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Chen C, Shang P, Yao Y. Positive end-expiratory pressure and postoperative pulmonary complications in laparoscopic bariatric surgery: systematic review and meta-analysis. BMC Anesthesiol 2024; 24:282. [PMID: 39123102 PMCID: PMC11311921 DOI: 10.1186/s12871-024-02658-8] [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: 12/03/2023] [Accepted: 07/24/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND This study compares the effect of positive end-expiratory pressure (PEEP) on postoperative pulmonary complications (PPCs) in patients with obesity undergoing laparoscopic bariatric surgery (LBS) under general anesthesia with mechanical ventilation. METHODS A comprehensive search was conducted in PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, China National Knowledge Internet, Wanfang database, and Google Scholar for studies published up to July 29, 2023, without time or language restrictions. The search terms included "PEEP," "laparoscopic," and "bariatric surgery." Randomized controlled trials comparing different levels of PEEP or PEEP with zero-PEEP (ZEEP) in patients with obesity undergoing LBS were included. The primary outcome was a composite of PPCs, and the secondary outcomes were intraoperative oxygenation, respiratory compliance, and mean arterial pressure (MAP). A fixed-effect or random-effect model was selected for meta-analysis based on the heterogeneity of the included studies. RESULTS Thirteen randomized controlled trials with a total of 708 participants were included for analysis. No statistically significant difference in PPCs was found between the PEEP and ZEEP groups (risk ratio = 0.27, 95% CI: 0.05-1.60; p = 0.15). However, high PEEP ≥ 10 cm H2O significantly decreased PPCs compared with low PEEP < 10 cm H2O (risk ratio = 0.20, 95% CI: 0.05-0.89; p = 0.03). The included studies showed no significant heterogeneity (I2 = 20% & 0%). Compared with ZEEP, PEEP significantly increased intraoperative oxygenation and respiratory compliance (WMD = 74.97 mm Hg, 95% CI: 41.74-108.21; p < 0.001 & WMD = 9.40 ml cm H2O- 1, 95% CI: 0.65-18.16; p = 0.04). High PEEP significantly improved intraoperative oxygenation and respiratory compliance during pneumoperitoneum compared with low PEEP (WMD = 66.81 mm Hg, 95% CI: 25.85-107.78; p = 0.001 & WMD = 8.03 ml cm H2O- 1, 95% CI: 4.70-11.36; p < 0.001). Importantly, PEEP did not impair hemodynamic status in LBS. CONCLUSIONS In patients with obesity undergoing LBS, high PEEP ≥ 10 cm H2O could decrease PPCs compared with low PEEP < 10 cm H2O, while there was a similar incidence of PPCs between PEEP (8-10 cm H2O) and the ZEEP group. The application of PEEP in ventilation strategies increased intraoperative oxygenation and respiratory compliance without affecting intraoperative MAP. A PEEP of at least 10 cm H2O is recommended to reduce PPCs in patients with obesity undergoing LBS. REGISTRATION NUMBER CRD42023391178 in PROSPERO.
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Affiliation(s)
- Chen Chen
- Department of Anesthesiology, The First People's Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, Changzhou, 213000, China
| | - Pingping Shang
- Department of Anesthesiology, the First Affiliated Hospital of Henan University, Kaifeng, 475000, China
| | - Yuntai Yao
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 10032, China.
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Anđelić N, Uvelin A, Stokić E, Popović R, Zdravković R, Preveden A, Zornić N. The Effect of Recruitment Maneuver on Static Lung Compliance in Patients Undergoing General Anesthesia for Laparoscopic Cholecystectomy: A Single-Centre Prospective Clinical Intervention Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:666. [PMID: 38674312 PMCID: PMC11052059 DOI: 10.3390/medicina60040666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/06/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024]
Abstract
Background and Objectives: The aim of this study was to examine whether the use of an alveolar recruitment maneuver (RM) leads to a significant increase in static lung compliance (Cstat) and an improvement in gas exchange in patients undergoing laparoscopic cholecystectomy. Material and Methods: A clinical prospective intervention study was conducted. Patients were divided into two groups according to their body mass index (BMI): normal-weight (group I) and pre-obese and obese grade I (group II). Lung mechanics were monitored (Cstat, dynamic compliance-Cdin, peak pressure-Ppeak, plateau pressure-Pplat, driving pressure-DP) alongside gas exchange, and hemodynamic changes (heart rate-HR, mean arterial pressure-MAP) at six time points: T1 (induction of anesthesia), T2 (formation of pneumoperitoneum), T3 (RM with a PEEP of 5 cm H2O), T4 (RM with a PEEP of 7 cm H2O), T5 (desufflation), and T6 (RM at the end). The RM was performed by increasing the peak pressure by +5 cm of H2O at an equal inspiration-to-expiration ratio (I/E = 1:1) and applying a PEEP of 5 and 7 cm of H2O. Results: Out of 96 patients, 33 belonged to group I and 63 to group II. An increase in Cstat values occurred after all three RMs. At each time point, the Cstat value was measured higher in group I than in group II. A higher increase in Cstat was observed in group II after the second and third RM. Cstat values were higher at the end of the surgical procedure compared to values after the induction of anesthesia. The RM led to a significant increase in PaO2 in both groups without changes in HR or MAP. Conclusions: During laparoscopic cholecystectomy, the application of RM leads to a significant increase in Cstat and an improvement in gas exchange. The prevention of atelectasis during anesthesia should be initiated immediately after the induction of anesthesia, using protective mechanical ventilation and RM.
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Affiliation(s)
- Nada Anđelić
- Clinic for Anesthesia, Intensive Care and Pain Medicine, Clinical Centre of Vojvodina, 21000 Novi Sad, Serbia; (N.A.); (R.P.)
- Faculty of Medical Sciences, Kragujevac, University of Kragujevac, 34000 Kragujevac, Serbia;
| | - Arsen Uvelin
- Clinic for Anesthesia, Intensive Care and Pain Medicine, Clinical Centre of Vojvodina, 21000 Novi Sad, Serbia; (N.A.); (R.P.)
- Faculty of Medicine, Novi Sad, University of Novi Sad, 21000 Novi Sad, Serbia; (E.S.); (R.Z.); (A.P.)
| | - Edita Stokić
- Faculty of Medicine, Novi Sad, University of Novi Sad, 21000 Novi Sad, Serbia; (E.S.); (R.Z.); (A.P.)
- Clinic for Endocrinology, Diabetes and Metabolism, Clinical Centre of Vojvodina, 21000 Novi Sad, Serbia
| | - Radmila Popović
- Clinic for Anesthesia, Intensive Care and Pain Medicine, Clinical Centre of Vojvodina, 21000 Novi Sad, Serbia; (N.A.); (R.P.)
- Faculty of Medicine, Novi Sad, University of Novi Sad, 21000 Novi Sad, Serbia; (E.S.); (R.Z.); (A.P.)
| | - Ranko Zdravković
- Faculty of Medicine, Novi Sad, University of Novi Sad, 21000 Novi Sad, Serbia; (E.S.); (R.Z.); (A.P.)
- Institute of Cardiovascular Diseases of Vojvodina, 21204 Sremska Kamenica, Serbia
| | - Andrej Preveden
- Faculty of Medicine, Novi Sad, University of Novi Sad, 21000 Novi Sad, Serbia; (E.S.); (R.Z.); (A.P.)
- Institute of Cardiovascular Diseases of Vojvodina, 21204 Sremska Kamenica, Serbia
| | - Nenad Zornić
- Faculty of Medical Sciences, Kragujevac, University of Kragujevac, 34000 Kragujevac, Serbia;
- Department of Surgery, Clinical Centre of Kragujevac, 34000 Kragujevac, Serbia
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Xavier TB, Coelho LV, Ferreira DAL, Cota y Raposeiras JM, Duran MS, Silva LA, da Motta-Ribeiro GC, Camilo LM, Carvalho ARS, Silva PL. Individualized positive end-expiratory pressure reduces driving pressure in obese patients during laparoscopic surgery under pneumoperitoneum: a randomized clinical trial. Front Physiol 2024; 15:1383167. [PMID: 38645690 PMCID: PMC11026699 DOI: 10.3389/fphys.2024.1383167] [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: 02/07/2024] [Accepted: 03/19/2024] [Indexed: 04/23/2024] Open
Abstract
Introduction During pneumoperitoneum (PNP), airway driving pressure (ΔPRS) increases due to the stiffness of the chest wall and cephalic shift of the diaphragm, which favors atelectasis. In addition, depending on the mechanical power (MP) formulas, they may lead to different interpretations. Methods Patients >18 years of age with body mass index >35 kg/m2 were included in a single-center randomized controlled trial during their admission for bariatric surgery by abdominal laparoscopy. Intra-abdominal pressure was set at 15 mmHg at the pneumoperitoneum time point (PNP). After the recruitment maneuver, the lowest respiratory system elastance (ERS) was detected during the positive end-expiratory pressure (PEEP) step-wise decrement. Patients were randomized to the 1) CTRL group: ventilated with PEEP of 5 cmH2O and 2) PEEPIND group: ventilated with PEEP value associated with ERS that is 5% higher than its lowest level. Respiratory system mechanics and mean arterial pressure (MAP) were assessed at the PNP, 5 min after randomization (T1), and at the end of the ventilation protocol (T2); arterial blood gas was assessed at PNP and T2. ΔPRS was the primary outcome. Three MP formulas were used: MPA, which computes static PEEP × volume, elastic, and resistive components; MPB, which computes only the elastic component; and MPC, which computes static PEEP × volume, elastic, and resistive components without inspiratory holds. Results Twenty-eight patients were assessed for eligibility: eight were not included and 20 patients were randomized and allocated to CTRL and PEEPIND groups (n = 10/group). The PEEPIND ventilator strategy reduced ΔPRS when compared with the CTRL group (PEEPIND, 13 ± 2 cmH2O; CTRL, 22 ± 4 cmH2O; p < 0.001). Oxygenation improved in the PEEPIND group when compared with the CTRL group (p = 0.029), whereas MAP was comparable between the PEEPIND and CTRL groups. At the end of surgery, MPA and MPB were correlated in both the CTRL (rho = 0.71, p = 0.019) and PEEPIND (rho = 0.84, p = 0.020) groups but showed different bias (CTRL, -1.9 J/min; PEEPIND, +10.0 J/min). At the end of the surgery, MPA and MPC were correlated in both the CTRL (rho = 0.71, p = 0.019) and PEEPIND (rho = 0.84, p = 0.020) groups but showed different bias (CTRL, -1.9 J/min; PEEPIND, +10.0 J/min). Conclusion Individualized PEEP was associated with a reduction in ΔPRS and an improvement in oxygenation with comparable MAP. The MP, which solely computes the elastic component, better reflected the improvement in ΔPRS observed in the individualized PEEP group. Clinical Trial Registration The protocol was registered at the Brazilian Registry of Clinical Trials (U1111-1220-7296).
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Affiliation(s)
- Tiago Batista Xavier
- Laboratório de Fisiologia da Respiração, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Instituto de Educação, Ciência e Tecnologia do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | | | | | - Leticia Almeida Silva
- Laboratório de Investigação Pulmonar, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Luciana Moisés Camilo
- Instituto de Educação, Ciência e Tecnologia do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Pedro Leme Silva
- Laboratório de Investigação Pulmonar, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Peták F, Südy R, Diaper J, Fontao F, Bizzotto D, Dellacà RL, Habre W, Schranc Á. Benefits of intratracheal and extrathoracic high-frequency percussive ventilation in a model of capnoperitoneum. J Appl Physiol (1985) 2024; 136:928-937. [PMID: 38420682 DOI: 10.1152/japplphysiol.00881.2023] [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: 12/08/2023] [Revised: 01/29/2024] [Accepted: 02/20/2024] [Indexed: 03/02/2024] Open
Abstract
Abdominal inflation with CO2 is used to facilitate laparoscopic surgeries, however, providing adequate mechanical ventilation in this scenario is of major importance during anesthesia management. We characterized high-frequency percussive ventilation (HFPV) in protecting from the gas exchange and respiratory mechanical impairments during capnoperitoneum. In addition, we aimed to assess the difference between conventional pressure-controlled mechanical ventilation (CMV) and HFPV modalities generating the high-frequency signal intratracheally (HFPVi) or extrathoracally (HFPVe). Anesthetized rabbits (n = 16) were mechanically ventilated by random sequences of CMV, HFPVi, and HFPVe. The ventilator superimposed the conventional waveform with two high-frequency signals (5 Hz and 10 Hz) during intratracheal HFPV (HFPVi) and HFPV with extrathoracic application of oscillatory signals through a sealed chest cuirass (HFPVe). Lung oxygenation index ([Formula: see text]/[Formula: see text]), arterial partial pressure of carbon dioxide ([Formula: see text]), intrapulmonary shunt (Qs/Qt), and respiratory mechanics were assessed before abdominal inflation, during capnoperitoneum, and after abdominal deflation. Compared with CMV, HFPVi with additional 5-Hz oscillations during capnoperitoneum resulted in higher [Formula: see text]/[Formula: see text], lower [Formula: see text], and decreased Qs/Qt. These improvements were smaller but remained significant during HFPVi with 10 Hz and HFPVe with either 5 or 10 Hz. The ventilation modes did not protect against capnoperitoneum-induced deteriorations in respiratory tissue mechanics. These findings suggest that high-frequency oscillations combined with conventional pressure-controlled ventilation improved lung oxygenation and CO2 removal in a model of capnoperitoneum. Compared with extrathoracic pressure oscillations, intratracheal generation of oscillatory pressure bursts appeared more effective. These findings may contribute to the optimization of mechanical ventilation during laparoscopic surgery.NEW & NOTEWORTHY The present study examines an alternative and innovative mechanical ventilation modality in improving oxygen delivery, CO2 clearance, and respiratory mechanical abnormalities in a clinically relevant experimental model of capnoperitoneum. Our data reveal that high-frequency oscillations combined with conventional ventilation improve gas exchange, with intratracheal oscillations being more effective than extrathoracic oscillations in this clinically relevant translational model.
