic prostatectomy: an observational intervention study. JA Clin Rep 2022; 8:10. [PMID: 35150377 PMCID: PMC8840948 DOI: 10.1186/s40981-022-00501-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/22/2022] [Accepted: 02/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background In robot-assisted laparoscopic prostatectomy (RALP), concerns include the formation of atelectasis and reduced functional residual capacity. The present study aimed to examine the feasibility of positive end-expiratory pressure (PEEP) setting based on transpulmonary pressure (Ptp) as well as the effects of incremental PEEP on respiratory mechanics, blood gases, cerebral oxygenation (rSO2), and hemodynamics. Methods Fourteen male patients who were scheduled to receive RALP were recruited. Patients received mechanical ventilation (tidal volume of 6 mL kg−1) and were placed in Trendelenburg position with positive-pressure capnoperitoneum. PEEP levels were increased from 0 to 15 cmH2O (5 cmH2O per increase) every 30 min. PEEP levels were assessed where end-expiratory Ptp levels of ≥0 cmH2O were achieved (PtpEEP0). Airway pressure, esophageal pressure, cardiac index, and blood gas and rSO2 values were measured after 30 min at each PEEP step and respiratory mechanics were calculated. Results With increasing PEEP levels from 0 to 15 cmH2O or PtpEEP0, the values of PaO2 and respiratory system compliance increased, and the values of driving pressure decreased. The median PEEP level associated with PtpEEP0 was 15 cmH2O. Respiratory system compliance values were higher at PtpEEP0 than those at PEEP5 (P = 0.02). Driving pressure was significantly lower at PtpEEP0 than at PEEP5 (P = 0.0036). The cardiac index remained unchanged, and the values of rSO2 were higher at PtpEEP0 than at PEEP0 (right; P = 0.0019, left; P = 0.036). Conclusions PEEP setting determined by transpulmonary pressure can help achieve higher respiratory system compliance values and lower driving pressure without disturbing hemodynamic parameters.
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Affiliation(s)
- Koichi Nakazawa
- Department of Anesthesia, Tokyo Medical University Hospital, 6-7-1 Nishishinjyuku, Shinjyuku-ku, Tokyo, 1600023, Japan.
| | - Ami Kodaira
- Department of Anesthesia, Mitsui Memorial Hospital, Kanda-Izumi-cho 1, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Rika Matsumoto
- Department of Anesthesia, Tokyo Medical University Hospital, 6-7-1 Nishishinjyuku, Shinjyuku-ku, Tokyo, 1600023, Japan
| | - Tomoko Matsushita
- Department of Anesthesia, Tokyo Medical University Hospital, 6-7-1 Nishishinjyuku, Shinjyuku-ku, Tokyo, 1600023, Japan
| | - Ryotaro Yoshikawa
- Department of Anesthesia, Tokyo Medical University Hospital, 6-7-1 Nishishinjyuku, Shinjyuku-ku, Tokyo, 1600023, Japan
| | - Yusuke Ishida
- Department of Anesthesia, Tokyo Medical University Hospital, 6-7-1 Nishishinjyuku, Shinjyuku-ku, Tokyo, 1600023, Japan
| | - Hiroyuki Uchino
- Department of Anesthesia, Tokyo Medical University Hospital, 6-7-1 Nishishinjyuku, Shinjyuku-ku, Tokyo, 1600023, Japan
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Joshi M, Dhakane P, Bhosale SJ, Phulambrikar R, Kulkarni AP. Correlation between Carotid and Brachial Artery Velocity Time Integral and Their Comparison to Pulse Pressure Variation and Stroke Volume Variation for Assessing Fluid Responsiveness. Indian J Crit Care Med 2022; 26:179-184. [PMID: 35712738 PMCID: PMC8857717 DOI: 10.5005/jp-journals-10071-24115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Fluid boluses are used in hemodynamically unstable patients with presumed hypovolemia, to improve tissue perfusion, in the perioperative period. Now less invasive methods, such as pulse pressure variation (PPV) and stroke volume variation (SVV) are increasingly being used. We investigated correlation between carotid and brachial artery velocity time integral (VTI) and compared both with PPV and SVV. Methods We recruited 27 patients undergoing supra-major abdominal surgeries. When indicated (hypotension or increased lactate), a fluid bolus was given after measuring carotid and brachial artery VTI, PPV, and SVV. The change in SV was noted and patients were categorized as responders if the SV increased by >15%. We performed Bland Altman Agreement and calculated best sensitivity and specificity for the parameters. Results Patients were found to be fluid responders on 29 