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Covotta M, Claroni C, Torregiani G, Menga LS, Venti E, Gazzè G, Anzellotti GM, Ceccarelli V, Gaglioti P, Orlando S, Rosà T, Forastiere E, Antonelli M, Grieco DL. Recruitment-to-inflation ratio to assess response to PEEP during laparoscopic surgery: A physiologic study. J Clin Anesth 2024; 98:111569. [PMID: 39106592 DOI: 10.1016/j.jclinane.2024.111569] [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: 01/12/2024] [Revised: 06/14/2024] [Accepted: 07/28/2024] [Indexed: 08/09/2024]
Abstract
STUDY OBJECTIVE During laparoscopic surgery, the role of PEEP to improve outcome is controversial. Mechanistically, PEEP benefits depend on the extent of alveolar recruitment, which prevents ventilator-induced lung injury by reducing lung dynamic strain. The hypotheses of this study were that pneumoperitoneum-induced aeration loss and PEEP-induced recruitment are inter-individually variable, and that the recruitment-to-inflation ratio (R/I) can identify patients who benefit from PEEP in terms of strain reduction. DESIGN Sequential study. SETTING Operating room. PATIENTS Seventeen ASA I-III patients receiving robot-assisted prostatectomy during Trendelenburg pneumoperitoneum. INTERVENTIONS AND MEASUREMENTS Patients underwent end-expiratory lung volume (EELV) and respiratory/lung/chest wall mechanics (esophageal manometry and inspiratory/expiratory occlusions) assessment at PEEP = 0 cmH2O before and after pneumoperitoneum, at PEEP = 4 and 12 cmH2O during pneumoperitoneum. Pneumoperitoneum-induced derecruitment and PEEP-induced recruitment were assessed through a simplified method based on multiple pressure-volume curve. Dynamic and static strain changes were evaluated. R/I between 12 and 4 cmH2O was assessed from EELV. Inter-individual variability was rated with the ratio of standard deviation to mean (CoV). MAIN RESULTS Pneumoperitoneum reduced EELV by (median [IqR]) 410 mL [80-770] (p < 0.001) and increased dynamic strain by 0.04 [0.01-0.07] (p < 0.001), with high inter-individual variability (CoV = 70% and 88%, respectively). Compared to PEEP = 4 cmH2O, PEEP = 12 cmH2O yielded variable amount of recruitment (139 mL [96-366] CoV = 101%), causing different extent of dynamic strain reduction (median decrease 0.02 [0.01-0.04], p = 0.002; CoV = 86%) and static strain increases (median increase 0.05 [0.04-0.07], p = 0.01, CoV = 33%). R/I (1.73 [0.58-3.35]) estimated the decrease in dynamic strain (p ≤0.001, r = -0.90) and the increase in static strain (p = 0.009, r = -0.73) induced by PEEP, while PEEP-induced changes in respiratory and lung mechanics did not. CONCLUSIONS Trendelenburg pneumoperitoneum yields variable derecruitment: PEEP capability to revert these phenomena varies significantly among individuals. High R/I identifies patients in whom higher PEEP mostly reduces dynamic strain with limited static strain increases, potentially allowing individualized settings.
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Affiliation(s)
- Marco Covotta
- Department of Anesthesiology, Intensive Care and Pain Therapy, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Claudia Claroni
- Department of Anesthesiology, Intensive Care and Pain Therapy, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Giulia Torregiani
- Department of Anesthesiology, Intensive Care and Pain Therapy, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Luca S Menga
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Emanuela Venti
- Department of Anesthesiology, Intensive Care and Pain Therapy, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Gaetano Gazzè
- Department of Anesthesiology, Critical Care and Pain Medicine, "Sapienza" University of Roma, Rome, Italy
| | - Gian Marco Anzellotti
- Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia, Analgesia, Perioperative and Intensive Care, SS. Annunziata Hospital, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Valentina Ceccarelli
- Department of Anesthesiology, Critical Care and Pain Medicine, "Sapienza" University of Roma, Rome, Italy
| | - Pierpaolo Gaglioti
- Department of Anesthesiology, Critical Care and Pain Medicine, "Sapienza" University of Roma, Rome, Italy
| | - Sara Orlando
- Department of Anesthesiology, Critical Care and Pain Medicine, "Sapienza" University of Roma, Rome, Italy
| | - Tommaso Rosà
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Ester Forastiere
- Department of Anesthesiology, Intensive Care and Pain Therapy, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Domenico L Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
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Dorland G, Vermeulen TD, Hollmann MW, Schultz MJ, Hol L, Nijbroek SGLH, Breel–Tebbutt JS, Neto AS, Mazzinari G, Gasteiger L, Ball L, Pelosi P, Almac E, Navarro MPA, Battaglini D, Besselink MG, Bokkerink PEMM, van den Broek J, Buise MP, Broens S, Davidson Z, Cambronero OD, Dejaco H, Ensink-Tjaberings PY, Florax AA, de Abreu MG, Godfried MB, Harmon MBA, Helmerhorst HJF, Huhn R, Huhle R, Jetten WD, de Jong M, Koopman JSHA, Koster SCE, de Korte-de Boer DJ, Kuiper GJAJM, Trip CNL, Morariu AM, Nass SA, Oei GTML, Pap−Brugmans AC, Paulus F, Potters JW, Rad M, Robba C, Sarton EY, Servaas S, Smit KF, Stamkot A, Thiel B, Struys MMRF, van de Wint TC, Wittenstein J, Zeillemaker-Hoekstra M, van der Zwan T, Hemmes SNT, van Meenen DMP, Staier N, Mörtl M. Driving pressure during general anesthesia for minimally invasive abdominal surgery (GENERATOR)-study protocol of a randomized clinical trial. Trials 2024; 25:719. [PMID: 39456048 PMCID: PMC11515191 DOI: 10.1186/s13063-024-08479-x] [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: 11/26/2023] [Accepted: 09/17/2024] [Indexed: 10/28/2024] Open
Abstract