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Affiliation(s)
- Ferenc Peták
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Roberta Südy
- Unit for Anesthesiological Investigations, Department of Acute Medicine, University of Geneva, Geneva, Switzerland
| | - John Diaper
- Unit for Anesthesiological Investigations, Department of Acute Medicine, University of Geneva, Geneva, Switzerland
| | - Fabienne Fontao
- Unit for Anesthesiological Investigations, Department of Acute Medicine, University of Geneva, Geneva, Switzerland
| | - Davide Bizzotto
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Raffaele L Dellacà
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Walid Habre
- Unit for Anesthesiological Investigations, Department of Acute Medicine, University of Geneva, Geneva, Switzerland
| | - Álmos Schranc
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
- Unit for Anesthesiological Investigations, Department of Acute Medicine, University of Geneva, Geneva, Switzerland
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Hartsuyker P, Kanczuk ME, Lawn D, Beg S, Mengistu TS, Hiskens M. The effect of class 3 obesity on the functionality of supraglottic airway devices: a historical cohort analysis with propensity score matching. Can J Anaesth 2023; 70:1744-1752. [PMID: 37833471 DOI: 10.1007/s12630-023-02582-4] [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: 05/22/2022] [Revised: 04/05/2023] [Accepted: 04/08/2023] [Indexed: 10/15/2023] Open
Abstract
PURPOSE Supraglottic airway devices (SGAs) have been increasingly used as a primary airway in patients undergoing anesthesia as an alternative to endotracheal tubes. Second-generation devices have expanded their applicability to include uses in patients with obesity. Nevertheless, there is limited evidence of SGA suitability for patients with class 3 obesity (body mass index [BMI] ≥ 40 kg·m-2). As such, we compared rates of SGA functionality between patients with class 3 obesity and patients without class 3 obesity undergoing general anesthesia. METHODS We performed a propensity score matching analysis using inverse probability of treatment weighting to compare the functionality of SGAs in adult patients with class 3 obesity vs without class 3 obesity. These patients underwent surgery at a hospital in Queensland, Australia from November 2017 to September 2020 and had a SGA inserted as part of their anesthetic care. All data were collected from patients' electronic medical records. We included 321 patients in the cohort with class 3 obesity and 471 in the cohort without class 3 obesity (control/comparison). The estimated effect of class 3 obesity on SGAs was calculated using adjusted odds ratios (AORs) with their 95% confidence intervals (CIs). RESULTS The overall weighted prevalence of nonfunctional SGAs was 3.2%, with a significantly higher rate in the class 3 obesity cohort compared with the control cohort (4.7% vs 2.1%) (P = 0.04). This adjusted analysis illustrates that class 3 obesity was associated with an almost four times higher odds of a nonfunctional SGA (odds ratio [OR], 2.3; 95% CI, 1.0 to 5.1; AOR, 3.9; 95% CI, 1.4 to 10.6) than patients without class 3 obesity. CONCLUSION Patients with class 3 obesity (BMI ≥ 40 kg·m-2) had greater than three-fold odds of nonfunctional intraoperative SGAs than patients without class 3 obesity.
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Affiliation(s)
- Patrick Hartsuyker
- James Cook University, North Mackay, QLD, Australia.
- Mackay Hospital and Health Service (MHHS), Mackay Base Hospital, Mackay, QLD, Australia.
- Mackay Institute of Research and Innovation, Mackay Base Hospital, Mackay, QLD, Australia.
| | - Marcelo E Kanczuk
- Mackay Hospital and Health Service (MHHS), Mackay Base Hospital, Mackay, QLD, Australia
- Mackay Institute of Research and Innovation, Mackay Base Hospital, Mackay, QLD, Australia
| | - David Lawn
- Mackay Hospital and Health Service (MHHS), Mackay Base Hospital, Mackay, QLD, Australia
| | - Salwa Beg
- Mackay Hospital and Health Service (MHHS), Mackay Base Hospital, Mackay, QLD, Australia
| | - Tesfaye S Mengistu
- Mackay Institute of Research and Innovation, Mackay Base Hospital, Mackay, QLD, Australia
- School of Public Health, University of Queensland, Herston, QLD, Australia
| | - Matthew Hiskens
- Mackay Institute of Research and Innovation, Mackay Base Hospital, Mackay, QLD, Australia
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Wang YH, Su PC, Huang HC, Au K, Lin FCF, Chen CY, Chou MC, Hsia JY. Pulmonary Recruitment Prior to Intraoperative Multiple Pulmonary Ground-Glass Nodule Localization Increases the Localization Accuracy-A Retrospective Study. J Clin Med 2023; 12:jcm12082998. [PMID: 37109340 PMCID: PMC10141549 DOI: 10.3390/jcm12082998] [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: 03/22/2023] [Revised: 04/08/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
The standard treatment for early-stage lung cancer is complete tumor excision by limited resection of the lung. Preoperative localization is used before video-assisted thoracoscopic surgery (VATS) to improve the accuracy of pulmonary nodule excision. However, lung atelectasis and hypoxia resulting from controlling apnea during the localization procedure may affect the localization accuracy. Pre-procedural pulmonary recruitment may improve the respiratory mechanics and oxygenation during localization. In this study, we investigated the potential benefits of pre-localization pulmonary recruitment prior to pulmonary ground-glass nodule localization in a hybrid operating room. We hypothesized that pre-localization pulmonary recruitment would increase the localization accuracy, improve oxygenation, and prevent the need for re-inflation during the localization procedure. We retrospectively enrolled patients with multiple pulmonary nodule localizations before surgical intervention in our hybrid operating room. We compared the localization accuracy between patients who had undergone pre-procedure pulmonary recruitment and patients who had not. Saturation, re-inflation rate, apnea time, procedure-related pneumothorax, and procedure time were also recorded as secondary outcomes. The patients who had undergone pre-procedure recruitment had better saturation, shorter procedure time, and higher localization accuracy. The pre-procedure pulmonary recruitment maneuver was effective in increasing regional lung ventilation, leading to improved oxygenation and localization accuracy.
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Affiliation(s)
- Yu Hsiang Wang
- Division of Thoracic Surgery, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Pei Chin Su
- Division of Thoracic Surgery, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Hsu Chih Huang
- Division of Thoracic Surgery, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
| | - Kenneth Au
- Division of Thoracic Surgery, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Frank Cheau Feng Lin
- Division of Thoracic Surgery, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
| | - Chih Yi Chen
- Division of Thoracic Surgery, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
| | - Ming Chih Chou
- Division of Thoracic Surgery, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
| | - Jiun Yi Hsia
- Division of Thoracic Surgery, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
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Ellenberger C, Pelosi P, de Abreu MG, Wrigge H, Diaper J, Hagerman A, Adam Y, Schultz MJ, Licker M. Distribution of ventilation and oxygenation in surgical obese patients ventilated with high versus low positive end-expiratory pressure: A substudy of a randomised controlled trial. Eur J Anaesthesiol 2022; 39:875-884. [PMID: 36093886 PMCID: PMC9553219 DOI: 10.1097/eja.0000000000001741] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND Intra-operative ventilation using low/physiological tidal volume and positive end-expiratory pressure (PEEP) with periodic alveolar recruitment manoeuvres (ARMs) is recommended in obese surgery patients. OBJECTIVES To investigate the effects of PEEP levels and ARMs on ventilation distribution, oxygenation, haemodynamic parameters and cerebral oximetry. DESIGN A substudy of a randomised controlled trial. SETTING Tertiary medical centre in Geneva, Switzerland, between 2015 and 2018. PATIENTS One hundred and sixty-two patients with a BMI at least 35 kg per square metre undergoing elective open or laparoscopic surgery lasting at least 120 min. INTERVENTION Patients were randomised to PEEP of 4 cmH 2 O ( n = 79) or PEEP of 12 cmH 2 O with hourly ARMs ( n = 83). MAIN OUTCOME MEASURES The primary endpoint was the fraction of ventilation in the dependent lung as measured by electrical impedance tomography. Secondary endpoints were the oxygen saturation index (SaO 2 /FIO 2 ratio), respiratory and haemodynamic parameters, and cerebral tissue oximetry. RESULTS Compared with low PEEP, high PEEP was associated with smaller intra-operative decreases in dependent lung ventilation [-11.2%; 95% confidence interval (CI) -8.7 to -13.7 vs. -13.9%; 95% CI -11.7 to -16.5; P = 0.029], oxygen saturation index (-49.6%; 95% CI -48.0 to -51.3 vs. -51.3%; 95% CI -49.6 to -53.1; P < 0.001) and a lower driving pressure (-6.3 cmH 2 O; 95% CI -5.7 to -7.0). Haemodynamic parameters did not differ between the groups, except at the end of ARMs when arterial pressure and cardiac index decreased on average by -13.7 mmHg (95% CI -12.5 to -14.9) and by -0.54 l min -1 m -2 (95% CI -0.49 to -0.59) along with increased cerebral tissue oximetry (3.0 and 3.2% on left and right front brain, respectively). CONCLUSION In obese patients undergoing abdominal surgery, intra-operative PEEP of 12 cmH 2 O with periodic ARMs, compared with intra-operative PEEP of 4 cmH 2 O without ARMs, slightly redistributed ventilation to dependent lung zones with minor improvements in peripheral and cerebral oxygenation. TRIAL REGISTRATION NCT02148692, https://clinicaltrials.gov/ct2.
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Affiliation(s)
- Christoph Ellenberger
- From the Department of Anaesthesia, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, rue Gabriel-Perret-Gentil (CE, JD, AH, YA, ML), Faculty of Medicine, University of Geneva, Geneva, Switzerland (CE, ML), Department of Surgical Sciences and Integrated Diagnostics, University of Genoa (PP), Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy (PP), Pulmonary Engineering Group, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany (MGdA), Department of Outcomes Research (MGdA), Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA (MGdA), Department of Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital (HW), Medical Faculty, Martin-Luther-University Halle-Wittenberg, Halle, Germany (HW), Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands (MJS)
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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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9
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Pei S, Wei W, Yang K, Yang Y, Pan Y, Wei J, Yao S, Xia H. Recruitment Maneuver to Reduce Postoperative Pulmonary Complications after Laparoscopic Abdominal Surgery: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11195841. [PMID: 36233708 PMCID: PMC9573602 DOI: 10.3390/jcm11195841] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 11/09/2022] Open
Abstract
Background: Lung-protective ventilation strategies are recommended for patients undergoing mechanical ventilation. However, there are currently no guidelines to follow regarding recruitment maneuvers (RMs). We attempted to identify the effects of RMs on patients undergoing laparoscopic abdominal surgery. Methods: We searched for randomized controlled trials (RCTs) in PubMed, the Cochrane Library databases, Embase, Web of Science and the ClinicalTrials.gov registry for trials published up to December 2021. The primary outcome was postoperative pulmonary complications (PPCs). The secondary outcomes consisted of the static lung compliance, driving pressure (DP), intraoperative oxygenation index (OI), OI in the post-anesthesia care unit (PACU), mean arterial pressure (MAP) and heart rate (HR). Seventeen RCTs with a total of 3480 patients were examined. Results: Patients who received RMs showed a considerable reduction in PPCs (risk ratio (RR) = 0.70; 95% confidence interval (CI): 0.62 to 0.79; p < 0.01), lower DP (weighted mean difference (WMD) = −3.96; 95% CI: −5.97 to −1.95; p < 0.01), elevated static lung compliance (WMD = 10.42; 95% CI: 6.13 to 14.71; p < 0.01) and improved OI (intraoperative: WMD = 53.54; 95% CI: 21.77 to 85.31; p < 0.01; PACU: WMD = 59.40; 95% CI: 39.10 to 79.69; p < 0.01) without substantial changes in MAP (WMD = −0.16; 95% CI −1.35 to 1.03; p > 0.05) and HR (WMD = −1.10; 95% CI: −2.29 to 0.10; p > 0.05). Conclusions: Recruitment maneuvers reduce postoperative pulmonary complications and improve respiratory mechanics and oxygenation in patients undergoing laparoscopic abdominal surgery. More data are needed to elucidate the effect of recruitment maneuver on the circulatory system.
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Affiliation(s)
- Shuaijie Pei
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Wei Wei
- Department of Anesthesiology, The People’s Hospital of Honghu, Honghu 433200, China
| | - Kai Yang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yiyi Yang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yu Pan
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Jinrui Wei
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Shanglong Yao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Correspondence: (S.Y.); (H.X.)
| | - Haifa Xia
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Department of Anesthesiology, The People’s Hospital of Honghu, Honghu 433200, China
- Department of Critical Care Medicine, The People’s Hospital of Honghu, Honghu 433200, China
- Correspondence: (S.Y.); (H.X.)
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10
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Di Bella C, Vicenti C, Araos J, Lacitignola L, Fracassi L, Stabile M, Grasso S, Crovace A, Staffieri F. Effects of two alveolar recruitment maneuvers in an “open-lung” approach during laparoscopy in dogs. Front Vet Sci 2022; 9:904673. [PMID: 36061108 PMCID: PMC9435385 DOI: 10.3389/fvets.2022.904673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 06/28/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives The aim of this study was to compare the effects of a sustained inflation alveolar recruiting maneuver (ARM) followed by 5 cmH2O of PEEP and a stepwise ARM, in dogs undergoing laparoscopic surgery. Materials and methods Twenty adult dogs were enrolled in this prospective randomized clinical study. Dogs were premedicated with methadone intramuscularly (IM); anesthesia was induced with propofol intravenously (IV) and maintained with inhaled isoflurane in pure oxygen. The baseline ventilatory setting (BVS) was as follows: tidal volume of 15 mL/kg, inspiratory pause of 25%, inspiratory to expiratory ratio of 1:2, and the respiratory rate to maintain the end-tidal carbon dioxide between 45 and 55 mmHg. 10 min after pneumoperitoneum, randomly, 10 dogs underwent sustained inflation ARM followed by 5 cmH2O of PEEP (ARMi), while 10 dogs underwent a stepwise recruitment maneuver followed by the setting of the “best PEEP” (ARMc). Gas exchange, respiratory system mechanics, and hemodynamic were evaluated before the pneumoperitoneum induction (BASE), 10 min after the pneumoperitoneum (PP), 10 min after the recruitment (ARM), and 10 min after the pneumoperitoneum resolution (PostPP). Statistical analysis was performed with the ANOVA test (p < 0.05). Results Static compliance decreased in both groups at PP (ARMc = 1.35 ± 0.21; ARMi = 1.16 ± 0.26 mL/cmH2O/kg) compared to BASE (ARMc = 1.78 ± 0.60; ARMi = 1.66 ± 0.66 mL/cmH2O/kg) and at ARM (ARMc = 1.71 ± 0.41; ARMi = 1.44 ± 0.84 mL/cmH2O/kg) and PostPP (ARMc = 1.75 ± 0.45; ARMi = 1.89 ± 0.59 mL/cmH2O/kg), and it was higher compared to PP and similar to BASE. The PaO2/FiO2, in both groups, was higher at ARM (ARMc = 455.11 ± 85.90; ARMi = 505.40 ± 31.70) and PostPP (ARMc = 521.30 ± 66.20; ARMi = 450.90 ± 70.60) compared to PP (ARMc = 369.53 ± 49.31; ARMi = 394.32 ± 37.72). Conclusion and clinical relevance The two ARMs improve lung function in dogs undergoing laparoscopic surgery similarly. Application of PEEP at the end of the ARMs prolonged the effects of the open-lung strategy.