instances. The correlation between PPV, SVV, carotid and brachial artery VTI was poor and the limits of agreement between them were wide. The Area under Curve (AUC) for PPV was 0.69, for SVV was 0.63, while those of Carotid and Brachial artery VTI (TAP and flow) were (0.53 and 0.54 for carotid) and (0.51 and 0.56 for brachial) respectively. Conclusion We found poor agreement and weak correlation between both VTi (TAP and flow) measured at carotid and brachial arteries, suggesting that the readings at brachial vessel cannot be used interchangeably with those at carotid artery. The PPV and SVV were better than these parameters for predicting fluid responsiveness; however, their predictive ability (AUROC), sensitivity and specificity were much lower than previously reported. Further studies in this area are therefore required (CTRI Reg No: CTRI/2017/08/009243). How to cite this article Joshi M, Dhakane P, Bhosale SJ, Phulambrikar R, Kulkarni AP. Correlation between Carotid and Brachial Artery Velocity Time Integral and Their Comparison to Pulse Pressure Variation and Stroke Volume Variation for Assessing Fluid Responsiveness. Indian J Crit Care Med 2022;26(2):179–184.
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Affiliation(s)
- Malini Joshi
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Praveen Dhakane
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Shilpushp J Bhosale
- Department of Critical Care Medicine, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Rutuja Phulambrikar
- Department of Community Medicine, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Atul P Kulkarni
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
- Atul P Kulkarni, Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India, Phone: +91 9869077526, e-mail:
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Blaine KP. Recommendations for Mechanical Ventilation During General Anesthesia for Trauma Surgery. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00512-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Deana C, Vetrugno L, Bignami E, Bassi F. Peri-operative approach to esophagectomy: a narrative review from the anesthesiological standpoint. J Thorac Dis 2021; 13:6037-6051. [PMID: 34795950 PMCID: PMC8575828 DOI: 10.21037/jtd-21-940] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/19/2021] [Indexed: 12/16/2022]
Abstract
Objective This review summarizes the peri-operative anesthesiological approaches to esophagectomy considering the best up-to-date, evidence-based medicine, discussed from the anesthesiologist’s standpoint. Background Esophagectomy is the only curative therapy for esophageal cancer. Despite the many advancements made in the surgical treatment of this tumour, esophagectomy still carries a morbidity rate reaching 60%. Patients undergoing esophagectomy should be referred to high volume centres where they can receive a multidisciplinary approach to treatment, associated with better outcomes. The anesthesiologist is the key figure who should guide the peri-operative phase, from diagnosis through to post-surgery rehabilitation. We performed an updated narrative review devoted to the study of anesthesia management for esophagectomy in cancer patients. Methods We searched MEDLINE, Scopus and Google Scholar databases from inception to May 2021. We used the following terms: “esophagectomy”, “esophagectomy AND pre-operative evaluation”, “esophagectomy AND protective lung ventilation”, “esophagectomy AND hemodynamic monitoring” and “esophagectomy AND analgesia”. We considered only articles with abstract written in English and available to the reader. We excluded single case-reports. Conclusions Pre-operative anesthesiological evaluation is mandatory in order to stratify and optimize any medical condition. During surgery, protective ventilation and judicious fluid management are the cornerstones of intraoperative “protective anesthesia”. Post-operative care should be provided by an intensive care unit or high-dependency unit depending on the patient’s condition, the type of surgery endured and the availability of local resources. The provision of adequate post-operative analgesia favours early mobilization and rapid recovery. Anesthesiologist has an important role during the peri-operative care for esophagectomy. However, there are still some topics that need to be further studied to improve the outcome of these patients.