BACKGROUND Intraoperative driving pressure (ΔP) has an independent association with the development of postoperative pulmonary complications (PPCs) in patients receiving ventilation during general anesthesia for major surgery. Ventilation with high intraoperative positive end-expiratory pressure (PEEP) with recruitment maneuvers (RMs) that result in a low ΔP has the potential to prevent PPCs. This trial tests the hypothesis that compared to standard low PEEP without RMs, an individualized high PEEP strategy, titrated to the lowest ΔP, with RMs prevents PPCs in patients receiving intraoperative protective ventilation during anesthesia for minimally invasive abdominal surgery. METHODS "DrivinG prEssure duriNg gEneRal AnesThesia fOr minimally invasive abdominal suRgery (GENERATOR)" is an international, multicenter, two-group, patient and outcome-assessor blinded randomized clinical trial. In total, 1806 adult patients scheduled for minimally invasive abdominal surgery and with an increased risk of PPCs based on (i) the ARISCAT risk score for PPCs (≥ 26 points) and/or (ii) a combination of age > 40 years and scheduled surgery lasting > 2 h and planned to receive an intra-arterial catheter for blood pressure monitoring during the surgery will be included. Patients are assigned to either an intraoperative ventilation strategy with individualized high PEEP, titrated to the lowest ΔP, with RMs or one with a standard low PEEP of 5 cm H2O without RMs. The primary outcome is a collapsed composite endpoint of PPCs until postoperative day 5. DISCUSSION GENERATOR will be the first adequately powered randomized clinical trial to compare the effects of individualized high PEEP with RMs versus standard low PEEP without RMs on the occurrence of PPCs after minimally invasive abdominal surgery. The results of the GENERATOR trial will support anesthesiologists in their decisions regarding PEEP settings during minimally invasive abdominal surgery. TRIAL REGISTRATION GENERATOR is registered at ClinicalTrials.gov (study identifier: NCT06101511) on 26 October 2023.
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Tham E, Campbell S, Hayanga H, Ammons J, Fang W, Sappington P, McCarthy P, Toker A, Badhwar V, Hayanga JWA. The relationship between body mass index and mortality is not linear in patients requiring venovenous extracorporeal support. J Thorac Cardiovasc Surg 2024; 168:1107-1115. [PMID: 38042401 PMCID: PMC11136873 DOI: 10.1016/j.jtcvs.2023.11.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 10/03/2023] [Accepted: 11/20/2023] [Indexed: 12/04/2023]
Abstract
OBJECTIVE Morbid obesity may influence candidacy for venovenous extracorporeal membrane oxygenation (VVECMO) support. Indeed, body mass index (BMI) >40 is considered to be a relative contraindication due to increased mortality observed in patients with BMI above this value. There is scant evidence to characterize this relationship beyond speculating about the technical challenges of cannulation and difficulty in optimizing flows. We examined a national cohort to evaluate the influence of BMI on mortality in patients requiring VVECMO for severe acute respiratory syndrome coronavirus 2 infection. METHODS We performed a retrospective cohort analysis on National COVID Cohort Collaborative data evaluating 1,033,229 patients with BMI ≤60 from 31 US hospital systems diagnosed with severe acute respiratory syndrome virus coronavirus 2 infection from September 2019 to August 2022. We performed univariate and multivariable mixed-effects logistic regression analysis on data pertaining to those who required VVECMO support during their hospitalization. A subgroup risk-adjusted analysis comparing ECMO mortality in patients with BMI 40 to 60 with the 25th, 50th, and 75th BMI percentile was performed. Outcomes of interest included BMI, age, comorbidity score, body surface area, and ventilation days. RESULTS A total of 774 adult patients required VVECMO. Of these, 542 were men, median age was 47 years, mean adjusted Charlson Comorbidity Index was 1, and median BMI was 33. Overall mortality was 47.8%. There was a nonsignificant overall difference in mortality across hospitals (SD, 0.31; 95% CI, 0-0.57). After mixed multivariable logistic regression analysis, advanced age (P < .0001) and Charlson Comorbidity Index (P = .009) were each associated with increased mortality. Neither gender (P = .14) nor duration on mechanical ventilation (P = .39) was associated with increased mortality. An increase in BMI from 25th to 75th percentile was not associated with a difference in mortality (P = .28). In our multivariable mixed-effects logistic regression analysis, there exists a nonlinear relationship between BMI and mortality. Between BMI of 25 and 32, patients experienced an increase in mortality. However, between BMI of 32 and 37, the adjusted mortality in these patients subsequently decreased. Our subgroup analysis comparing BMIs 40 to 60 with the 25th, 50th, and 75th percentile of BMI found no significant difference in ECMO mortality between BMI values of 40 and 60 with the 25th, 50th, 75th percentile. CONCLUSIONS Advancing age and higher CCI are each associated with increased risk for mortality in patients requiring VVECMO. A nonlinear relationship exists between mortality and BMI and those between 32 and 37 have lower odds of mortality than those between BMI 25 and 32. This nonlinear pattern suggests a need for further adjudication of the contraindications associated with VVECMO, particularly those based solely on BMI.
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Affiliation(s)
- Elwin Tham
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Morgantown, WVa
| | - Stuart Campbell
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Morgantown, WVa
| | - Heather Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Morgantown, WVa
| | - Jeffrey Ammons
- West Virginia Clinical and Translational Science Institute, Morgantown, WVa
| | - Wei Fang
- West Virginia Clinical and Translational Science Institute, Morgantown, WVa
| | - Penny Sappington
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Morgantown, WVa
| | - Paul McCarthy
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Morgantown, WVa
| | - Alper Toker
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Morgantown, WVa
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Morgantown, WVa
| | - J W Awori Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Morgantown, WVa.