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Affiliation(s)
- Caterina Di Bella
- School of Bioscience and Veterinary Medicine, University of Camerino, Camerino, Italy
| | - Caterina Vicenti
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantations, University of Bari, Bari, Italy
| | - Joaquin Araos
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Luca Lacitignola
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantations, University of Bari, Bari, Italy
| | - Laura Fracassi
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantations, University of Bari, Bari, Italy
| | - Marzia Stabile
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantations, University of Bari, Bari, Italy
| | - Salvatore Grasso
- Section of Anesthesia and Intensive Care, Department of Emergency and Organ Transplantations, University of Bari, Bari, Italy
| | - Alberto Crovace
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantations, University of Bari, Bari, Italy
| | - Francesco Staffieri
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantations, University of Bari, Bari, Italy
- *Correspondence: Francesco Staffieri
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11
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Wu XZ, Xia HM, Zhang P, Li L, Hu QH, Guo SP, Li TY. Effects of ultrasound-guided alveolar recruitment manoeuvres compared with sustained inflation or no recruitment manoeuvres on atelectasis in laparoscopic gynaecological surgery as assessed by ultrasonography: a randomized clinical trial. BMC Anesthesiol 2022; 22:261. [PMID: 35974310 PMCID: PMC9380300 DOI: 10.1186/s12871-022-01798-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/03/2022] [Indexed: 12/16/2022] Open
Abstract
Background The majority of patients may experience atelectasis under general anesthesia, and the Trendelenburg position and pneumoperitoneum can aggravate atelectasis during laparoscopic surgery, which promotes postoperative pulmonary complications. Lung recruitment manoeuvres have been proven to reduce perioperative atelectasis, but it remains controversial which method is optimal. Ultrasonic imaging can be conducive to confirming the effect of lung recruitment manoeuvres. The purpose of our study was to assess the effects of ultrasound-guided alveolar recruitment manoeuvres by ultrasonography on reducing perioperative atelectasis and to check whether the effects of recruitment manoeuvres under ultrasound guidance (visual and semiquantitative) on atelectasis are superior to sustained inflation recruitment manoeuvres (classical and widely used) in laparoscopic gynaecological surgery. Methods In this randomized, controlled, double-blinded study, women undergoing laparoscopic gynecological surgery were enrolled. Patients were randomly assigned to receive either lung ultrasound-guided alveolar recruitment manoeuvres (UD group), sustained inflation alveolar recruitment manoeuvres (SI group), or no RMs (C group) using a computer-generated table of random numbers. Lung ultrasonography was performed at four predefined time points. The primary outcome was the difference in lung ultrasound score (LUS) among groups at the end of surgery. Results Lung ultrasound scores in the UD group were significantly lower than those in both the SI group and the C group immediately after the end of surgery (7.67 ± 1.15 versus 9.70 ± 102, difference, -2.03 [95% confidence interval, -2.77 to -1.29], P < 0.001; 7.67 ± 1.15 versus 11.73 ± 1.96, difference, -4.07 [95% confidence interval, -4.81 to -3.33], P < 0.001;, respectively). The intergroup differences were sustained until 30 min after tracheal extubation (9.33 ± 0.96 versus 11.13 ± 0.97, difference, -1.80 [95% confidence interval, -2.42 to -1.18], P < 0.001; 9.33 ± 0.96 versus 10.77 ± 1.57, difference, -1.43 [95% confidence interval, -2.05 to -0.82], P < 0.001;, respectively). The SI group had a significantly lower LUS than the C group at the end of surgery (9.70 ± 1.02 versus 11.73 ± 1.96, difference, -2.03 [95% confidence interval, -2.77 to -1.29] P < 0.001), but the benefit did not persist 30 min after tracheal extubation. Conclusions During general anesthesia, ultrasound-guided recruitment manoeuvres can reduce perioperative aeration loss and improve oxygenation. Furthermore, these effects of ultrasound-guided recruitment manoeuvres on atelectasis are superior to sustained inflation recruitment manoeuvres. Trial registration Chictr.org.cn, ChiCTR2100042731, Registered 27 January 2021, www.chictr.org.cn.
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Affiliation(s)
- Xiong-Zhi Wu
- Department of Anesthesiology, First Affiliated Hospital of Nanchang University, NO. 17, Yongwaizheng Street, Nanchang, Jiangxi, 330006, China.,Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), NO.568, North Zhongxing Road, Shaoxing, Zhejiang, China
| | - Hai-Mei Xia
- Department of Anesthesiology, First Affiliated Hospital of Nanchang University, NO. 17, Yongwaizheng Street, Nanchang, Jiangxi, 330006, China
| | - Ping Zhang
- Department of Anesthesiology, Jiangxi Provincial People's Hospital, NO.152 Aiguo Road, Nanchang, Jiangxi, 330006, China
| | - Lei Li
- Department of Anesthesiology, First Affiliated Hospital of Nanchang University, NO. 17, Yongwaizheng Street, Nanchang, Jiangxi, 330006, China
| | - Qiao-Hao Hu
- Department of Anesthesiology, First Affiliated Hospital of Nanchang University, NO. 17, Yongwaizheng Street, Nanchang, Jiangxi, 330006, China
| | - Su-Ping Guo
- Department of Ultrasound Medicine, First Affiliated Hospital of Nanchang University, NO. 17, Yongwaizheng Street, Nanchang, Jiangxi, 330006, China
| | - Tian-Yuan Li
- Department of Anesthesiology, First Affiliated Hospital of Nanchang University, NO. 17, Yongwaizheng Street, Nanchang, Jiangxi, 330006, China.
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12
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Balonov K. Intraoperative protective lung ventilation strategies in patients with morbid obesity. Saudi J Anaesth 2022; 16:327-331. [PMID: 35898523 PMCID: PMC9311182 DOI: 10.4103/sja.sja_386_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/14/2022] [Indexed: 11/21/2022] Open
Abstract
Postoperative pulmonary complications (PPCs) occur frequently and are associated with a prolonged hospital stay, increased mortality, and high costs. Patients with morbid obesity are at higher risk of perioperative complications, in particular associated with those related to respiratory function. One of the most prominent concerns of the anesthesiologists while taking care of the patient with obesity in the perioperative setting should be the status of the lung and delivery of mechanical ventilation as its strategy affects clinical outcomes. Negative effects of mechanical ventilation on the respiratory system known as ventilator-induced lung injury include barotrauma, volutrauma, and atelectrauma. However, the optimal regimen of mechanical ventilation still remains a matter of debate. While low tidal volume (VT) strategy has become a widely accepted standard of care, the protective role of PEEP and recruitment maneuvers is less clear. This review focuses on the pathophysiology of respiratory function in patients with morbid obesity, the effects of mechanical ventilation on the lungs, and optimal intraoperative strategy based on the current state of knowledge.
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13
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Sevdi MS, Demirgan S, Erkalp K, Erol MK, Ozalp A, Altinel Y, Alagol A. Comparison of Intra-operative Pressure-Controlled Ventilation and Volume-Controlled Ventilation in Bariatric Surgery: A Prospective Randomized Study. Cureus 2021; 13:e17567. [PMID: 34646623 PMCID: PMC8480357 DOI: 10.7759/cureus.17567] [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] [Accepted: 08/30/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Mechanical ventilation may be particularly challenging in obese patients undergoing laparoscopic bariatric surgery. The present study aimed to compare the effects of pressure-controlled ventilation (PCV) with those of volume-controlled ventilation (VCV) on peripheral tissue oxygenation (PTO), respiratory function, hemodynamic status, and ventilation-related complications in patients undergoing laparoscopic bariatric surgery. Methods: A total of 100 patients with obesity who underwent gastric plication or sleeve gastrectomy were recruited for the study, and 60 patients (n=32, in group PCV; n=28, in group VCV) were ultimately enrolled. Data on peri-operative PTO (arterial blood gas [ABG] analysis and tissue oxygen saturation [StO2]) and respiratory functions were recorded for each patient, along with post-operative hemodynamic status, fluid intake, urinary output, Numeric Pain Rating Scale (NPRS) score , and complications. Results: The two groups were similar in pH, partial pressure of oxygen, partial pressure of carbon dioxide, oxygen saturation, and lactate values at baseline, intra-operative and post-operative periods. The peri-operative StO2 values were also similar between the two groups at all times. The two groups were identical in terms of preoperative values for respiratory function tests and post-operative hemodynamic status, fluid intake, urinary output, pain scores, and complication rates. Conclusions: In conclusion, the choice of the mechanical ventilation mode did not appear to influence oxygen delivery, respiratory function, hemodynamic status, post-operative pain, or ventilation-related complications in obese patients undergoing laparoscopic bariatric surgery.
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Affiliation(s)
- Mehmet Salih Sevdi
- Department of Anesthesiology, Bağcılar Training and Research Hospital, University of Health Sciences, Istanbul, TUR
| | - Serdar Demirgan
- Department of Anesthesiology, Bağcılar Training and Research Hospital, University of Health Sciences, Istanbul, TUR
| | - Kerem Erkalp
- Department of Anesthesiology, Istanbul University-Cerrahpaşa Institute of Cardiology, Istanbul, TUR
| | - Melahat Karatmanlı Erol
- Department of Anesthesiology, Bağcılar Training and Research Hospital, University of Health Sciences, Istanbul, TUR
| | - Ali Ozalp
- Department of Anesthesiology, Bağcılar Training and Research Hospital, University of Health Sciences, Istanbul, TUR
| | - Yuksel Altinel
- Department of General Surgery, Bağcılar Training and Research Hospital, University of Health Sciences, Istanbul, TUR
| | - Aysin Alagol
- Department of Anesthesiology, Bağcılar Training and Research Hospital, University of Health Sciences, Istanbul, TUR
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14
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Yang YC, Huai Q, Cui SZ, Cao XW, Gao BL. Effects of inverse ratio ventilation combined with lung protective ventilation on pulmonary function in patients with severe burns for surgery. Libyan J Med 2021; 15:1767276. [PMID: 32441571 PMCID: PMC7654640 DOI: 10.1080/19932820.2020.1767276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective To investigate the effects of inverse ratio ventilation combined with lung-protective ventilation on pulmonary function and inflammatory factors in severe burn patients undergoing surgery. Populations and Methods: Eighty patients with severe burns undergoing elective surgery were divided randomly into two groups: control (CG, n = 40) and experiment (EG, n = 40). The CG had conventional ventilation, whereas the EG were ventilated with tidal volume (TV) of 6–8 ml/kg, I (inspiration): E (expiration) of 2:1, and positive end-expiratory pressure (PEEP) 5 cm H2O. The following variables were evaluated before (T0), 1 h after start of surgery (T1) and after surgery (T2): oxygenation index (OI), partial pressure of carbon dioxide (PaCO2), TV, peak airway pressure (Ppeak), mean airway pressure (Pmean), PEEP, pulmonary dynamic compliance (Cdyn), alveolar–arterial difference of oxygen partial pressure D(A-a)O2, lactic acid (Lac), interleukin (IL)-6 and IL-10, and lung complications. Results: At T1 and T2 time points, the OI, Pmean and Cdyn were significantly greater in the EG than in the CG while the TV, Ppeak, D(A-a)O2, IL-6 and IL-10 were significantly smaller in the EG than in the CG. At the end of the surgery, the Lac was significantly smaller in the EG than in the CG (1.28 ± 0.19 vs. 1.40 ± 0.23 mmol/L). Twenty-four hours after the surgery, significantly more patients had hypoxemia (27.5 vs. 10.0%), increased expectoration (45.0 vs. 22.5%), increased lung texture or exudation (37.5 vs. 17.5%) in the CG than in the EG. Conclusions: Inverse ratio ventilation combined with lung-protective ventilation can reduce Ppeak, increase Pmean and Cdyn, improve the pulmonary oxygenation function, and decrease ILs in severe burn surgery patients.