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Affiliation(s)
- Cristian Deana
- Department of Anesthesia and Intensive Care, ASUFC-Academic Hospital of Udine, Udine, Italy
| | - Luigi Vetrugno
- Department of Anesthesia and Intensive Care, ASUFC-Academic Hospital of Udine, Udine, Italy.,Department of Medical Area, University of Udine, Udine, Italy
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Flavio Bassi
- Department of Anesthesia and Intensive Care, ASUFC-Academic Hospital of Udine, Udine, Italy
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Lei M, Bao Q, Luo H, Huang P, Xie J. Effect of Intraoperative Ventilation Strategies on Postoperative Pulmonary Complications: A Meta-Analysis. Front Surg 2021; 8:728056. [PMID: 34671638 PMCID: PMC8521033 DOI: 10.3389/fsurg.2021.728056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 08/30/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: The role of intraoperative ventilation strategies in subjects undergoing surgery is still contested. This meta-analysis study was performed to assess the relationship between the low tidal volumes strategy and conventional mechanical ventilation in subjects undergoing surgery. Methods: A systematic literature search up to December 2020 was performed in OVID, Embase, Cochrane Library, PubMed, and Google scholar, and 28 studies including 11,846 subjects undergoing surgery at baseline and reporting a total of 2,638 receiving the low tidal volumes strategy and 3,632 receiving conventional mechanical ventilation, were found recording relationships between low tidal volumes strategy and conventional mechanical ventilation in subjects undergoing surgery. Odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CIs) were calculated between the low tidal volumes strategy vs. conventional mechanical ventilation using dichotomous and continuous methods with a random or fixed-effect model. Results: The low tidal volumes strategy during surgery was significantly related to a lower rate of postoperative pulmonary complications (OR, 0.60; 95% CI, 0.44-0.83, p < 0.001), aspiration pneumonitis (OR, 0.63; 95% CI, 0.46-0.86, p < 0.001), and pleural effusion (OR, 0.72; 95% CI, 0.56-0.92, p < 0.001) compared to conventional mechanical ventilation. However, the low tidal volumes strategy during surgery was not significantly correlated with length of hospital stay (MD, -0.48; 95% CI, -0.99-0.02, p = 0.06), short-term mortality (OR, 0.88; 95% CI, 0.70-1.10, p = 0.25), atelectasis (OR, 0.76; 95% CI, 0.57-1.01, p = 0.06), acute respiratory distress (OR, 1.06; 95% CI, 0.67-1.66, p = 0.81), pneumothorax (OR, 1.37; 95% CI, 0.88-2.15, p = 0.17), pulmonary edema (OR, 0.70; 95% CI, 0.38-1.26, p = 0.23), and pulmonary embolism (OR, 0.65; 95% CI, 0.26-1.60, p = 0.35) compared to conventional mechanical ventilation. Conclusions: The low tidal volumes strategy during surgery may have an independent relationship with lower postoperative pulmonary complications, aspiration pneumonitis, and pleural effusion compared to conventional mechanical ventilation. This relationship encouraged us to recommend the low tidal volumes strategy during surgery to avoid any possible complications.
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Affiliation(s)
- Min Lei
- Department of Anesthesiology, Sir Run Run Shaw Hospital of School of Medicine, Zhejiang University, Zhejiang, China
| | - Qi Bao
- Department of Anesthesiology, Sir Run Run Shaw Hospital of School of Medicine, Zhejiang University, Zhejiang, China
| | - Huanyu Luo
- Department of Anesthesiology, Sir Run Run Shaw Hospital of School of Medicine, Zhejiang University, Zhejiang, China
| | - Pengfei Huang
- Department of Anesthesiology, Sir Run Run Shaw Hospital of School of Medicine, Zhejiang University, Zhejiang, China
| | - Junran Xie
- Department of Anesthesiology, Sir Run Run Shaw Hospital of School of Medicine, Zhejiang University, Zhejiang, China