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Fiedler-Kalenka MO, Brenner T, Bernhard M, Reuß CJ, Beynon C, Hecker A, Jungk C, Nusshag C, Michalski D, Weigand MA, Dietrich M. [Focus on ventilation, oxygen therapy and weaning 2022-2024 : Summary of selected intensive care studies]. DIE ANAESTHESIOLOGIE 2024; 73:698-711. [PMID: 39210065 DOI: 10.1007/s00101-024-01455-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/05/2024] [Indexed: 09/04/2024]
Affiliation(s)
- M O Fiedler-Kalenka
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland.
- Translationales Lungenforschungszentrum Heidelberg (TLRC-H), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - T Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine Universität, Düsseldorf, Deutschland
| | - C J Reuß
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Stuttgart, Stuttgart, Deutschland
| | - C Beynon
- Neurochirurgische Klinik, Universitätsklinikum Mannheim, Mannheim, Deutschland
| | - A Hecker
- Klinik für Allgemein- Viszeral‑, Thorax‑, Transplantations- und Kinderchirurgie, Universitätsklinikum Gießen und Marburg, Standort Gießen, Gießen, Deutschland
| | - C Jungk
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C Nusshag
- Klinik für Endokrinologie, Stoffwechsel und klinische Chemie/Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - D Michalski
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
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Wang Z, Cheng Q, Huang S, Sun J, Xu J, Xie J, Cao H, Guo F. Effect of perioperative sigh ventilation on postoperative hypoxemia and pulmonary complications after on-pump cardiac surgery (E-SIGHT): study protocol for a randomized controlled trial. Trials 2024; 25:585. [PMID: 39232795 PMCID: PMC11373100 DOI: 10.1186/s13063-024-08416-y] [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: 05/17/2024] [Accepted: 08/21/2024] [Indexed: 09/06/2024] Open
Abstract
BACKGROUND Postoperative hypoxemia and pulmonary complications remain a frequent event after on-pump cardiac surgery and mostly characterized by pulmonary atelectasis. Surfactant dysfunction or hyposecretion happens prior to atelectasis formation, and sigh represents the strongest stimulus for surfactant secretion. The role of sigh breaths added to conventional lung protective ventilation in reducing postoperative hypoxemia and pulmonary complications among cardiac surgery is unknown. METHODS The perioperative sigh ventilation in cardiac surgery (E-SIGHT) trial is a single-center, two-arm, randomized controlled trial. In total, 192 patients scheduled for elective cardiac surgery with cardiopulmonary bypass (CPB) and aortic cross-clamp will be randomized into one of the two treatment arms. In the experimental group, besides conventional lung protective ventilation, sigh volumes producing plateau pressures of 35 cmH2O (or 40 cmH2O for patients with body mass index > 35 kg/m2) delivered once every 6 min from intubation to extubation. In the control group, conventional lung protective ventilation without preplanned recruitment maneuvers is used. Lung protective ventilation (LPV) consists of low tidal volumes (6-8 mL/kg of predicted body weight) and positive end-expiratory pressure (PEEP) setting according to low PEEP/FiO2 table for acute respiratory distress syndrome (ARDS). The primary endpoint is time-weighted average SpO2/FiO2 ratio during the initial post-extubation hour. Main secondary endpoint is the severity of postoperative pulmonary complications (PPCs) computed by postoperative day 7. DISCUSSION The E-SIGHT trial will be the first randomized controlled trial to evaluate the impact of perioperative sigh ventilation on the postoperative outcomes after on-pump cardiac surgery. The trial will introduce and assess a novel perioperative ventilation approach to mitigate the risk of postoperative hypoxemia and PPCs in patients undergoing cardiac surgery. Also provide the basis for a future larger trial aiming at verifying the impact of sigh ventilation on postoperative pulmonary complications. TRIAL REGISTRATION ClinicalTrials.gov NCT06248320. Registered on January 30, 2024. Last updated February 26, 2024.
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Affiliation(s)
- Zhichang Wang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Qiyu Cheng
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Shenglun Huang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Jie Sun
- Department of Anesthesiology, Surgery and Pain Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Jingyuan Xu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Hailong Cao
- Department of Cardiothoracic Surgery, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China.
| | - Fengmei Guo
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China.
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Gu WJ, Cen Y, Zhao FZ, Wang HJ, Yin HY, Zheng XF. Association between driving pressure-guided ventilation and postoperative pulmonary complications in surgical patients: a meta-analysis with trial sequential analysis. Br J Anaesth 2024; 133:647-657. [PMID: 38937217 DOI: 10.1016/j.bja.2024.04.060] [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: 01/22/2024] [Revised: 03/22/2024] [Accepted: 04/15/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Prior studies have reported inconsistent results regarding the association between driving pressure-guided ventilation and postoperative pulmonary complications (PPCs). We aimed to investigate whether driving pressure-guided ventilation is associated with a lower risk of PPCs. METHODS We systematically searched electronic databases for RCTs comparing driving pressure-guided ventilation with conventional protective ventilation in adult surgical patients. The primary outcome was a composite of PPCs. Secondary outcomes were pneumonia, atelectasis, and acute respiratory distress syndrome (ARDS). Meta-analysis and subgroup analysis were conducted to calculate risk ratios (RRs) with 95% confidence intervals (CI). Trial sequential analysis (TSA) was used to assess the conclusiveness of evidence. RESULTS Thirteen RCTs with 3401 subjects were included. Driving pressure-guided ventilation was associated with a lower risk of PPCs (RR 0.70, 95% CI 0.56-0.87, P=0.001), as indicated by TSA. Subgroup analysis (P for interaction=0.04) found that the association was observed in non-cardiothoracic surgery (nine RCTs, 1038 subjects, RR 0.61, 95% CI 0.48-0.77, P< 0.0001), with TSA suggesting sufficient evidence and conclusive result; however, it did not reach significance in cardiothoracic surgery (four RCTs, 2363 subjects, RR 0.86, 95% CI 0.67-1.10, P=0.23), with TSA indicating insufficient evidence and inconclusive result. Similarly, a lower risk of pneumonia was found in non-cardiothoracic surgery but not in cardiothoracic surgery (P for interaction=0.046). No significant differences were found in atelectasis and ARDS between the two ventilation strategies. CONCLUSIONS Driving pressure-guided ventilation was associated with a lower risk of postoperative pulmonary complications in non-cardiothoracic surgery but not in cardiothoracic surgery. SYSTEMATIC REVIEW PROTOCOL INPLASY 202410068.