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Affiliation(s)
- Yan-Chao Yang
- Department of Anesthesiology, Shijiazhuang First Hospital, Hebei Medical University , Shijiazhuang, Hebei Province, China
| | - Qiao Huai
- Department of Anesthesiology, Shijiazhuang First Hospital, Hebei Medical University , Shijiazhuang, Hebei Province, China
| | - Shu-Zhen Cui
- Department of Anesthesiology, Shijiazhuang First Hospital, Hebei Medical University , Shijiazhuang, Hebei Province, China
| | - Xiao-Wei Cao
- Respiratory Department, Shijiazhuang First Hospital, Hebei Medical University , Shijiazhuang, Hebei Province, China
| | - Bu-Lang Gao
- Department of Anesthesiology, Shijiazhuang First Hospital, Hebei Medical University , Shijiazhuang, Hebei Province, China
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15
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Zhou J, Wang C, Lv R, Liu N, Huang Y, Wang W, Yu L, Xie J. Protective mechanical ventilation with optimal PEEP during RARP improves oxygenation and pulmonary indexes. Trials 2021; 22:351. [PMID: 34011404 PMCID: PMC8135157 DOI: 10.1186/s13063-021-05310-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 05/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This trial aimed to evaluate the effects of a protective ventilation strategy on oxygenation/pulmonary indexes in patients undergoing robot-assisted radical prostatectomy (RARP) in the steep Trendelenburg position. METHODS In phase 1, the most optimal positive end-expiratory pressure (PEEP) was determined in 25 patients at 11 cmH2O. In phase 2, 64 patients were randomized to the traditional ventilation group with tidal volume (VT) of 9 ml/kg of predicted body weight (PBW) and the protective ventilation group with VT of 7 ml/kg of PBW with optimal PEEP and recruitment maneuvers (RMs). The primary endpoint was the intraoperative and postoperative PaO2/FiO2. The secondary endpoints were the PaCO2, SpO2, modified clinical pulmonary infection score (mCPIS), and the rate of complications in the postoperative period. RESULTS Compared with controls, PaO2/FiO2 in the protective group increased after the second RM (P=0.018), and the difference remained until postoperative day 3 (P=0.043). PaCO2 showed transient accumulation in the protective group after the first RM (T2), but this phenomenon disappeared with time. SpO2 in the protective group was significantly higher during the first three postoperative days. Lung compliance was significantly improved after the second RM in the protective group (P=0.025). The mCPIS was lower in the protective group on postoperative day 3 (0.59 (1.09) vs. 1.46 (1.27), P=0.010). CONCLUSION A protective ventilation strategy with lower VT combined with optimal PEEP and RMs could improve oxygenation and reduce mCPIS in patients undergoing RARP. TRIAL REGISTRATION ChiCTR ChiCTR1800015626 . Registered on 12 April 2018.
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Affiliation(s)
- Jianwei Zhou
- Department of Anesthesia, Lishui Hospital, School of Medicine, Zhejiang University, kuocang Road 289, Lishui, 323000, Zhejiang, China
| | - Chuanguang Wang
- Department of Anesthesia, Lishui Hospital, School of Medicine, Zhejiang University, kuocang Road 289, Lishui, 323000, Zhejiang, China
| | - Ran Lv
- Department of Anesthesia, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, East Qingchun Road 3, Hangzhou, 310016, Zhejiang, China
| | - Na Liu
- Department of Anesthesia, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, East Qingchun Road 3, Hangzhou, 310016, Zhejiang, China
| | - Yan Huang
- Department of Anesthesia, Lishui Hospital, School of Medicine, Zhejiang University, kuocang Road 289, Lishui, 323000, Zhejiang, China
| | - Wu Wang
- Department of Anesthesia, Lishui Hospital, School of Medicine, Zhejiang University, kuocang Road 289, Lishui, 323000, Zhejiang, China
| | - Lina Yu
- Department of Anesthesia, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, Zhejiang, China
| | - Junran Xie
- Department of Anesthesia, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, East Qingchun Road 3, Hangzhou, 310016, Zhejiang, China.
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16
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Sümer I, Topuz U, Alver S, Umutoglu T, Bakan M, Zengin SÜ, Coşkun H, Salihoglu Z. Effect of the "Recruitment" Maneuver on Respiratory Mechanics in Laparoscopic Sleeve Gastrectomy Surgery. Obes Surg 2021; 30:2684-2692. [PMID: 32207048 PMCID: PMC7224081 DOI: 10.1007/s11695-020-04551-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Purpose LSG surgery is used for surgical treatment of morbid obesity. Obesity, anesthesia, and pneumoperitoneum cause reduced pulmoner functions and a tendency for atelectasis. The alveolar “recruitment” maneuver (RM) keeps airway pressure high, opening alveoli, and increasing arterial oxygenation. The aim of our study is to research the effect on respiratory mechanics and arterial blood gases of performing the RM in LSG surgery. Materials and Methods Sixty patients undergoing LSG surgery were divided into two groups (n = 30) Patients in group R had the RM performed 5 min after desufflation with 100% oxygen, 40 cmH2O pressure for 40 s. Group C had standard mechanical ventilation. Assessments of respiratory mechanics and arterial blood gases were made in the 10th min after induction (T1), 10th min after insufflation (T2), 5th min after desufflation (T3), and 15th min after desufflation (T4). Arterial blood gases were assessed in the 30th min (T5) in the postoperative recovery unit. Results In group R, values at T5, PaO2 were significantly high, while PaCO2 were significantly low compared with group C. Compliance in both groups reduced with pneumoperitoneum. At T4, the compliance in the recruitment group was higher. In both groups, there was an increase in PIP with pneumoperitoneum and after desufflation this was identified to reduce to levels before pneumoperitoneum. Conclusion Adding the RM to PEEP administration for morbidly obese patients undergoing LSG surgery is considered to be effective in improving respiratory mechanics and arterial blood gas values and can be used safely.
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Affiliation(s)
- Ismail Sümer
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey.
| | - Ufuk Topuz
- Health Cares Vocational School, İstanbul Esenyurt University, Istanbul, Turkey
- İstanbul Acıbadem Taksim Hospital, Istanbul, Turkey
| | - Selçuk Alver
- Department of Anesthesiology and Reanimation, Faculty of Medicine, İstanbul Medipol University, Istanbul, Turkey
| | | | - Mefkur Bakan
- Health Cares Vocational School, İstanbul Esenyurt University, Istanbul, Turkey
- İstanbul Acıbadem Taksim Hospital, Istanbul, Turkey
| | - Seniyye Ülgen Zengin
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Halil Coşkun
- Department of General Surgery, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Ziya Salihoglu
- Department of Anesthesiology and Reanimation, Cerrahpasa Faculty of Medicine, İstanbul University Cerrahpasa, Istanbul, Turkey
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17
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Nguyen TK, Mai DH, Le AN, Nguyen QH, Nguyen CT, Vu TA. A review of intraoperative lung-protective mechanical ventilation strategy. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.1016/j.tacc.2020.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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18
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Halawa NM, Elshafie MA, Fernandez JG, Metwally AAR, Yassen KA. Respiratory and Hemodynamic Effects of Prophylactic Alveolar Recruitment During Liver Transplant: A Randomized Controlled Trial. EXP CLIN TRANSPLANT 2021; 19:462-472. [PMID: 33736584 DOI: 10.6002/ect.2020.0412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Prolonged surgical retraction may cause atelectasis. We aimed to recruit collapsed alveoli, stepwise, monitored by lung dynamic compliance and observe effects on arterial oxygenation and systemic and graft hemodynamics. Secondarily, we observed alveolar recruitment effects on postoperative mechanical ventilation, international normalized ratio, and pulmonary complications. MATERIALS AND METHODS For 58 recipients (1 excluded), randomized with optimal positive end-expiratory pressure (n = 28) versus control (fixed positive end-expiratory pressure, 5 cm H₂O; n = 29), alveolar recruitment was initiated (pressure-controlled ventilation guided by lung dynamic compliance) to identify optimal conditions. Ventilation shifted to volume-control mode with 0.4 fraction of inspired oxygen, 6 mL/kg tidal volume, and 1:2 inspiratory-to-expiratory ratio. Alveolar recruitment was repeated postretraction and at intensive care unit admission. Primary endpoints were changes in lung dynamic compliance, arterial oxygenation, and hemodynamics (cardiac output, invasive arterial and central venous pressures, graft portal and hepatic vein flows). Secondary endpoints were mechanical ventilation period and postoperative international normalized ratio, aspartate/alanine aminotransferases, lactate, and pulmonary complications. RESULTS Alveolar recruitment increased positive end-expiratory pressure, lung dynamic compliance, and arterial oxygenation (P < .01) and central venous pressure (P = .004), without effects on corrected flow time (P = .7). Cardiac output and invasive arterial pressure were stable with (P = .11) and without alveolar recruitment (P = .1), as were portal (P = .27) and hepatic vein flow (P = .30). Alveolar recruitment reduced postoperative pulmonary complications (n = 0/28 vs 8/29; P = .001), without reduction in postoperative mechanical ventilation period (P = .08). International normalization ratio, aspartate/alanine aminotransferases, and lactate were not different from control (P > .05). CONCLUSIONS Stepwise alveolar recruitment identified the optimal positive end-expiratory pressure to improve lung mechanics and oxygenation with minimal hemodynamic changes, without liver graft congestion/dysfunction, and was associated with significant reduction in postoperative pulmonary complications.
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Affiliation(s)
- Naglaa Moustafa Halawa
- From the Anesthesia Department, National Liver Institute, Menoufia University, Sheeben Elkom City, Egypt
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19
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Van Hecke D, Bidgoli JS, Van der Linden P. Does Lung Compliance Optimization Through PEEP Manipulations Reduce the Incidence of Postoperative Hypoxemia in Laparoscopic Bariatric Surgery? A Randomized Trial. Obes Surg 2020; 29:1268-1275. [PMID: 30612327 DOI: 10.1007/s11695-018-03662-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND In obese patients (OP), the best intraoperative ventilation strategy remains to be defined. Dynamic lung compliance (Cdyn) and dead space fraction are indicators of efficient ventilation at an optimal positive end-expiratory pressure (PEEP). Herein, we investigated whether intraoperative dynamic lung compliance optimization through PEEP manipulations affects the incidence of postoperative hypoxemia (SpO2 < 90%) in OP undergoing laparoscopic bariatric surgery (LBS). METHODS This was a single-center, prospective, randomized controlled study conducted from July 2013 to December 2015. After obtaining institutional review board approval and informed consent, 100 OP undergoing LBS under volume-controlled ventilation (tidal volume 8 mL/kg of ideal body weight) were randomized according to the PEEP level maintained during the surgery. In the control group, a PEEP of 10 cm H2O was maintained, while in the intervention group, the PEEP was adapted to achieve the best dynamic lung compliance. Anesthesia and analgesia were standardized. The patients received supplemental nasal oxygen on the first postoperative day and were monitored up to the second postoperative day with a portable pulse oximeter. RESULTS Demographics were similar between groups. There was no difference in the incidence of hypoxemia during the first 2 postoperative days (control: 1.3%; intervention: 2.1%; p = 0.264). CONCLUSIONS The incidence of postoperative hypoxemia was not reduced by an open-lung approach with protective ventilation strategy in obese patients undergoing LBS. A pragmatic application of a PEEP level of 10 cm H2O was comparable to individual PEEP titration in these patients. TRIAL REGISTRATION Clinicaltrials.gov identifier, NCT02579798; https://clinicaltrials.gov/ct2/show/NCT02579798.
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Affiliation(s)
- Delphine Van Hecke
- Department of Anaesthesiology, CUB Erasme, Université Libre de Bruxelles, 1070, Brussels, Belgium.
| | - Javad S Bidgoli
- Department of Anaesthesiology, CHU Brugmann-HUDERF, Université Libre de Bruxelles, 1090, Brussels, Belgium
| | - Philippe Van der Linden
- Department of Anaesthesiology, CHU Brugmann-HUDERF, Université Libre de Bruxelles, 1090, Brussels, Belgium
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20
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Ozyurt E, Kavakli AS, Ozturk NK. [Comparison of volume-controlled and pressure-controlled ventilation on respiratory mechanics in laparoscopic bariatric surgery: randomized clinical trial]. Rev Bras Anestesiol 2019; 69:546-552. [PMID: 31806235 DOI: 10.1016/j.bjan.2019.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 07/25/2019] [Accepted: 08/13/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND It is not clear which mechanical ventilation mode should be used in bariatric surgery, one of the treatment options for patients with obesity. OBJECTIVES To compare volume-controlled ventilation and pressure-controlled ventilation in terms of respiratory mechanics and arterial blood gas values in patients undergoing laparoscopic bariatric surgery. METHODS Sixty-two patients with morbid obesity scheduled for gastric bypass were included in this study. Their ideal body weights were calculated during preoperative visits, and patients were divided into two groups, volume-controlled ventilation and pressure-controlled ventilation. The patients were ventilated in accordance with a previously determined algorithm. Mechanical ventilation parameters and arterial blood gas analysis were recorded 5 minutes after induction, 30 minutes after pneumoperitoneum, and at the end of surgery. Also, the dynamic compliance, inspired O2 pressure/fractional O2 ratio, and alveolar-arterial oxygen gradient pressure were calculated. RESULTS Peak airway pressures were lower in patients ventilated in pressure-controlled ventilation mode at the end of surgery (p = 0.011). Otherwise, there was no difference between groups in terms of intraoperative respiratory parameters and arterial blood gas analyses. CONCLUSIONS Pressure-controlled ventilation mode is not superior to volume-controlled ventilation mode in patients with laparoscopic bariatric surgery.
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Affiliation(s)
- Erhan Ozyurt
- University of Health Sciences, Antalya Training and Research Hospital, Department of Anesthesiology and Reanimation, Antália, Turquia.
| | - Ali Sait Kavakli
- University of Health Sciences, Antalya Training and Research Hospital, Department of Anesthesiology and Reanimation, Antália, Turquia
| | - Nilgun Kavrut Ozturk
- University of Health Sciences, Antalya Training and Research Hospital, Department of Anesthesiology and Reanimation, Antália, Turquia
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21
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Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations. Br J Anaesth 2019; 123:898-913. [DOI: 10.1016/j.bja.2019.08.017] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/22/2019] [Accepted: 08/04/2019] [Indexed: 12/16/2022] Open
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22
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Ozyurt E, Kavakli AS, Ozturk NK. Comparison of volume-controlled and pressure-controlled ventilation on respiratory mechanics in laparoscopic bariatric surgery: randomized clinical trial. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2019. [PMID: 31806235 PMCID: PMC9391852 DOI: 10.1016/j.bjane.2019.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background It is not clear which mechanical ventilation mode should be used in bariatric surgery, one of the treatment options for patients with obesity. Objectives To compare volume-controlled ventilation and pressure-controlled ventilation in terms of respiratory mechanics and arterial blood gas values in patients undergoing laparoscopic bariatric surgery. Methods Sixty-two patients with morbid obesity scheduled for gastric bypass were included in this study. Their ideal body weights were calculated during preoperative visits, and patients were divided into two groups, volume-controlled ventilation and pressure-controlled ventilation. The patients were ventilated in accordance with a previously determined algorithm. Mechanical ventilation parameters and arterial blood gas analysis were recorded 5minutes after induction, 30minutes after pneumoperitoneum, and at the end of surgery. Also, the dynamic compliance, inspired O2 pressure/fractional O2 ratio, and alveolar-arterial oxygen gradient pressure were calculated. Results Peak airway pressures were lower in patients ventilated in pressure-controlled ventilation mode at the end of surgery (p = 0.011). Otherwise, there was no difference between groups in terms of intraoperative respiratory parameters and arterial blood gas analyses. Conclusions Pressure-controlled ventilation mode is not superior to volume-controlled ventilation mode in patients with laparoscopic bariatric surgery.