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Individualized versus Fixed Positive End-expiratory Pressure for Intraoperative Mechanical Ventilation in Obese Patients: A Secondary Analysis. Anesthesiology 2021; 134:887-900. [PMID: 33843980 DOI: 10.1097/aln.0000000000003762] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND General anesthesia may cause atelectasis and deterioration in oxygenation in obese patients. The authors hypothesized that individualized positive end-expiratory pressure (PEEP) improves intraoperative oxygenation and ventilation distribution compared to fixed PEEP. METHODS This secondary analysis included all obese patients recruited at University Hospital of Leipzig from the multicenter Protective Intraoperative Ventilation with Higher versus Lower Levels of Positive End-Expiratory Pressure in Obese Patients (PROBESE) trial (n = 42) and likewise all obese patients from a local single-center trial (n = 54). Inclusion criteria for both trials were elective laparoscopic abdominal surgery, body mass index greater than or equal to 35 kg/m2, and Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score greater than or equal to 26. Patients were randomized to PEEP of 4 cm H2O (n = 19) or a recruitment maneuver followed by PEEP of 12 cm H2O (n = 21) in the PROBESE study. In the single-center study, they were randomized to PEEP of 5 cm H2O (n = 25) or a recruitment maneuver followed by individualized PEEP (n = 25) determined by electrical impedance tomography. Primary endpoint was Pao2/inspiratory oxygen fraction before extubation and secondary endpoints included intraoperative tidal volume distribution to dependent lung and driving pressure. RESULTS Ninety patients were evaluated in three groups after combining the two lower PEEP groups. Median individualized PEEP was 18 (interquartile range, 16 to 22; range, 10 to 26) cm H2O. Pao2/inspiratory oxygen fraction before extubation was 515 (individual PEEP), 370 (fixed PEEP of 12 cm H2O), and 305 (fixed PEEP of 4 to 5 cm H2O) mmHg (difference to individualized PEEP, 145; 95% CI, 91 to 200; P < 0.001 for fixed PEEP of 12 cm H2O and 210; 95% CI, 164 to 257; P < 0.001 for fixed PEEP of 4 to 5 cm H2O). Intraoperative tidal volume in the dependent lung areas was 43.9% (individualized PEEP), 25.9% (fixed PEEP of 12 cm H2O) and 26.8% (fixed PEEP of 4 to 5 cm H2O) (difference to individualized PEEP: 18.0%; 95% CI, 8.0 to 20.7; P < 0.001 for fixed PEEP of 12 cm H2O and 17.1%; 95% CI, 10.0 to 20.6; P < 0.001 for fixed PEEP of 4 to 5 cm H2O). Mean intraoperative driving pressure was 9.8 cm H2O (individualized PEEP), 14.4 cm H2O (fixed PEEP of 12 cm H2O), and 18.8 cm H2O (fixed PEEP of 4 to 5 cm H2O), P < 0.001. CONCLUSIONS This secondary analysis of obese patients undergoing laparoscopic surgery found better oxygenation, lower driving pressures, and redistribution of ventilation toward dependent lung areas measured by electrical impedance tomography using individualized PEEP. The impact on patient outcome remains unclear. EDITOR’S PERSPECTIVE
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Ledowski T, Szabó-Maák Z, Loh PS, Turlach BA, Yang HS, de Boer HD, Asztalos L, Shariffuddin II, Chan L, Fülesdi B. Reversal of residual neuromuscular block with neostigmine or sugammadex and postoperative pulmonary complications: a prospective, randomised, double-blind trial in high-risk older patients. Br J Anaesth 2021; 127:316-323. [PMID: 34127252 DOI: 10.1016/j.bja.2021.04.026] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 03/29/2021] [Accepted: 04/14/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Residual neuromuscular block is associated with an increased risk of postoperative pulmonary complications in retrospective studies. The aim of our study was to investigate prospectively the incidence of postoperative pulmonary complications after reversal with either sugammadex (SUG) or neostigmine (NEO) in high-risk older patients. METHODS We randomly allocated 180 older patients with significant morbidity (ASA physical status 3) ≥75 yr old to reversal of rocuronium with either SUG or NEO. Adverse events in the recovery room and pulmonary complications (defined by a 5-point [0-4; 0=best to 4=worst] outcome score) on postoperative Days 1, 3, and 7 were compared between groups. RESULTS Data from 168 patients aged 80 (4) yr were analysed; SUG vs NEO resulted in a reduced probability (0.052 vs 0.122) of increased pulmonary outcome score (impaired outcome) on postoperative Day 7, but not on Days 1 and 3. More patients in the NEO group were diagnosed with radiographically confirmed pneumonia (9.6% vs 2.4%; P=0.046). The NEO group showed a non-significant trend towards longer hospital length of stay across all individual centres (combined 9 vs 7.5 days), with a significant difference in Malaysia (6 vs 4 days; P=0.011). CONCLUSIONS Reversal of rocuronium neuromuscular block with SUG resulted in a small, but possibly clinically relevant improvement in pulmonary outcome in a select cohort of high-risk older patients. CLINICAL TRIAL REGISTRATION ACTRN12614000108617.