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Affiliation(s)
- Wan-Jie Gu
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yun Cen
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Feng-Zhi Zhao
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Hua-Jun Wang
- Department of Bone and Joint Surgery and Sports Medicine Center, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Hai-Yan Yin
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China.
| | - Xiao-Fei Zheng
- Department of Bone and Joint Surgery and Sports Medicine Center, The First Affiliated Hospital of Jinan University, Guangzhou, China.
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Setlers K, Jurcenko A, Arklina B, Zvaigzne L, Sabelnikovs O, Stradins P, Strike E. Identifying Early Risk Factors for Postoperative Pulmonary Complications in Cardiac Surgery Patients. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1398. [PMID: 39336439 PMCID: PMC11433804 DOI: 10.3390/medicina60091398] [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: 07/28/2024] [Revised: 08/15/2024] [Accepted: 08/25/2024] [Indexed: 09/30/2024]
Abstract
Background and Objectives: Postoperative pulmonary complications (PPCs) are common in patients who undergo cardiac surgery and are widely acknowledged as significant contributors to increased morbidity, mortality rates, prolonged hospital stays, and healthcare costs. Clinical manifestations of PPCs can vary from mild to severe symptoms, with different radiological findings and varying incidence. Detecting early signs and identifying influencing factors of PPCs is essential to prevent patients from further complications. Our study aimed to determine the frequency, types, and risk factors significant for each PPC on the first postoperative day. The main goal of this study was to identify the incidence of pleural effusion (right-sided, left-sided, or bilateral), atelectasis, pulmonary edema, and pneumothorax as well as detect specific factors related to its development. Materials and Methods: This study was a retrospective single-center trial. It involved 314 adult patients scheduled for elective open-heart surgery under CPB. Results: Of the 314 patients reviewed, 42% developed PPCs within 12 h post-surgery. Up to 60.6% experienced one PPC, while 35.6% developed two PPCs. Pleural effusion was the most frequently observed complication in 89 patients. Left-sided effusion was the most common, presenting in 45 cases. Regression analysis showed a significant association between left-sided pleural effusion development and moderate hypoalbuminemia. Valve surgery was associated with reduced risk for left-sided effusion. Independent parameters for bilateral effusion include increased urine output and longer ICU stays. Higher BMI was inversely related to the risk of pulmonary edema. Conclusions: At least one PPC developed in almost half of the patients. Left-sided pleural effusion was the most common PPC, with hypoalbuminemia as a risk factor for effusion development. Atelectasis was the second most common. Bilateral effusion was the third most common PPC, significantly related to increased urine output. BMI was an independent risk factor for pulmonary edema development.
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Affiliation(s)
- Kaspars Setlers
- Department of Cardiovascular Anesthesia and Intensive Care, Pauls Stradins Clinical University Hospital, LV-1002 Riga, Latvia
- Department of Anesthesiology, Riga Stradins University, LV-1007 Riga, Latvia
| | | | - Baiba Arklina
- Department of Cardiovascular Anesthesia and Intensive Care, Pauls Stradins Clinical University Hospital, LV-1002 Riga, Latvia
- Department of Anesthesiology, Riga Stradins University, LV-1007 Riga, Latvia
| | - Ligita Zvaigzne
- Institute of Radiology, Pauls Stradins Clinical University Hospital, LV-1002 Riga, Latvia
| | - Olegs Sabelnikovs
- Department of Anesthesiology, Riga Stradins University, LV-1007 Riga, Latvia
- Department of Intensive Care, Pauls Stradins Clinical University Hospital, LV-1002 Riga, Latvia
| | - Peteris Stradins
- Department of Cardiac Surgery, Pauls Stradins Clinical University Hospital, LV-1002 Riga, Latvia
- Department of Surgery, Riga Stradins University, LV-1007 Riga, Latvia
| | - Eva Strike
- Department of Cardiovascular Anesthesia and Intensive Care, Pauls Stradins Clinical University Hospital, LV-1002 Riga, Latvia
- Department of Anesthesiology, Riga Stradins University, LV-1007 Riga, Latvia
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Hamid M, Mostafa OES, Mohamedahmed AYY, Zaman S, Kumar P, Waterland P, Akingboye A. Comparison of low versus high (standard) intraabdominal pressure during laparoscopic colorectal surgery: systematic review and meta-analysis. Int J Colorectal Dis 2024; 39:104. [PMID: 38985344 PMCID: PMC11236862 DOI: 10.1007/s00384-024-04679-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND To evaluate outcomes of low with high intraabdominal pressure during laparoscopic colorectal resection surgery. METHODS A systematic search of multiple electronic data sources was conducted, and all studies comparing low with high (standard) intraabdominal pressures were included. Our primary outcomes were post-operative ileus occurrence and return of bowel movement/flatus. The evaluated secondary outcomes included: total operative time, post-operative haemorrhage, anastomotic leak, pneumonia, surgical site infection, overall post-operative complications (categorised by Clavien-Dindo grading), and length of hospital stay. Revman 5.4 was used for data analysis. RESULTS Six randomised controlled trials (RCTs) and one observational study with a total of 771 patients (370 surgery at low intraabdominal pressure and 401 at high pressures) were included. There was no statistically significant difference in all the measured outcomes; post-operative ileus [OR 0.80; CI (0.42, 1.52), P = 0.50], time-to-pass flatus [OR -4.31; CI (-12.12, 3.50), P = 0.28], total operative time [OR 0.40; CI (-10.19, 11.00), P = 0.94], post-operative haemorrhage [OR 1.51; CI (0.41, 5.58, P = 0.53], anastomotic leak [OR 1.14; CI (0.26, 4.91), P = 0.86], pneumonia [OR 1.15; CI (0.22, 6.09), P = 0.87], SSI [OR 0.69; CI (0.19, 2.47), P = 0.57], overall post-operative complications [OR 0.82; CI (0.52, 1.30), P = 0.40], Clavien-Dindo grade ≥ 3 [OR 1.27; CI (0.59, 2.77), P = 0.54], and length of hospital stay [OR -0.68; CI (-1.61, 0.24), P = 0.15]. CONCLUSION Low intraabdominal pressure is safe and feasible approach to laparoscopic colorectal resection surgery with non-inferior outcomes to standard or high pressures. More robust and well-powered RCTs are needed to consolidate the potential benefits of low over high pressure intra-abdominal surgery.