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23
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Multimodal non-invasive monitoring to apply an open lung approach strategy in morbidly obese patients during bariatric surgery. J Clin Monit Comput 2019; 34:1015-1024. [PMID: 31654282 DOI: 10.1007/s10877-019-00405-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 10/14/2019] [Indexed: 01/20/2023]
Abstract
To evaluate the use of non-invasive variables for monitoring an open-lung approach (OLA) strategy in bariatric surgery. Twelve morbidly obese patients undergoing bariatric surgery received a baseline protective ventilation with 8 cmH2O of positive-end expiratory pressure (PEEP). Then, the OLA strategy was applied consisting in lung recruitment followed by a decremental PEEP trial, from 20 to 8 cmH2O, in steps of 2 cmH2O to find the lung's closing pressure. Baseline ventilation was then resumed setting open lung PEEP (OL-PEEP) at 2 cmH2O above this pressure. The multimodal non-invasive variables used for monitoring OLA consisted in pulse oximetry (SpO2), respiratory compliance (Crs), end-expiratory lung volume measured by a capnodynamic method (EELVCO2), and esophageal manometry. OL-PEEP was detected at 15.9 ± 1.7 cmH2O corresponding to a positive end-expiratory transpulmonary pressure (PL,ee) of 0.9 ± 1.1 cmH2O. ROC analysis showed that SpO2 was more accurate (AUC 0.92, IC95% 0.87-0.97) than Crs (AUC 0.76, IC95% 0.87-0.97) and EELVCO2 (AUC 0.73, IC95% 0.64-0.82) to detect the lung's closing pressure according to the change of PL,ee from positive to negative values. Compared to baseline ventilation with 8 cmH2O of PEEP, OLA increased EELVCO2 (1309 ± 517 vs. 2177 ± 679 mL) and decreased driving pressure (18.3 ± 2.2 vs. 10.1 ± 1.7 cmH2O), estimated shunt (17.7 ± 3.4 vs. 4.2 ± 1.4%), lung strain (0.39 ± 0.07 vs. 0.22 ± 0.06) and lung elastance (28.4 ± 5.8 vs. 15.3 ± 4.3 cmH2O/L), respectively; all p < 0.0001. The OLA strategy can be monitored using noninvasive variables during bariatric surgery. This strategy decreased lung strain, elastance and driving pressure compared with standard protective ventilatory settings.Clinical trial number NTC03694665.
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24
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Zhang P, Wu L, Shi X, Zhou H, Liu M, Chen Y, Lv X. Positive End-Expiratory Pressure During Anesthesia for Prevention of Postoperative Pulmonary Complications: A Meta-analysis With Trial Sequential Analysis of Randomized Controlled Trials. Anesth Analg 2019; 130:879-889. [PMID: 31567322 DOI: 10.1213/ane.0000000000004421] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Whether intraoperative positive end-expiratory pressure (PEEP) can reduce the risk of postoperative pulmonary complications remains controversial. We performed a systematic review of currently available literature to investigate whether intraoperative PEEP decreases pulmonary complications in anesthetized patients undergoing surgery. METHODS We searched PubMed, Embase, and the Cochrane Library to identify randomized controlled trials (RCTs) that compared intraoperative PEEP versus zero PEEP (ZEEP) for postoperative pulmonary complications in adults. The prespecified primary outcome was postoperative pulmonary atelectasis. RESULTS Fourteen RCTs enrolling 1238 patients met the inclusion criteria. Meta-analysis using a random-effects model showed a decrease in postoperative atelectasis (relative risk [RR], 0.51; 95% confidence interval [CI], 0.35-0.76; trial sequential analyses [TSA]-adjusted CI, 0.10-2.55) and postoperative pneumonia (RR, 0.48; 95% CI, 0.27-0.84; TSA-adjusted CI, 0.05-4.86) in patients receiving PEEP ventilation. However, TSA showed that the cumulative Z-curve of 2 outcomes crossed the conventional boundary but did not cross the trial sequential monitoring boundary, indicating a possible false-positive result. We observed no effect of PEEP versus ZEEP ventilation on postoperative mortality (RR, 1.78; 95% CI, 0.55-5.70). CONCLUSIONS The evidence that intraoperative PEEP reduces postoperative pulmonary complications is suggestive but too unreliable to allow definitive conclusions to be drawn.
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Affiliation(s)
- Pengcheng Zhang
- From the Department of Anesthesiology, The First Hospital of Anhui Medical University, Hefei, China
| | - Lingmin Wu
- From the Department of Anesthesiology, The First Hospital of Anhui Medical University, Hefei, China
| | - Xuan Shi
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Huanping Zhou
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Meiyun Liu
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yuanli Chen
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xin Lv
- From the Department of Anesthesiology, The First Hospital of Anhui Medical University, Hefei, China.,Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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25
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Papazian L, Aubron C, Brochard L, Chiche JD, Combes A, Dreyfuss D, Forel JM, Guérin C, Jaber S, Mekontso-Dessap A, Mercat A, Richard JC, Roux D, Vieillard-Baron A, Faure H. Formal guidelines: management of acute respiratory distress syndrome. Ann Intensive Care 2019. [PMID: 31197492 DOI: 10.1186/s13613-019-0540-9.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Fifteen recommendations and a therapeutic algorithm regarding the management of acute respiratory distress syndrome (ARDS) at the early phase in adults are proposed. The Grade of Recommendation Assessment, Development and Evaluation (GRADE) methodology has been followed. Four recommendations (low tidal volume, plateau pressure limitation, no oscillatory ventilation, and prone position) had a high level of proof (GRADE 1 + or 1 -); four (high positive end-expiratory pressure [PEEP] in moderate and severe ARDS, muscle relaxants, recruitment maneuvers, and venovenous extracorporeal membrane oxygenation [ECMO]) a low level of proof (GRADE 2 + or 2 -); seven (surveillance, tidal volume for non ARDS mechanically ventilated patients, tidal volume limitation in the presence of low plateau pressure, PEEP > 5 cmH2O, high PEEP in the absence of deleterious effect, pressure mode allowing spontaneous ventilation after the acute phase, and nitric oxide) corresponded to a level of proof that did not allow use of the GRADE classification and were expert opinions. Lastly, for three aspects of ARDS management (driving pressure, early spontaneous ventilation, and extracorporeal carbon dioxide removal), the experts concluded that no sound recommendation was possible given current knowledge. The recommendations and the therapeutic algorithm were approved by the experts with strong agreement.
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Affiliation(s)
- Laurent Papazian
- Service de Médecine Intensive - Réanimation, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France.
| | - Cécile Aubron
- Medical Intensive Care Unit, Centre Hospitalier Régional et Universitaire de Brest, site La Cavale Blanche, Bvd Tanguy Prigent, 29609, Brest Cedex, France
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Jean-Daniel Chiche
- Service de Médecine Intensive - Réanimation, Hôpital Cochin, Hôpitaux Universitaires Paris-Centre, Assistance Publique - Hôpitaux de Paris, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Alain Combes
- Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié- Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, boulevard de l'Hôpital, 75013, Paris, France
| | - Didier Dreyfuss
- Intensive Care Unit, Louis Mourier Hospital, AP-HP, 178 Rue des Renouillers, 92700, Colombes, France
| | - Jean-Marie Forel
- Service de Médecine Intensive - Réanimation, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France
| | - Claude Guérin
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Samir Jaber
- Department of Anesthesiology and Intensive Care (DAR B), Saint Eloi University Hospital, Montpellier, France
| | - Armand Mekontso-Dessap
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri-Mondor, AP-HP, DHU A-TVB, 94010, Créteil, France
| | - Alain Mercat
- Medical Intensive Care Department, Angers University Hospital, 4, rue Larrey, 49933, Angers Cedex, France
| | | | - Damien Roux
- Intensive Care Unit, Louis Mourier Hospital, AP-HP, 178 Rue des Renouillers, 92700, Colombes, France
| | | | - Henri Faure
- Service de Médecine Intensive - Réanimation, Centre Hospitalier Intercommunal Robert Ballanger, 93602, Aulnay-sous-Bois, France
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26
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Papazian L, Aubron C, Brochard L, Chiche JD, Combes A, Dreyfuss D, Forel JM, Guérin C, Jaber S, Mekontso-Dessap A, Mercat A, Richard JC, Roux D, Vieillard-Baron A, Faure H. Formal guidelines: management of acute respiratory distress syndrome. Ann Intensive Care 2019; 9:69. [PMID: 31197492 PMCID: PMC6565761 DOI: 10.1186/s13613-019-0540-9] [Citation(s) in RCA: 422] [Impact Index Per Article: 84.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 05/27/2019] [Indexed: 12/16/2022] Open
Abstract
Fifteen recommendations and a therapeutic algorithm regarding the management of acute respiratory distress syndrome (ARDS) at the early phase in adults are proposed. The Grade of Recommendation Assessment, Development and Evaluation (GRADE) methodology has been followed. Four recommendations (low tidal volume, plateau pressure limitation, no oscillatory ventilation, and prone position) had a high level of proof (GRADE 1 + or 1 −); four (high positive end-expiratory pressure [PEEP] in moderate and severe ARDS, muscle relaxants, recruitment maneuvers, and venovenous extracorporeal membrane oxygenation [ECMO]) a low level of proof (GRADE 2 + or 2 −); seven (surveillance, tidal volume for non ARDS mechanically ventilated patients, tidal volume limitation in the presence of low plateau pressure, PEEP > 5 cmH2O, high PEEP in the absence of deleterious effect, pressure mode allowing spontaneous ventilation after the acute phase, and nitric oxide) corresponded to a level of proof that did not allow use of the GRADE classification and were expert opinions. Lastly, for three aspects of ARDS management (driving pressure, early spontaneous ventilation, and extracorporeal carbon dioxide removal), the experts concluded that no sound recommendation was possible given current knowledge. The recommendations and the therapeutic algorithm were approved by the experts with strong agreement.
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Affiliation(s)
- Laurent Papazian
- Service de Médecine Intensive - Réanimation, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France.
| | - Cécile Aubron
- Medical Intensive Care Unit, Centre Hospitalier Régional et Universitaire de Brest, site La Cavale Blanche, Bvd Tanguy Prigent, 29609, Brest Cedex, France
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Jean-Daniel Chiche
- Service de Médecine Intensive - Réanimation, Hôpital Cochin, Hôpitaux Universitaires Paris-Centre, Assistance Publique - Hôpitaux de Paris, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Alain Combes
- Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié- Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, boulevard de l'Hôpital, 75013, Paris, France
| | - Didier Dreyfuss
- Intensive Care Unit, Louis Mourier Hospital, AP-HP, 178 Rue des Renouillers, 92700, Colombes, France
| | - Jean-Marie Forel
- Service de Médecine Intensive - Réanimation, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France
| | - Claude Guérin
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Samir Jaber
- Department of Anesthesiology and Intensive Care (DAR B), Saint Eloi University Hospital, Montpellier, France
| | - Armand Mekontso-Dessap
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri-Mondor, AP-HP, DHU A-TVB, 94010, Créteil, France
| | - Alain Mercat
- Medical Intensive Care Department, Angers University Hospital, 4, rue Larrey, 49933, Angers Cedex, France
| | | | - Damien Roux
- Intensive Care Unit, Louis Mourier Hospital, AP-HP, 178 Rue des Renouillers, 92700, Colombes, France
| | | | - Henri Faure
- Service de Médecine Intensive - Réanimation, Centre Hospitalier Intercommunal Robert Ballanger, 93602, Aulnay-sous-Bois, France
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Abdel‐Ghaffar HS, Youseff HA, Abdelal FA, Osman MA, Sayed JA, Riad MAF, Abdel‐Rady MM. Post-extubation continuous positive airway pressure improves oxygenation after pediatric laparoscopic surgery: A randomized controlled trial. Acta Anaesthesiol Scand 2019; 63:620-629. [PMID: 30761530 DOI: 10.1111/aas.13324] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 08/28/2018] [Accepted: 09/05/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Effects of intraoperative recruitment maneuvers (RMs) on oxygenation and pulmonary compliance are lost during recovery if high inspired oxygen and airway suctioning are used. We investigated the effect of post-extubation noninvasive CPAP mask application on the alveolar arterial oxygen difference [(A-a) DO2 ] after pediatric laparoscopic surgery. METHODS Sixty patients (1-6 years) were randomly allocated to three groups of 20 patients, to receive zero end-expiratory pressure (ZEEP group), RM with decremental PEEP titration only (RM group), or followed with post-extubation CPAP for 5 minutes (RM-CPAP group). Primary outcome was [(A-a) DO2 ] at 1 hour postoperatively. Secondary outcomes were respiratory mechanics, arterial blood gas analysis, hemodynamics, and adverse events. RESULTS At 1 hour postoperatively, mean [(A-a) DO2 ] (mm Hg) was lower in the RM-CPAP group (41.5 ± 13.2, [95% CI 37.6-45.8]) compared to (80.2 ± 13.7 [72.6-87.5], P < 0.0001] and (59.2 ± 14.6, [54.8-62.6], P < 0.001) in the ZEEP and RM groups. The mean PaO2 (mm Hg) at 1 hour postoperatively was higher in the RM-CPAP group (156.2 ± 18.3 [95% CI 147.6-164.7]) compared with the ZEEP (95.9 ± 15.9 [88.5-103.3], P < 0.0001) and RM groups (129.1 ± 15.9 [121.6-136.5], P < 0.0001). At 12 hours postoperatively, mean [(A-a) DO2 ] and PaO2 were (9.6 ± 2.1 [8.4-10.8]) and (91.9 ± 9.4 [87.5-96.3]) in the RM-CPAP group compared to (25.8 ± 5.5 [23.6-27.6]) and (69.9 ± 5.5 [67.4-72.5], P < 0.0001) in the ZEEP group and (34.3 ± 13.2, [28.4-40.2], P < 0.0001) and (74.03 ± 9.8 [69.5-78.6], P < 0.0001) in the RM group. No significant differences of perioperative adverse effects were found between groups. CONCLUSIONS An RM done after pneumoperitoneum inflation followed by decremental PEEP titration improved oxygenation at 1 hour postoperatively. The addition of an early post-extubation noninvasive CPAP mask ventilation improved oxygenation at 12 hours postoperatively.