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Affiliation(s)
- Thomas Ledowski
- Medical School, University of Western Australia, Perth, Australia; Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia.
| | - Zoltan Szabó-Maák
- Department of Anaesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
| | - Pui San Loh
- Department of Anaesthesiology, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Berwin A Turlach
- Centre of Applied Statistics, University of Western Australia, Perth, Australia
| | - Hong Seuk Yang
- Department of Anesthesiology and Pain Medicine, Eulji University, School of Medicine, DaejeonEulji University Hospital, Daejeon, Republic of Korea; College of Medicine, University of Ulsan, Seoul, Republic of Korea
| | - Hans D de Boer
- Department of Anaesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital, Groningen, the Netherlands
| | - László Asztalos
- Department of Anaesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
| | | | - Lucy Chan
- Department of Anaesthesiology, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Béla Fülesdi
- Department of Anaesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
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Ultrasound-guided versus conventional lung recruitment manoeuvres in laparoscopic gynaecological surgery: A randomised controlled trial. Eur J Anaesthesiol 2021; 38:275-284. [PMID: 33399385 DOI: 10.1097/eja.0000000000001435] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Pneumoperitoneum and steep Trendelenburg position promote the formation of pulmonary atelectasis during laparoscopic gynaecological surgery. OBJECTIVE To determine whether lung ultrasound-guided alveolar recruitment manoeuvres could reduce peri-operative atelectasis compared with conventional recruitment manoeuvres during laparoscopic gynaecological surgery. DESIGN Randomised controlled trial. SETTING Tertiary hospital, Republic of Korea, from August 2018 to January 2019. PATIENTS Adult patients scheduled for laparoscopic gynaecological surgery under general anaesthesia. INTERVENTION Forty patients were randomised to receive either ultrasound-guided recruitment manoeuvres (manual inflation until no visibly collapsed area was seen with lung ultrasonography; intervention group) or conventional recruitment manoeuvres (single manual inflation with 30 cmH2O pressure; control group). Recruitment manoeuvres were performed 5 min after induction and at the end of surgery in both groups. All patients received volume-controlled ventilation with a tidal volume of 8 ml kg-1 and a positive end-expiratory pressure of 5 cmH2O. MAIN OUTCOME MEASURES The primary outcome was the lung ultrasound score at the end of surgery; a higher score indicates worse lung aeration. RESULTS Lung ultrasound scores at the end of surgery were significantly lower in the intervention group compared with control group (median [IQR], 7.5 [6.5 to 8.5] versus 9.5 [8.5 to 13.5]; difference, -2 [95% CI, -4.5 to -1]; P = 0.008). The intergroup difference persisted in the postanaesthesia care unit (7 [5 to 8.8] versus 10 [7.3 to 12.8]; difference, -3 [95% CI, -5.5 to -1.5]; P = 0.005). The incidence of atelectasis was lower in the intervention group compared with control group at the end of surgery (35 versus 80%; P = 0.010) but was comparable in the postanaesthesia care unit (40 versus 55%; P = 0.527). CONCLUSIONS The use of ultrasound-guided recruitment manoeuvres improves peri-operative lung aeration; these effects may persist in the postanaesthesia care unit. However, the long-term effects of ultrasound-guided recruitment manoeuvres on clinical outcomes should be the subject of future trials. TRIAL REGISTRATION ClinicalTrials.gov (NCT03607240).
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Briggs C, Melia D. Lung-protective ventilation vs conventional ventilation in emergency surgery. Br J Hosp Med (Lond) 2021; 82:1-2. [PMID: 33792395 DOI: 10.12968/hmed.2020.0620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Lung-protective ventilation significantly reduces mortality in patients with acute respiratory distress syndrome, but do the advantages of this approach transfer from the intensive care unit to the operating room?