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Affiliation(s)
- Mohammed Hamid
- Department of General Surgery, Wye Valley NHS Trust, Hereford County Hospital, Hereford, Herefordshire, UK
| | - Omar E S Mostafa
- Department of General and Colorectal Surgery, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, West Midlands, UK
| | - Ali Yasen Y Mohamedahmed
- Department of General Surgery, University Hospitals of Derby and Burton NHS Foundation Trust, Queen's Hospital Burton, Burton on Trent, Staffordshire, UK
| | - Shafquat Zaman
- Department of General and Colorectal Surgery, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, West Midlands, UK.
- College of Medical and Dental Sciences, School of Medicine, University of Birmingham, Edgbaston, Birmingham, UK.
| | - Prajeesh Kumar
- Department of General and Colorectal Surgery, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, West Midlands, UK
| | - Peter Waterland
- Department of General and Colorectal Surgery, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, West Midlands, UK
| | - Akinfemi Akingboye
- Department of General and Colorectal Surgery, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, West Midlands, UK
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Sun TT, Chen KX, Tao Y, Zhang GW, Zeng L, Lin M, Huang J, Hu Y. Effect of flow-optimized pressure control ventilation-volume guaranteed (PCV-VG) on postoperative pulmonary complications: a consort study. J Cardiothorac Surg 2024; 19:425. [PMID: 38978064 PMCID: PMC11229334 DOI: 10.1186/s13019-024-02881-x] [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: 03/27/2024] [Accepted: 06/15/2024] [Indexed: 07/10/2024] Open
Abstract
BACKGROUND Postoperative pulmonary complications (PPCs) after one-lung ventilation (OLV) significantly impact patient prognosis and quality of life. OBJECTIVE To study the impact of an optimal inspiratory flow rate on PPCs in thoracic surgery patients. METHODS One hundred eight elective thoracic surgery patients were randomly assigned to 2 groups in this consort study (control group: n = 53 with a fixed inspiratory expiratory ratio of 1:2; and experimental group [flow rate optimization group]: n = 55). Measurements of Ppeak, Pplat, PETCO2, lung dynamic compliance (Cdyn), respiratory rate, and oxygen concentration were obtained at the following specific time points: immediately after intubation (T0); immediately after starting OLV (T1); 30 min after OLV (T2); and 10 min after 2-lung ventilation (T4). The PaO2:FiO2 ratio was measured using blood gas analysis 30 min after initiating one-lung breathing (T2) and immediately when OLV ended (T3). The lung ultrasound score (LUS) was assessed following anesthesia and resuscitation (T5). The occurrence of atelectasis was documented immediately after the surgery. PPCs occurrences were noted 3 days after surgery. RESULTS The treatment group had a significantly lower total prevalence of PPCs compared to the control group (3.64% vs. 16.98%; P = 0.022). There were no notable variations in peak airway pressure, airway plateau pressure, dynamic lung compliance, PETCO2, respiratory rate, and oxygen concentration between the two groups during intubation (T0). Dynamic lung compliance and the oxygenation index were significantly increased at T1, T2, and T4 (P < 0.05), whereas the CRP level and number of inflammatory cells decreased dramatically (P < 0.05). CONCLUSION Optimizing inspiratory flow rate and utilizing pressure control ventilation -volume guaranteed (PCV-VG) mode can decrease PPCs and enhance lung dynamic compliance in OLV patients.
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Affiliation(s)
- Ting Ting Sun
- Department of Anesthesia Operation, The First People's Hospital of Shuangliu District (West China Airport Hospital of Sichuan University), No.120, Chengbei Street, Dongsheng Street, Shuangliu District, Chengdu, 610200, China
| | - Ke Xin Chen
- Department of Anesthesia Operation, The First People's Hospital of Shuangliu District (West China Airport Hospital of Sichuan University), No.120, Chengbei Street, Dongsheng Street, Shuangliu District, Chengdu, 610200, China
| | - Yong Tao
- Department of Anesthesia Operation, The First People's Hospital of Shuangliu District (West China Airport Hospital of Sichuan University), No.120, Chengbei Street, Dongsheng Street, Shuangliu District, Chengdu, 610200, China
| | - Gong Wei Zhang
- Department of Anesthesia Operation, The First People's Hospital of Shuangliu District (West China Airport Hospital of Sichuan University), No.120, Chengbei Street, Dongsheng Street, Shuangliu District, Chengdu, 610200, China
| | - Li Zeng
- Department of Anesthesia Operation, The First People's Hospital of Shuangliu District (West China Airport Hospital of Sichuan University), No.120, Chengbei Street, Dongsheng Street, Shuangliu District, Chengdu, 610200, China
| | - Min Lin
- Department of Anesthesia Operation, The First People's Hospital of Shuangliu District (West China Airport Hospital of Sichuan University), No.120, Chengbei Street, Dongsheng Street, Shuangliu District, Chengdu, 610200, China
| | - Jing Huang
- Department of Anesthesia Operation, The First People's Hospital of Shuangliu District (West China Airport Hospital of Sichuan University), No.120, Chengbei Street, Dongsheng Street, Shuangliu District, Chengdu, 610200, China
| | - Yue Hu
- Department of Anesthesia Operation, The First People's Hospital of Shuangliu District (West China Airport Hospital of Sichuan University), No.120, Chengbei Street, Dongsheng Street, Shuangliu District, Chengdu, 610200, China.