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Affiliation(s)
- Hala S. Abdel‐Ghaffar
- Anesthesia and Intensive Care Department, Faculty of Medicine Assiut University Assiut Egypt
| | - Hamdy A. Youseff
- Anesthesia and Intensive Care Department, Faculty of Medicine Assiut University Assiut Egypt
| | - Fatma A. Abdelal
- Anesthesia and Intensive Care Department, Faculty of Medicine Assiut University Assiut Egypt
| | - Mohamed A. Osman
- Pediatric Surgery Department, Faculty of Medicine Assiut University Assiut Egypt
| | - Jehan A. Sayed
- Anesthesia and Intensive Care Department, Faculty of Medicine Assiut University Assiut Egypt
| | | | - Marwa M. Abdel‐Rady
- Anesthesia and Intensive Care Department, Faculty of Medicine Assiut University Assiut Egypt
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28
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Ferrando C, Puig J, Serralta F, Carrizo J, Pozo N, Arocas B, Gutierrez A, Villar J, Belda FJ, Soro M. High-flow nasal cannula oxygenation reduces postoperative hypoxemia in morbidly obese patients: a randomized controlled trial. Minerva Anestesiol 2019; 85:1062-1070. [PMID: 30994312 DOI: 10.23736/s0375-9393.19.13364-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Postoperative pulmonary complications (PPCs) are common in high-risk surgical patients. Postoperative ventilatory management may improve their outcome. Supplemental oxygen through a high-flow nasal cannula (HFNC) has become an alternative to classical oxygenation techniques, although the results published for postoperative patients are contradictory. We examined the efficacy of HFNC in postoperative morbidly obese patients who were ventilated intraoperatively with an open-lung approach (OLA). METHODS We performed an open, two-arm, randomized controlled trial in 64 patients undergoing bariatric surgery (N.=32 in each arm) from May to November 2017 at the Hospital Clínico of Valencia. Patients were randomly assigned to receive HFNC oxygen therapy at the time of extubation or to receive conventional oxygen therapy, both applied during the first three postoperative hours. Intraoperatively, a recruitment maneuver and individualized positive end-expiratory pressure was applied in all patients. The primary outcome was postoperative hypoxemia. RESULTS All patients were included in the final analysis. There were no significant differences between the baseline characteristics. Postoperative hypoxemia was less frequent in the HFNC group compared to those who received standard care (28.6% vs. 80.0%, relative risk [RR]: 0.35; 95%CI: 0.150-0.849, P=0.009). Prevalence of atelectasis was lower in the HFNC group (31% vs. 77%, RR: 0.39; 95%CI: 0.166-0.925, P=0.013). No severe PPCs were reported in any patient. CONCLUSIONS Early application of HFNC in the operating room before extubation and during the immediate postoperative period decreases postoperative hypoxemia in obese patients after bariatric surgery who were intraoperatively ventilated using an OLA approach.
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Affiliation(s)
- Carlos Ferrando
- CIBER de Enfermedades Respiratorias, Carlos III Health Institute, Madrid, Spain - .,Department of Anesthesiology and Critical Care, Hospital Clínic, Institut D'investigació August Pi i Sunyer, Barcelona, Spain -
| | - Jaume Puig
- Department of Anesthesiology and Critical Care, General University Hospital, Valencia, Spain
| | - Ferran Serralta
- Department of Anesthesiology and Critical Care, Clinical University Hospital, Valencia, Spain
| | - Juan Carrizo
- Department of Anesthesiology and Critical Care, Clinical University Hospital, Valencia, Spain
| | - Natividad Pozo
- Department of Anesthesiology and Critical Care, Clinical University Hospital, Valencia, Spain
| | - Blanca Arocas
- Department of Anesthesiology and Critical Care, Clinical University Hospital, Valencia, Spain
| | - Andrea Gutierrez
- Department of Anesthesiology and Critical Care, Clinical University Hospital, Valencia, Spain
| | - Jesús Villar
- CIBER de Enfermedades Respiratorias, Carlos III Health Institute, Madrid, Spain.,Research Unit, Multidisciplinary Organ Dysfunction Evaluation Research Network, Dr. Negrin University Hospital, Las Palmas de Gran Canaria, Spain.,Keenan Research Center for Biomedical Sciences, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Francisco J Belda
- Department of Anesthesiology and Critical Care, Clinical University Hospital, Valencia, Spain
| | - Marina Soro
- Department of Anesthesiology and Critical Care, Clinical University Hospital, Valencia, Spain
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Application of Positive End-Expiratory Pressure (PEEP) in Patients During Prolonged Gynecological Surgery. ACTA MEDICA BULGARICA 2019. [DOI: 10.2478/amb-2019-0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction: A lot of clinical studies have shown that during prolonged surgery protective ventilation strategy, including low tidal volume, PEEP and recruitment maneuvers (RM) can reduce the rate of postoperative pulmonary complications, which are the second most common cause for postoperative mortality. Therefore, it is important to investigate clinical methods for preventing them. The strategy of protective ventilation is easy and safe for the patients and inexpensive for application during prolonged surgery.
Aims: The objective of this trial was to study whether application of PEEP in patients during prolonged gynecological surgery could decrease the postoperative complications.
Material and Methods: We compared the rates of postoperative complications in patients after prolonged open gynecological surgery, who were divided into 2 groups – group A, which was the control group on non-protective ventilation (35 patients) and group B on protective ventilation (35 patients). The patients in the control group were ventilated with tidal volume (VT) of 8-10 ml/kg without PEEP and RM; the patients in group B were ventilated with VT = 6-8 ml/kg according to their Predicted Body Weight, with a PEEP of 6 cm H2O and RM, which consisted of applying continuous positive airway pressure of 30 cm H2O for 30 seconds. RM was performed after intubation, after every disconnection from ventilator and before extubation. The study was successfully performed without a need for a change in the type of ventilation strategy because of hypoxia or hemodynamic instability. Statistical nonparametric test (e.g. chi-square) was applied.
Results: Total rate of all postoperative complications observed in both groups was 27,1%. We found a significant relationship between application of PEEP and lower rates of postoperative pulmonary complications in group A (39,4%) compared to group B (12,1%), lower rate of respiratory failure (33,3% in group A vs. 9,1% in group B -) and atelectasis (21,2% in group A vs. 0% in group B).
Conclusion: The protective ventilation strategy (low VT, PEEP and RM) in patients during prolonged gynecological surgery can reduce the rate of postoperative pulmonary complications such as respiratory failure and atelectasis.
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Gad M, Gaballa K, Abdallah A, Abdelkhalek M, Zayed A, Nabil H. Pressure-Controlled Ventilation with Volume Guarantee Compared to Volume-Controlled Ventilation with Equal Ratio in Obese Patients Undergoing Laparoscopic Hysterectomy. Anesth Essays Res 2019; 13:347-353. [PMID: 31198258 PMCID: PMC6545942 DOI: 10.4103/aer.aer_82_19] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background: Laparoscopic hysterectomy operations especially for obese patients necessitate Trendelenburg position and pneumoperitoneum with carbon dioxide, which could affect cardiac and pulmonary functions. The present study aimed to compare the impact of pressure-controlled ventilation with volume-guaranteed (PCV-VG) and volume-controlled ventilation (VCV) with equal ratio ventilation (ERV), i.e., I: E ratio of 1:1 on hemodynamics, respiratory mechanics, and oxygenation. Patients and Methods: Eighty females with body mass index (BMI) >30 kg/m2 and with physical status American Society of Anesthesiologists Classes I and II undergoing laparoscopic hysterectomy were allocated randomly to either PCV-VG (Group P) or VCV with ERV (Group V). The ventilation parameters, hemodynamics, and arterial blood gases (ABGs) analysis were recorded at four times: (T1): after the anesthetic induction while in supine position by 10 min, (T2 and T3): after the CO2 pneumoperitoneum and Trendelenburg positioning by 30 and 60 min, respectively, and (T4): after desufflation and resuming the supine position. Results: The peak inspiratory pressure in Group P recorded significant lower values than in Group V while the dynamic compliance was greater significantly in Group P than in Group V. No significant differences were reported as regards the ABG analysis, oxygenation, and hemodynamic data between both groups. Conclusion: In obese females undergoing laparoscopic hysterectomy surgeries, PCV-VG was superior to VCV with ERV as it provided higher dynamic compliance and lower peak inspiratory pressure that could be preferable, especially in those patients in whom cardiopulmonary function could be more susceptible to impairment.
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Affiliation(s)
- Mona Gad
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Khaled Gaballa
- Department of Surgical Oncology, Mansoura Oncology Center, Mansoura University, Mansoura, Egypt
| | - Ahmed Abdallah
- Department of Surgical Oncology, Mansoura Oncology Center, Mansoura University, Mansoura, Egypt
| | - Mohamed Abdelkhalek
- Department of Surgical Oncology, Mansoura Oncology Center, Mansoura University, Mansoura, Egypt
| | - Abdelhady Zayed
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Hanan Nabil
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Walesa M, Bayat S, Albu G, Baudat A, Petak F, Habre W. Comparison between neurally-assisted, controlled, and physiologically variable ventilation in healthy rabbits. Br J Anaesth 2018; 121:918-927. [DOI: 10.1016/j.bja.2018.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 01/08/2018] [Accepted: 01/25/2018] [Indexed: 10/17/2022] Open
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Effect of prolonged inspiratory time on gas exchange during robot-assisted laparoscopic urologic surgery. Anaesthesist 2018; 67:859-867. [PMID: 30225665 DOI: 10.1007/s00101-018-0486-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 07/18/2018] [Accepted: 08/27/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Gas exchange disturbance may develop during urologic robotic laparoscopic surgery with the patient in a steep Trendelenburg position. This study investigated whether prolonged inspiratory time could mitigate gas exchange disturbances including hypercapnia. METHODS In this randomized cross-over trial, 32 patients scheduled for robot-assisted urologic surgery were randomized to receive an inspiratory to expiratory time ratio (I:E) of 1:1 for the first hour of pneumoperitoneum followed by 1:2 for last period of surgery (group A, n = 17) or I:E of 1:2 followed by 1:1 (group B, n = 15). Arterial blood gas analysis, airway pressure and hemodynamic variables were assessed at four time points (T1: 10 min after induction of general anesthesia, T2: 1 h after the initiation of pneumoperitoneum, T3: 1 h after T2 and T4: at skin closure). The carry over effect of initial I:E was also evaluated over the next hour through arterial blood gas analysis. RESULTS There was a significant decrease in partial pressure of oxygen in arterial blood (PaO2) for both groups at T2 and T3 compared to T1 but in group B the PaO2 at T4 was not decreased from the baseline. Partial pressure of carbon dioxide in arterial blood (PaCO2) increased with I:E of 1:2 but did not significantly increase with I:E of 1:1; however, there were no differences in PaO2 and PaCO2 between the groups. CONCLUSION Decreased oxygenation by pneumoperitoneum was improved and PaCO2 did not increase after 1 h of I:E of 1:1; however, the effect of equal ratio ventilation longer than 1 h remains to be determined. There was no carryover effect of the two different I:E ratios.
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Abstract
Perioperative lung injury is a major source of postoperative morbidity, excess healthcare use, and avoidable mortality. Many potential inciting factors can lead to this condition, including intraoperative ventilator induced lung injury. Questions exist as to whether protective ventilation strategies used in the intensive care unit for patients with acute respiratory distress syndrome are equally beneficial for surgical patients, most of whom do not present with any pre-existing lung pathology. Studied both individually and in combination as a package of intraoperative lung protective ventilation, the use of low tidal volumes, moderate positive end expiratory pressure, and recruitment maneuvers have been shown to improve oxygenation and pulmonary physiology and to reduce postoperative pulmonary complications in at risk patient groups. Further work is needed to define the potential contributions of alternative ventilator strategies, limiting excessive intraoperative oxygen supplementation, use of non-invasive techniques in the postoperative period, and personalized mechanical ventilation. Although the weight of evidence strongly suggests a role for lung protective ventilation in moderate risk patient groups, definitive evidence of its benefit for the general surgical population does not exist. However, given the shift in understanding of what is needed for adequate oxygenation and ventilation under anesthesia, the largely historical arguments against the use of intraoperative lung protective ventilation may soon be outdated, on the basis of its expanding track record of safety and efficacy in multiple settings.
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Affiliation(s)
- Brian O'Gara
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Daniel Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
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Di Bella C, Lacitignola L, Grasso S, Centonze P, Greco A, Ostuni R, Crovace A, Staffieri F. An alveolar recruitment maneuver followed by positive end-expiratory pressure improves lung function in healthy dogs undergoing laparoscopy. Vet Anaesth Analg 2018; 45:618-629. [DOI: 10.1016/j.vaa.2018.03.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 01/27/2018] [Accepted: 03/07/2018] [Indexed: 01/16/2023]
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Golparvar M, Mofrad SZ, Mahmoodieh M, Kalidarei B. Comparative Evaluation of the Effects of Three Different Recruitment Maneuvers during Laparoscopic Bariatric Surgeries of Morbid Obese Patients on Cardiopulmonary Indices. Adv Biomed Res 2018; 7:89. [PMID: 29930929 PMCID: PMC5991281 DOI: 10.4103/abr.abr_75_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background: Laparoscopic bariatric surgeries in morbid obese patients may be associated with atelectasis, hypercapnia, and hypoxemia, intra and postoperatively. Several strategies are used for the prevention of these consequences. This study aimed to examine the effects of three different recruitment maneuvers comparatively during surgery and the influence of the maneuvers on some cardiopulmonary indices. Materials and Methods: In a clinical trial, ninety participants of laparoscopic surgery with body mass index higher than 40 were randomly divided into three equal groups. The first group was subject to 10 cmH2O positive end-expiratory pressure (PEEP) during surgery, the second group, after venting the pneumoperitoneum, had 5 deep breaths with a positive pressure of 40 cmH2O, and the third group was subject to both. Some pulmonary and hemodynamic parameters were measured every 15 min and compared between three groups. Results: The average of peak airway pressure, plateau airway pressure, and SpO2 static and dynamic compliance between the three groups had no meaningful differences (P > 0.05), but PaCO2in the second group was statistically higher than the other two groups (P < 0.05). Conclusion: Multiple deep breaths alone are not as effective as PEEP or PEEP plus MDB in preventing adverse pulmonary effects in laparoscopic bariatric surgeries of morbid obese patients.