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Huang D, Zhou S, Yu Z, Chen J, Xie H. Lung protective ventilation strategy to reduce postoperative pulmonary complications (PPCs) in patients undergoing robot-assisted laparoscopic radical cystectomy for bladder cancer: A randomized double blinded clinical trial. J Clin Anesth 2021; 71:110156. [PMID: 33662902 DOI: 10.1016/j.jclinane.2020.110156] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 11/06/2020] [Accepted: 11/21/2020] [Indexed: 01/31/2023]
Abstract
STUDY OBJECTIVE To evaluate the effects of ventilation with low tidal volume and positive end-expiratory pressure (PEEP) on postoperative pulmonary complications in patients undergoing robot-assisted laparoscopic radical cystectomy (RARC) for bladder cancer. DESIGN A prospective randomized double-blinded study. SETTING A single center trial in a comprehensive tertiary hospital from January 2017 to January 2019. PATIENTS A total of 258 patients undergoing RARC for bladder cancer. INTERVENTIONS Patients were randomly assigned to receive either lung-protective ventilation (LPV group) [tidal volume 6 ml/ kg predicated body weight (PBW) + PEEP 7 cmH2O] or nonprotective ventilation (control group) (tidal volume 9 ml/ kg PBW without PEEP) during anesthesia. MEASUREMENTS The primary outcome was the occurrence of postoperative pulmonary complications (PPCs) during the first 90 days after surgery. The secondary outcomes were extubation time, oxygenation index (OI) after extubation and at postoperative day 1 in blood gas. MAIN RESULTS The incidence of PPCs at postoperative day1, 2 and 3 were lower in LPV group [26.8% vs. 47.2%, odds ratio (OR) 0.41, 95% confidence interval (CI), 0.24-0.69, P = 0.0007, 21.3% vs. 43.3%, OR 0.36, 95% CI, 0.20-0.61, P = 0.0002, 14.2% vs. 27.5%, OR0.43, 95%CI, 0.23-0.82, P = 0.0087, respectively], while no differences were observed at day 7 and 28 (3.9% vs. 9.4%, P = 0.0788, 0% vs. 1.6%, P = 0.4980, respectively). No PPCs were observed at postoperative day 90 in both groups. Furthermore, immediately after extubating and at postoperative day 1, OI was significantly higher in LPV group compared with control group [390(337-467) vs. 343(303-420), P = 0.0005, 406.7(73.0) vs. 425.5(74.7), P = 0.0440, respectively]. Patients in LPV group had a significant shorter extubation time after operation compared with control group [38(33-54) vs. 35(25-46), P = 0.0012]. CONCLUSION LPV combining low tidal volume and PEEP during anesthesia for RARC may decrease the incidence of postoperative pulmonary complications.
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Affiliation(s)
- Dan Huang
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, Suzhou 215004, China.; Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - Shujing Zhou
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, Suzhou 215004, China.; Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - Zhangjie Yu
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - Jie Chen
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China..
| | - Hong Xie
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, Suzhou 215004, China..
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Comparison of different methods for lung immobilization in an animal model. Radiother Oncol 2020; 150:151-158. [PMID: 32580000 DOI: 10.1016/j.radonc.2020.06.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/28/2020] [Accepted: 06/17/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Respiratory-induced motion introduces uncertainties in the delivery of dose in radiotherapy treatments. Various methods are used clinically, e.g. breath-holding, while there is limited experience with other methods such as apneic oxygenation and high frequency jet ventilation (HFJV). This study aims to compare the latter approaches for lung immobilization and their clinical impact on gas exchange in an animal model. MATERIALS AND METHODS Two radiopaque tumor surrogate markers (TSM) were placed in the central (cTSM) and peripheral (dTSM) regions of the lungs in 9 anesthetized and muscle relaxed pigs undergoing 3 ventilatory interventions (1) HFJV at rates of 200 (JV200), 300 (JV300) and 400 (JV400) min-1; (2) apnea at continuous positive airway pressure (CPAP) levels of 0, 8 and 16 cmH2O; (3) conventional mechanical ventilation (CMV) as reference mode. cTSM and dTSM were visualized using fluoroscopy and their coordinates were computed. The ventilatory pattern was registered, and oxygen and carbon dioxide (pCO2) partial pressures were measured. RESULTS The highest range of TSM motion, and ventilation was found during CMV, the lowest during apnea. During HFJV the amount of motion varied inversely with increasing frequency. The reduction of TSM motion at JV300, JV400 and all CPAP levels came at the cost of increased pCO2, however the relatively low frequency of 200 min-1 for HFJV was the only ventilatory setting that enabled adequate CO2 removal. CONCLUSION In this model, HFJV at 200 min-1 was the best compromise between immobilization and gas exchange for sessions of 10-min duration.
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