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10
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Wang L, Pang X, Ding S, Pei K, Li Z, Wan J. Effect of postoperative oxygen therapy regimen modification on oxygenation in patients with acute type A aortic dissection. Heliyon 2024; 10:e29108. [PMID: 38638990 PMCID: PMC11024556 DOI: 10.1016/j.heliyon.2024.e29108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/31/2024] [Accepted: 04/01/2024] [Indexed: 04/20/2024] Open
Abstract
Objective In this study, we investigated the effect of various oxygen therapy regimens on oxygenation in patients with acute type A aortic dissection (AAD). Methods A quasi-randomized controlled trial was conducted, in which patients with AAD hospitalized for surgery from June to September 2021 were assigned to the control group (patients received conventional oxygen therapy after postoperative mechanical ventilation, weaning, and extubation) and those who were admitted from October to December 2021 were assigned to the observation group [patients underwent optimally adjusted therapy based on the treatment of the control group, which mainly included prioritized elevation of positive end-expiratory pressure (PEEP) and restricted use of the fraction of inspired oxygen (FiO2)].The postoperative oxygenation index, blood gas analysis, and duration of mechanical ventilation were compared between the two groups. Results There were significant differences in oxygenation observed at 2 h postoperatively between the groups. 12, 24, and 72 h postoperatively, the oxygenation index varied significantly between the two groups. There were statistically significant differences in the time effects of the oxygenation index and PaO2 between the two groups, as well as significant differences in the length of stay in the intensive care unit. Conclusion For the postoperative care of patients with AAD, it is suggested that the minimum FiO2 required for oxygenation of patients be maintained. In addition, it is possible to enhance PEEP as a priority when PaO2 is low.
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Affiliation(s)
- Li Wang
- Department of Hospital Infection Control, The Second Hospital of Shandong University, Jinan, 250033, PR China
| | - Xinyan Pang
- Department of Cardiovascular Surgery, The Second Hospital of Shandong University, Jinan, 250033, PR China
| | - Shouluan Ding
- Institute of Medicine Sciences, The Second Hospital of Shandong University, Jinan, 250033, PR China
| | - Ke Pei
- Department of Cardiovascular Surgery, The Second Hospital of Shandong University, Jinan, 250033, PR China
| | - Zijia Li
- Department of Cardiovascular Surgery, The Second Hospital of Shandong University, Jinan, 250033, PR China
| | - Jianhong Wan
- Department of Cardiovascular Surgery, The Second Hospital of Shandong University, Jinan, 250033, PR China
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11
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Grant MC, Crisafi C, Alvarez A, Arora RC, Brindle ME, Chatterjee S, Ender J, Fletcher N, Gregory AJ, Gunaydin S, Jahangiri M, Ljungqvist O, Lobdell KW, Morton V, Reddy VS, Salenger R, Sander M, Zarbock A, Engelman DT. Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS). Ann Thorac Surg 2024; 117:669-689. [PMID: 38284956 DOI: 10.1016/j.athoracsur.2023.12.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/27/2023] [Accepted: 12/09/2023] [Indexed: 01/30/2024]
Abstract
Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.
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Affiliation(s)
- Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Cheryl Crisafi
- Heart and Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
| | - Adrian Alvarez
- Department of Anesthesia, Hospital Italiano, Buenos Aires, Argentina
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mary E Brindle
- Departments of Surgery and Community Health Services, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Joerg Ender
- Department of Anaesthesiology and Intensive Care Medicine, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Nick Fletcher
- Institute of Anesthesia and Critical Care, Cleveland Clinic London, London, United Kingdom; St George's University Hospital, London, United Kingdom
| | - Alexander J Gregory
- Department of Anesthesia, Perioperative and Pain Medicine, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Serdar Gunaydin
- Department of Cardiovascular Surgery, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Marjan Jahangiri
- Department of Cardiac Surgery, St George's Hospital, London, United Kingdom
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Kevin W Lobdell
- Regional Cardiovascular and Thoracic Quality, Education, and Research, Atrium Health, Charlotte, North Carolina
| | - Vicki Morton
- Clinical and Quality Outcomes, Providence Anesthesiology Associates, Charlotte, North Carolina
| | - V Seenu Reddy
- Centennial Heart & Vascular Center, Nashville, Tennessee
| | - Rawn Salenger
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael Sander
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Giessen, Germany
| | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Daniel T Engelman
- Heart and Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
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12
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Ferrando C, Carramiñana A, Piñeiro P, Mirabella L, Spadaro S, Librero J, Ramasco F, Scaramuzzo G, Cervantes O, Garutti I, Parera A, Argilaga M, Herranz G, Unzueta C, Vives M, Regi K, Costa-Reverte M, Sonsoles Leal M, Nieves-Alonso J, García E, Rodríguez-Pérez A, Fariña R, Cabrera S, Guerra E, Gallego-Ligorit L, Herrero-Izquierdo A, Vallés-Torres J, Ramos S, López-Herrera D, De La Matta M, Gokhan S, Kucur E, Mugarra A, Soro M, García L, Sastre JA, Aguirre P, Salazar CJ, Ramos MC, Morocho DR, Trespalacios R, Ezequiel-Fernández F, Lamanna A, Pia Cantatore L, Laforgia D, Bellas S, López C, Navarro-Ripoll R, Martínez S, Vallverdú J, Jacas A, Yepes-Temiño MJ, Belda FJ, Tusman G, Suárez-Sipmann F, Villar J. Individualised, perioperative open-lung ventilation strategy during one-lung ventilation (iPROVE-OLV): a multicentre, randomised, controlled clinical trial. THE LANCET. RESPIRATORY MEDICINE 2024; 12:195-206. [PMID: 38065200 DOI: 10.1016/s2213-2600(23)00346-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 09/05/2023] [Accepted: 09/19/2023] [Indexed: 03/02/2024]