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Affiliation(s)
- Mohammad Golparvar
- Department of Anesthesia, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Simaa Zangouei Mofrad
- Department of Anesthesia, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohsen Mahmoodieh
- Department of Surgery, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Behrooz Kalidarei
- Department of Surgery, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran
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Abstract
BACKGROUND Bariatric surgery has proven a successful approach in the treatment of morbid obesity and its concomitant diseases such as diabetes mellitus and arterial hypertension. Aiming for optimal management of this challenging patient cohort, tailored concepts directly guided by individual patient physiology may outperform standardized care. Implying esophageal pressure measurement and electrical impedance tomography-increasingly applied monitoring approaches to individually adjust mechanical ventilation in challenging circumstances like acute respiratory distress syndrome (ARDS) and intraabdominal hypertension-we compared our institutions standard ventilator regimen with an individually adjusted positive end expiratory pressure (PEEP) level aiming for a positive transpulmonary pressure (P L) throughout the respiratory cycle. METHODS After obtaining written informed consent, 37 patients scheduled for elective bariatric surgery were studied during mechanical ventilation in reverse Trendelenburg position. Before and after installation of capnoperitoneum, PEEP levels were gradually raised from a standard value of 10 cm H2O until a P L of 0 +/- 1 cm H2O was reached. Changes in ventilation were monitored by electrical impedance tomography (EIT) and arterial blood gases (ABGs) were obtained at the end of surgery and 5 and 60 min after extubation, respectively. RESULTS To achieve the goal of a transpulmonary pressure (P L) of 0 cm H2O at end expiration, PEEP levels of 16.7 cm H2O (95% KI 15.6-18.1) before and 23.8 cm H2O (95% KI 19.6-40.4) during capnoperitoneum were necessary. EIT measurements confirmed an optimal PEEP level between 10 and 15 cm H2O before and 20 and 25 cm H2O during capnoperitoneum, respectively. Intra- and postoperative oxygenation did not change significantly. CONCLUSION Patients during laparoscopic bariatric surgery require high levels of PEEP to maintain a positive transpulmonary pressure throughout the respiratory cycle. EIT monitoring allows for non-invasive monitoring of increasing PEEP demand during capnoperitoneum. Individually adjusted PEEP levels did not result in improved postoperative oxygenation.
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Saxena D, Singh P, Dixit A, Arya B, Bhandari M, Sanwatsarkar S. Does Pulmonary Artery Systolic Pressure as Estimated by Transthoracic Echocardiography Alter the Effect of Positive End-Expiratory Pressure on Arterial Blood Gases and Hemodynamics in Morbidly Obese Patients? Anesth Essays Res 2017; 11:1013-1017. [PMID: 29284866 PMCID: PMC5735441 DOI: 10.4103/aer.aer_73_17] [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] [Indexed: 11/04/2022] Open
Abstract
Background Positive end-expiratory pressure (PEEP) at the time of induction increases oxygenation by preventing lung atelectasis. However, PEEP may not prove beneficial in all cases. Factors affecting the action of PEEP have not been elucidated well and remain controversial. Pulmonary vasculature has direct bearing on the action of PEEP as has been proven in the previous studies. Thus, this prospective study was planned to evaluate the action of PEEP on the basis of pulmonary artery systolic pressure (PASP) which is noninvasive and easily measured by transthoracic echocardiography. Materials and Methods Seventy morbidly obese patients, the American Society of Anesthesiologists Grade II, or III, aged 20-65 years with body mass index >40 kg/m2, scheduled for elective laparoscopic bariatric surgery were included. Patients who denied consent, those undergoing emergency and/or open surgery and those requiring >2 attempts for intubation were excluded from the study. Ten patients had to be excluded. Thus, a total of sixty patients participated in the study. Thirty patients received no PEEP at the time of induction while other thirty patients were given a PEEP of 10 cm of H2O. Serial ABG samples were taken preoperatively, at the time of intubation, 5 min after intubation, and 10 min after intubation. Patients were then divided into four groups on the basis of PASP value of ≤30 mm Hg with and without PEEP or >30 mm Hg with and without PEEP. Primary Outcome The primary outcome was the effect of PEEP of 10 cm of H2 O on ABG and hemodynamics in morbidly obese patients. Secondary Outcome The secondary outcome was the effect of PASP on the action of PEEP in morbidly obese patients undergoing laparoscopic surgery. Results Patients having PASP of >30 mm Hg had significant improvement in oxygenation on PEEP application (270.11 ± 119.26 mm Hg) as compared to those without PEEP (157.57 ± 109.29 mm Hg) just after intubation. The increase in oxygenation remained significant at all time intervals. Patients with PASP ≤30 mm Hg did not show significant improvement in oxygenation with PEEP application (177.09 ± 85.85 mm Hg as compared to 226.27 ± 92.42 mm Hg without PEEP). Hemodynamic parameters did not show statistically significant alterations. Conclusion Morbidly obese patients who have PASP >30 mm Hg benefit most from the PEEP. Thus, PASP which is an easily measurable noninvasive parameter can be used as a criterion for selecting patients who benefit from PEEP application.
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Affiliation(s)
- Dipti Saxena
- Department of Anesthesiology, Sri Aurobindo Institute of Medical Sciences, MOHAK Hi-Tech Hospital, Indore, Madhya Pradesh, India
| | - Priyank Singh
- Department of Anesthesiology, Sri Aurobindo Institute of Medical Sciences, MOHAK Hi-Tech Hospital, Indore, Madhya Pradesh, India
| | - Atul Dixit
- Department of Anesthesiology, Sri Aurobindo Institute of Medical Sciences, MOHAK Hi-Tech Hospital, Indore, Madhya Pradesh, India
| | - Bipin Arya
- Department of Anesthesiology, Sri Aurobindo Institute of Medical Sciences, MOHAK Hi-Tech Hospital, Indore, Madhya Pradesh, India
| | - Mohit Bhandari
- Department of Bariatric and Metabolic Surgeries, MOHAK Hi-Tech Hospital, Indore, Madhya Pradesh, India
| | - Sadhana Sanwatsarkar
- Department of Anesthesiology, Sri Aurobindo Institute of Medical Sciences, MOHAK Hi-Tech Hospital, Indore, Madhya Pradesh, India
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Rodrigues JC, Teixeira-Neto FJ, Cerejo SA, Celeita-Rodríguez N, Garofalo NA, Quitzan JG, Rocha TLA. Effects of pneumoperitoneum and of an alveolar recruitment maneuver followed by positive end-expiratory pressure on cardiopulmonary function in sheep anesthetized with isoflurane-fentanyl. Vet Anaesth Analg 2017; 44:841-853. [PMID: 28888803 DOI: 10.1016/j.vaa.2016.05.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 05/13/2016] [Accepted: 05/29/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To investigate the effects of pneumoperitoneum alone or combined with an alveolar recruitment maneuver (ARM) followed by positive end-expiratory pressure (PEEP) on cardiopulmonary function in sheep. STUDY DESIGN Prospective, randomized, crossover study. ANIMALS A total of nine adult sheep (36-52 kg). METHODS Sheep were administered three treatments (≥10-day intervals) during isoflurane-fentanyl anesthesia and volume-controlled ventilation (tidal volume: 12 mL kg-1) with oxygen: CONTROL (no intervention); PNEUMO (120 minutes of CO2 pneumoperitoneum); PNEUMOARM/PEEP (PNEUMO protocol with an ARM instituted after 60 minutes of pneumoperitoneum). The ARM (5 cmH2O increases in PEEP of 1 minute duration until 20 cmH2O of PEEP) was followed by 10 cmH2O of PEEP until the end of anesthesia. Cardiopulmonary data were recorded until 30 minutes after abdominal deflation. RESULTS PaO2 was decreased from 435-462 mmHg (58.0-61.6 kPa) (range of mean values in CONTROL) to 377-397 mmHg (50.3-52.9 kPa) in PNEUMO (p < 0.05). Quasistatic compliance (Cqst, mL cmH2O-1 kg-1) was decreased from 0.85-0.92 in CONTROL to 0.52-0.58 in PNEUMO. PaO2 increased from 383-385 mmHg (51.1-51.3 kPa) in PNEUMO to 429-444 mmHg (57.2-59.2 kPa) in PNEUMOARM/PEEP (p < 0.05) and Cqst increased from 0.52-0.53 in PNEUMO to 0.70-0.74 in PNEUMOARM/PEEP. Abdominal deflation in PNEUMO did not restore PaO2 and Cqst to control values. Cardiac index (L minute-1 m2) decreased from 4.80-4.70 in CONTROL to 3.45-3.74 in PNEUMO and 3.63-3.76 in PNEUMOARM/PEEP. Compared with controls, ARM/PEEP with pneumoperitoneum decreased mean arterial pressure from 81 to 68 mmHg and increased mean pulmonary artery pressure from 10 to 16 mmHg. CONCLUSIONS AND CLINICAL RELEVANCE Abdominal deflation did not reverse the pulmonary function impairment associated with pneumoperitoneum. The ARM/PEEP improved respiratory compliance and reversed the oxygenation impairment induced by pneumoperitoneum with acceptable hemodynamic changes in healthy sheep.
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Affiliation(s)
| | - Francisco J Teixeira-Neto
- Faculdade de Medicina, Univ Estadual Paulista (UNESP), Botucatu, Brazil; Faculdade de Medicina Veterinária e Zootecnia, Univ Estadual Paulista (UNESP), Botucatu, Brazil.
| | - Sofia A Cerejo
- Faculdade de Medicina, Univ Estadual Paulista (UNESP), Botucatu, Brazil
| | | | - Natache A Garofalo
- Faculdade de Medicina Veterinária e Zootecnia, Univ Estadual Paulista (UNESP), Botucatu, Brazil
| | - Juliany G Quitzan
- Faculdade de Medicina Veterinária e Zootecnia, Univ Estadual Paulista (UNESP), Botucatu, Brazil
| | - Thalita L A Rocha
- Faculdade de Medicina, Univ Estadual Paulista (UNESP), Botucatu, Brazil
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Abstract
INTRODUCTION Obesity has become an epidemic in the Arabian Gulf, with the prevalence of obesity according to the latest report from the World Health Organization (WHO) showing the gulf region to be countries with the highest incidence of obesity in the 30% plus group. This study aims to examine publications on bariatric surgery and compare them with the other countries with a high incidence of obesity in the world. METHODS A literature review on bariatric surgery published from the earliest detected year of publication up until March 2016 using SCOPUS, PubMed, Ovid, and Google Scholar was conducted. Individual papers were assessed for types of surgery, preoperative measures, names of journals, authors, and outcomes. The data was analyzed using Endnote library and SPSS. Key words used in the search included "Bariatric Surgery," "Arabian Gulf," "Kuwait," "Qatar," "Saudi Arabia," "United Arab Emirates," "Oman," "USA," "Australia," "weight loss surgery," "sleeve gastrectomy," "gastric bypass," "gastric band," "mini-gastric bypass," "biliropancreatic diversion," "duodenal switch," and "intragastric balloon." Original papers, systematic reviews and case reports were included. RESULTS From our review, the gastric sleeve proved to be the most popular published on procedure in the Arabian Gulf, whereas the USA had the highest percentage of gastric bypass surgeries and Australia had equivalent numbers when it came to gastric bypass and band. The numbers of studies from Saudi Arabia, Kuwait, UAE, Bahrain, Qatar, and Oman were 70, 44, 20, 7, 6, and 0, respectively. The mean impact factor of the published articles was 2.53 +/- 1.76 SD. Most of the publications were published in Obesity Surgery (29%), Surgery for Obesity and Related Diseases (5%), and Surgical Endoscopy (5%). CONCLUSION The Arabian Gulf has both the highest percentage of bariatric procedures performed as well as the highest prevalence of obesity. However, they have the lowest number of publications and research when compared to their western counterparts; therefore, more research and publications are needed in the Arabian Gulf region, as well as the possibility of producing a regional registry to be able to have a good overview of bariatric surgery in the region.
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Maia LDA, Silva PL, Pelosi P, Rocco PRM. Controlled invasive mechanical ventilation strategies in obese patients undergoing surgery. Expert Rev Respir Med 2017; 11:443-452. [PMID: 28436715 DOI: 10.1080/17476348.2017.1322510] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The obesity prevalence is increasing in surgical population. As the number of obese surgical patients increases, so does the demand for mechanical ventilation. Nevertheless, ventilatory strategies in this population are challenging, since obesity results in pathophysiological changes in respiratory function. Areas covered: We reviewed the impact of obesity on respiratory system and the effects of controlled invasive mechanical ventilation strategies in obese patients undergoing surgery. To date, there is no consensus regarding the optimal invasive mechanical ventilation strategy for obese surgical patients, and no evidence that possible intraoperative beneficial effects on oxygenation and mechanics translate into better postoperative pulmonary function or improved outcomes. Expert commentary: Before determining the ideal intraoperative ventilation strategy, it is important to analyze the pathophysiology and comorbidities of each obese patient. Protective ventilation with low tidal volume, driving pressure, energy, and mechanical power should be employed during surgery; however, further studies are required to clarify the most effective ventilation strategies, such as the optimal positive end-expiratory pressure and whether recruitment maneuvers minimize lung injury. In this context, an ongoing trial of intraoperative ventilation in obese patients (PROBESE) should help determine the mechanical ventilation strategy that best improves clinical outcome in patients with body mass index≥35kg/m2.