Abstract
BACKGROUND It is uncertain whether individualisation of the perioperative open-lung approach (OLA) to ventilation reduces postoperative pulmonary complications in patients undergoing lung resection. We compared a perioperative individualised OLA (iOLA) ventilation strategy with standard lung-protective ventilation in patients undergoing thoracic surgery with one-lung ventilation. METHODS This multicentre, randomised controlled trial enrolled patients scheduled for open or video-assisted thoracic surgery using one-lung ventilation in 25 participating hospitals in Spain, Italy, Turkey, Egypt, and Ecuador. Eligible adult patients (age ≥18 years) were randomly assigned to receive iOLA or standard lung-protective ventilation. Eligible patients (stratified by centre) were randomly assigned online by local principal investigators, with an allocation ratio of 1:1. Treatment with iOLA included an alveolar recruitment manoeuvre to 40 cm H2O of end-inspiratory pressure followed by individualised positive end-expiratory pressure (PEEP) titrated to best respiratory system compliance, and individualised postoperative respiratory support with high-flow oxygen therapy. Participants allocated to standard lung-protective ventilation received combined intraoperative 4 cm H2O of PEEP and postoperative conventional oxygen therapy. The primary outcome was a composite of severe postoperative pulmonary complications within the first 7 postoperative days, including atelectasis requiring bronchoscopy, severe respiratory failure, contralateral pneumothorax, early extubation failure (rescue with continuous positive airway pressure, non-invasive ventilation, invasive mechanical ventilation, or reintubation), acute respiratory distress syndrome, pulmonary infection, bronchopleural fistula, and pleural empyema. Due to trial setting, data obtained in the operating and postoperative rooms for routine monitoring were not blinded. At 24 h, data were acquired by an investigator blinded to group allocation. All analyses were performed on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov, NCT03182062, and is complete. FINDINGS Between Sept 11, 2018, and June 14, 2022, we enrolled 1380 patients, of whom 1308 eligible patients (670 [434 male, 233 female, and three with missing data] assigned to iOLA and 638 [395 male, 237 female, and six with missing data] to standard lung-protective ventilation) were included in the final analysis. The proportion of patients with the composite outcome of severe postoperative pulmonary complications within the first 7 postoperative days was lower in the iOLA group compared with the standard lung-protective ventilation group (40 [6%] vs 97 [15%], relative risk 0·39 [95% CI 0·28 to 0·56]), with an absolute risk difference of -9·23 (95% CI -12·55 to -5·92). Recruitment manoeuvre-related adverse events were reported in five patients. INTERPRETATION Among patients subjected to lung resection under one-lung ventilation, iOLA was associated with a reduced risk of severe postoperative pulmonary complications when compared with conventional lung-protective ventilation. FUNDING Instituto de Salud Carlos III and the European Regional Development Funds.
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Affiliation(s)
- Carlos Ferrando
- Institut D'investigació August Pi I Sunyer, Barcelona, Spain; CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
| | - Albert Carramiñana
- Department of Anesthesiology and Critical Care, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Patricia Piñeiro
- Department of Anesthesiology and Critical Care, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Lucia Mirabella
- Department of Medical and Surgical Sciences, Università Degli Studi di Foggia, Foggia, Italy
| | - Savino Spadaro
- Department of Anesthesiology and Critical Care, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy
| | - Julián Librero
- UPNA, REDISSEC Red de Investigación en Servicios de Salud, Navarrabiomed, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Fernando Ramasco
- Department of Anesthesiology and Critical Care, Hospital Universitario de La Princesa, Madrid, Spain
| | - Gaetano Scaramuzzo
- Department of Anesthesiology and Critical Care, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy
| | - Oriol Cervantes
- Department of Anesthesiology and Critical Care, Hospital Universitario Germans Trías i Pujol, Barcelona, Spain
| | - Ignacio Garutti
- Department of Anesthesiology and Critical Care, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Ana Parera
- Department of Anesthesiology and Critical Care, Hospital Universitario Santa Creu i Sant Pau, Barcelona, Spain
| | - Marta Argilaga
- Department of Anesthesiology and Critical Care, Hospital Universitario Santa Creu i Sant Pau, Barcelona, Spain
| | - Gracia Herranz
- Department of Anesthesiology and Critical Care, Hospital Universitario Santa Creu i Sant Pau, Barcelona, Spain
| | - Carmen Unzueta
- Department of Anesthesiology and Critical Care, Hospital Universitario Santa Creu i Sant Pau, Barcelona, Spain
| | - Marc Vives
- Department of Anesthesiology and Critical Care, Hospital Universitario Josep Trueta, Girona, Spain
| | - Kevin Regi
- Department of Anesthesiology and Critical Care, Hospital Universitario Josep Trueta, Girona, Spain
| | - Marta Costa-Reverte
- Department of Anesthesiology and Critical Care, Hospital Universitario de Bellvitge, Barcelona, Spain
| | | | - Jesús Nieves-Alonso