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Affiliation(s)
- Lígia de Albuquerque Maia
- a Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute , Federal University of Rio de Janeiro , Rio de Janeiro , Brazil
| | - Pedro Leme Silva
- a Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute , Federal University of Rio de Janeiro , Rio de Janeiro , Brazil.,b National Institute of Science and Technology for Regenerative Medicine , Rio de Janeiro , Brazil
| | - Paolo Pelosi
- c Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino-IST , University of Genoa , Genoa , Italy
| | - Patricia Rieken Macedo Rocco
- a Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute , Federal University of Rio de Janeiro , Rio de Janeiro , Brazil.,b National Institute of Science and Technology for Regenerative Medicine , Rio de Janeiro , Brazil
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Preoxygenation and intraoperative ventilation strategies in obese patients: a comprehensive review. Curr Opin Anaesthesiol 2016; 29:109-18. [PMID: 26545146 DOI: 10.1097/aco.0000000000000267] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Obesity along with its pathophysiological changes increases risk of intraoperative and perioperative respiratory complications. The aim of this review is to highlight recent updates in preoxygenation techniques and intraoperative ventilation strategies in obese patients to optimize gas exchange and pulmonary mechanics and reduce pulmonary complications. RECENT FINDINGS There is no gold standard in preoxygenation or intraoperative ventilatory management protocol for obese patients. Preoxygenation in head up or sitting position has been shown to be superior to supine position. Apneic oxygenation and use of continuous positive airway pressure increases safe apnea duration. Recent evidence encourages the intraoperative use of low tidal volume to improve oxygenation and lung compliance without adverse effects. Contrary to nonobese patients, some studies have reported the beneficial effect of recruitment maneuvers and positive end-expiratory pressure in obese patients. No difference has been observed between volume controlled and pressure controlled ventilation. SUMMARY The ideal ventilatory plan for obese patients is indeterminate. A multimodal preoxygenation and intraoperative ventilation plan is helpful in obese patients to reduce perioperative respiratory complications. More studies are needed to identify the role of low tidal volume, positive end-expiratory pressure, and recruitment maneuvers in obese patients undergoing general anesthesia.
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Uludağ Ö, Türktan M. Obezite Hastalarında Anestezi Yönetimi. ARŞIV KAYNAK TARAMA DERGISI 2016. [DOI: 10.17827/aktd.248423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Kozanhan B, Apiliogullari S, Basaran B, Iyisoy MS, Ozmen S. The Effects of Positive End-Expiratory Pressure on Cross-Sectional Area of Internal Jugular Vein in Obese Patients. Bariatr Surg Pract Patient Care 2016. [DOI: 10.1089/bari.2016.0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Betul Kozanhan
- Department of Anesthesiology and Reanimation, Konya Education and Research Hospital, Konya, Turkey
| | - Seza Apiliogullari
- Department of Anesthesiology and Reanimation, Selcuk University Medical Faculty, Konya, Turkey
| | - Betul Basaran
- Department of Anesthesiology and Reanimation, Konya Education and Research Hospital, Konya, Turkey
| | - Mehmet Sinan Iyisoy
- Department of Medical Education and Informatics, Necmettin Erbakan University, Meram Faculty of Medicine, Konya, Turkey
| | - Sadik Ozmen
- Department of Anesthesiology and Reanimation, Konya Education and Research Hospital, Konya, Turkey
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Guo L, Wang W, Zhao N, Guo L, Chi C, Hou W, Wu A, Tong H, Wang Y, Wang C, Li E. Mechanical ventilation strategies for intensive care unit patients without acute lung injury or acute respiratory distress syndrome: a systematic review and network meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:226. [PMID: 27448995 PMCID: PMC4957383 DOI: 10.1186/s13054-016-1396-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 06/29/2016] [Indexed: 01/25/2023]
Abstract
Background It has been shown that the application of a lung-protective mechanical ventilation strategy can improve the prognosis of patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). However, the optimal mechanical ventilation strategy for intensive care unit (ICU) patients without ALI or ARDS is uncertain. Therefore, we performed a network meta-analysis to identify the optimal mechanical ventilation strategy for these patients. Methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, EMBASE, MEDLINE, CINAHL, and Web of Science for studies published up to July 2015 in which pulmonary compliance or the partial pressure of arterial oxygen/fraction of inspired oxygen (PaO2/FIO2) ratio was assessed in ICU patients without ALI or ARDS, who received mechanical ventilation via different strategies. The data for study characteristics, methods, and outcomes were extracted. We assessed the studies for eligibility, extracted the data, pooled the data, and used a Bayesian fixed-effects model to combine direct comparisons with indirect evidence. Results Seventeen randomized controlled trials including a total of 575 patients who received one of six ventilation strategies were included for network meta-analysis. Among ICU patients without ALI or ARDS, strategy C (lower tidal volume (VT) + higher positive end-expiratory pressure (PEEP)) resulted in the highest PaO2/FIO2 ratio; strategy B (higher VT + lower PEEP) was associated with the highest pulmonary compliance; strategy A (lower VT + lower PEEP) was associated with a shorter length of ICU stay; and strategy D (lower VT + zero end-expiratory pressure (ZEEP)) was associated with the lowest PaO2/FiO2 ratio and pulmonary compliance. Conclusions For ICU patients without ALI or ARDS, strategy C (lower VT + higher PEEP) was associated with the highest PaO2/FiO2 ratio. Strategy B (higher VT + lower PEEP) was superior to the other strategies in improving pulmonary compliance. Strategy A (lower VT + lower PEEP) was associated with a shorter length of ICU stay, whereas strategy D (lower VT + ZEEP) was associated with the lowest PaO2/FiO2 ratio and pulmonary compliance. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1396-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lei Guo
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, No 23 Youzheng St., Nangang District, Harbin, Heilongjiang, 150001, China
| | - Weiwei Wang
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, No 23 Youzheng St., Nangang District, Harbin, Heilongjiang, 150001, China
| | - Nana Zhao
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, No 23 Youzheng St., Nangang District, Harbin, Heilongjiang, 150001, China
| | - Libo Guo
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, No 23 Youzheng St., Nangang District, Harbin, Heilongjiang, 150001, China
| | - Chunjie Chi
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, No 23 Youzheng St., Nangang District, Harbin, Heilongjiang, 150001, China
| | - Wei Hou
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, No 23 Youzheng St., Nangang District, Harbin, Heilongjiang, 150001, China
| | - Anqi Wu
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, No 23 Youzheng St., Nangang District, Harbin, Heilongjiang, 150001, China
| | - Hongshuang Tong
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, No 23 Youzheng St., Nangang District, Harbin, Heilongjiang, 150001, China
| | - Yue Wang
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, No 23 Youzheng St., Nangang District, Harbin, Heilongjiang, 150001, China
| | - Changsong Wang
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, No 23 Youzheng St., Nangang District, Harbin, Heilongjiang, 150001, China.
| | - Enyou Li
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, No 23 Youzheng St., Nangang District, Harbin, Heilongjiang, 150001, China.
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Zhang W, Zhu S. The effects of inverse ratio ventilation on cardiopulmonary function and inflammatory cytokine of bronchoaveolar lavage in obese patients undergoing gynecological laparoscopy. ACTA ACUST UNITED AC 2016; 54:1-5. [DOI: 10.1016/j.aat.2015.11.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/20/2015] [Accepted: 11/02/2015] [Indexed: 11/15/2022]
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Edmark L, Östberg E, Scheer H, Wallquist W, Hedenstierna G, Zetterström H. Preserved oxygenation in obese patients receiving protective ventilation during laparoscopic surgery: a randomized controlled study. Acta Anaesthesiol Scand 2016; 60:26-35. [PMID: 26235391 DOI: 10.1111/aas.12588] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 05/28/2015] [Accepted: 06/08/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Venous admixture from atelectasis and airway closure impedes oxygenation during general anaesthesia. We tested the hypothesis that continuous positive airway pressure (CPAP) during pre-oxygenation and reduced fraction of inspiratory oxygen (FIO2 ) during emergence from anaesthesia can improve oxygenation in patients with obesity undergoing laparoscopic surgery. METHODS In the intervention group (n = 20, median BMI 41.9), a CPAP of 10 cmH2 O was used during pre-oxygenation and induction of anaesthesia, but no CPAP was used in the control group (n = 20, median BMI 38.1). During anaesthesia, all patients were ventilated in volume-controlled mode with an FIO2 of 0.4 and a positive end-expiratory pressure (PEEP) of 10 cmH2 O. During emergence, before extubation, the control group was given an FIO2 of 1.0 and the intervention group was divided into two subgroups, which were given an FIO2 of 1.0 or 0.31. Oxygenation was assessed perioperatively by the estimated venous admixture (EVA). RESULTS The median EVA before pre-oxygenation was about 8% in both groups. During anaesthesia after intubation, the median EVA was 8.2% in the intervention vs. 13.2% in the control group (P = 0.048). After CO2 pneumoperitoneum, the median EVA was 8.4% in the intervention vs. 9.9% in the control group (P > 0.05). One hour post-operatively, oxygenation had deteriorated in patients given an FIO2 of 1.0 during emergence but not in patients given an FIO2 of 0.31. CONCLUSIONS A CPAP of 10 cmH2 O during pre-oxygenation and induction, followed by PEEP after intubation, seemed to preserve oxygenation during anaesthesia. Post-operative oxygenation depended on the FIO2 used during emergence.
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Affiliation(s)
- L. Edmark
- Department of Anaesthesiology and Intensive Care; Västmanland Hospital Västerås; Västerås Sweden
| | - E. Östberg
- Department of Anaesthesiology and Intensive Care; Västmanland Hospital Västerås; Västerås Sweden
| | - H. Scheer
- Department of Anaesthesiology and Intensive Care; Västmanland Hospital Västerås; Västerås Sweden
| | - W. Wallquist
- Department of Anaesthesiology and Intensive Care; Västmanland Hospital Västerås; Västerås Sweden
| | - G. Hedenstierna
- Department of Medical Sciences, Clinical Physiology; Uppsala University; Uppsala Sweden
| | - H. Zetterström
- Department of Surgical Sciences, Anaesthesiology and Critical Care Medicine; Uppsala University; Uppsala Sweden
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Martin JB, Garbee D, Bonanno L. Effectiveness of positive end-expiratory pressure, decreased fraction of inspired oxygen and vital capacity recruitment maneuver in the prevention of pulmonary atelectasis in patients undergoing general anesthesia: a systematic review. ACTA ACUST UNITED AC 2015. [DOI: 10.11124/01938924-201513080-00017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Souza GMC, Santos GMS, Barbosa FT, Melnik T. Intraoperative ventilation strategies for obese patients undergoing bariatric surgery. Hippokratia 2015. [DOI: 10.1002/14651858.cd011758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- George MC Souza
- State University of Health Sciences of Alagoas; Department of Physical Therapy; Av. Júlio Marques Luz, n 92, ap 801, Ponta Verde Maceió Brazil 57035-700
| | - Gianni Mara S Santos
- Federal University of São Paulo; Department of Statistics; Rua Dr. Diogo de Farias, 1087, conjunto 809/810, Vila Clementino São Paulo São Paulo Brazil 04037-003
| | - Fabiano T Barbosa
- Hospital Geral do Estado Professor Osvaldo Brandão Vilela; Department of Clinical Medicine; Siqueira Campos Avenue, 2095 Trapiche da Barra Maceió Alagoas Brazil 57010000
| | - Tamara Melnik
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde; Brazilian Cochrane Centre; Federal University of Sao Paulo (Unifesp) Martiniano de Carvalho Street, 864/ cj 302 São Paulo São Paulo Brazil 01321-000
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Wang C, Zhao N, Wang W, Guo L, Guo L, Chi C, Wang X, Pi X, Cui Y, Li E. Intraoperative mechanical ventilation strategies for obese patients: a systematic review and network meta-analysis. Obes Rev 2015; 16:508-17. [PMID: 25788167 DOI: 10.1111/obr.12274] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 12/09/2014] [Accepted: 02/11/2015] [Indexed: 11/27/2022]
Abstract
Several intraoperative ventilation strategies are available for obese patients. However, the same ventilation interventions have exhibited different effects on PaO2 /FIO2 concerning obese patients in different trials, and the issue remains controversial. Therefore, we conducted a network meta-analysis to identify the optimal mechanical ventilation strategy. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, Embase, MEDLINE, CINAHL and Web of Science for studies published up to June 2014, and the PaO2 /FIO2 in obese patients given different mechanical ventilation strategies was assessed. We assessed the studies for eligibility and extracted data and then pooled the data and used a Bayesian fixed-effect model to combine direct comparisons with indirect evidence. Eligible studies evaluated different ventilation strategies for obese patients and reported the intraoperative PaO2 /FIO2 ratio, atelectasis and pulmonary compliance. Thirteen randomized controlled trials were included for network meta-analysis, including 476 patients who received 1 of 12 ventilation strategies. Volume-controlled ventilation with higher PEEP plus single recruitment manoeuvres (VCV + higher PEEP + single RM) was associated with the highest PaO2 /FiO2 ratio, improving intraoperative pulmonary compliance and reducing the incidence of intraoperative atelectasis.
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Affiliation(s)
- C Wang
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - N Zhao
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - W Wang
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Libo Guo
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Lei Guo
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - C Chi
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - X Wang
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - X Pi
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Y Cui
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - E Li
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
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Abstract
PURPOSE OF REVIEW To provide the most recent and relevant clinical evidence regarding the use of prophylactic lung-protective mechanical ventilation in abdominal surgery. RECENT FINDINGS Evidence is accumulating, suggesting an association between intraoperative mechanical ventilation strategy and postoperative pulmonary complications in patients undergoing abdominal surgery. Nonprotective ventilator settings, especially high tidal volume (>10-12 ml/kg), very low level of positive end-expiratory pressure (PEEP, <5 cm H2O), or no PEEP, may cause alveolar overdistension and repetitive tidal recruitment leading to ventilator-associated lung injury in patients with healthy lungs. Stimulated by the previous findings in patients with acute respiratory distress syndrome, the use of lower tidal volume ventilation is becoming increasingly more common in the operating room. However, lowering tidal volume, though important, is only part of the overall multifaceted approach of lung-protective mechanical ventilation. Recent data provide compelling evidence that prophylactic lung-protective mechanical ventilation using lower tidal volume (6-8 ml/kg of predicted body weight), moderate PEEP (6-8 cm H2O), and recruitment maneuvers is associated with improved functional or physiological and clinical postoperative outcome in patients undergoing abdominal surgery. SUMMARY The use of prophylactic lung-protective ventilation can help in improving the postoperative outcome.
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