- Department of Anesthesiology and Critical Care, Hospital Universitario de La Princesa, Madrid, Spain
| | - Esther García
- Department of Anesthesiology and Critical Care, Hospital Universitario de La Princesa, Madrid, Spain
| | - Aurelio Rodríguez-Pérez
- Department of Anesthesiology and Critical Care, Hospital Universitario de Gran Canaria Dr Negrín, Gran Canarias, Spain
| | - Roberto Fariña
- Department of Anesthesiology and Critical Care, Hospital Universitario de Gran Canaria Dr Negrín, Gran Canarias, Spain
| | - Sergio Cabrera
- Department of Anesthesiology and Critical Care, Hospital Universitario de Gran Canaria Dr Negrín, Gran Canarias, Spain
| | - Elisabeth Guerra
- Department of Anesthesiology and Critical Care, Hospital Universitario de Gran Canaria Dr Negrín, Gran Canarias, Spain
| | - Lucia Gallego-Ligorit
- Department of Anesthesiology and Critical Care, Hospital Universitario Miguel Servet, Zaragoza, Spain; Instituto de Investigación Sanitaria Aragón IIS Aragón, Zaragoza, Spain
| | - Alba Herrero-Izquierdo
- Department of Anesthesiology and Critical Care, Hospital Universitario Miguel Servet, Zaragoza, Spain; Instituto de Investigación Sanitaria Aragón IIS Aragón, Zaragoza, Spain
| | - J Vallés-Torres
- Department of Anesthesiology and Critical Care, Hospital Universitario Miguel Servet, Zaragoza, Spain; Instituto de Investigación Sanitaria Aragón IIS Aragón, Zaragoza, Spain
| | - Silvia Ramos
- Department of Anesthesiology and Critical Care, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Daniel López-Herrera
- Department of Anesthesiology and Critical Care, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Manuel De La Matta
- Department of Anesthesiology and Critical Care, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Sertcakacilar Gokhan
- Department of Anesthesiology and Critical Care, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey; Outcomes Research Consortium, Cleveland, OH, USA
| | - Evrim Kucur
- Department of Anesthesiology and Critical Care, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Ana Mugarra
- Department of Anesthesiology and Critical Care, Hospital Universitario Clínico de Valencia, Valencia, Spain
| | - Marina Soro
- Department of Anesthesiology and Critical Care, Hospital Universitario Clínico de Valencia, Valencia, Spain
| | - Laura García
- Department of Anesthesiology and Critical Care, Hospital Universitario Clínico de Valencia, Valencia, Spain
| | - José Alfonso Sastre
- Department of Anesthesiology and Critical Care, Hospital Universitario de Salamanca, Salamanca, Spain
| | - Pilar Aguirre
- Department of Anesthesiology and Critical Care, Hospital Álvaro Cunqueiro, Vigo, Spain
| | - Claudia Jimena Salazar
- Department of Anesthesiology and Critical Care, Hospital Universitario Ntra Sra de Candelaria, Santa Cruz de Tenerife, Spain
| | - María Carolina Ramos
- Department of Anesthesiology and Critical Care, Hospital Universitario Ntra Sra de Candelaria, Santa Cruz de Tenerife, Spain
| | | | - Ramón Trespalacios
- Department of Anesthesiology and Critical Care, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Félix Ezequiel-Fernández
- Department of Anesthesiology and Critical Care, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Angella Lamanna
- Department of Medical and Surgical Sciences, Università Degli Studi di Foggia, Foggia, Italy
| | - Leonarda Pia Cantatore
- Department of Medical and Surgical Sciences, Università Degli Studi di Foggia, Foggia, Italy
| | - Donato Laforgia
- Department of Medical and Surgical Sciences, Università Degli Studi di Foggia, Foggia, Italy
| | - Soledad Bellas
- Department of Anesthesiology and Critical Care, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Carlos López
- Department of Anesthesiology and Critical Care, Hospital Universitario Marques de Valdecilla, Santander, Spain
| | - Ricard Navarro-Ripoll
- Department of Anesthesiology and Critical Care, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Samira Martínez
- Department of Anesthesiology and Critical Care, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Jordi Vallverdú
- Department of Anesthesiology and Critical Care, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Adriana Jacas
- Department of Anesthesiology and Critical Care, Hospital Clinic de Barcelona, Barcelona, Spain
| | - María José Yepes-Temiño
- Department of Anesthesiology and Critical Care, Clínica Universidad de Navarra, Pamplona, Spain
| | - Francisco Javier Belda
- Department of Anesthesiology and Critical Care, Hospital Universitario Clínico de Valencia, Valencia, Spain
| | - Gerardo Tusman
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar de Plata, Buenos Aires, Argentina
| | - Fernando Suárez-Sipmann
- CIBER de Enfermedades Respiratorias CIBERES, Instituto de Salud Carlos III, Madrid, Spain; Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Jesús Villar
- CIBER de Enfermedades Respiratorias, Madrid, Spain; Hospital Universitario Dr Negrín, Las Palmas de Gran Canaria, Spain; Li Ka Shing Knowledge Institute for Medical Science, St Michael's Hospital, Toronto, ON, Canada
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13
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von Wedel D, Redaelli S, Suleiman A, Wachtendorf LJ, Fosset M, Santer P, Shay D, Munoz-Acuna R, Chen G, Talmor D, Jung B, Baedorf-Kassis EN, Schaefer MS. Adjustments of Ventilator Parameters during Operating Room-to-ICU Transition and 28-Day Mortality. Am J Respir Crit Care Med 2024; 209:553-562. [PMID: 38190707 DOI: 10.1164/rccm.202307-1168oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 01/08/2024] [Indexed: 01/10/2024] Open
Abstract
Rationale: Lung-protective mechanical ventilation strategies have been proven beneficial in the operating room (OR) and the ICU. However, differential practices in ventilator management persist, often resulting in adjustments of ventilator parameters when transitioning patients from the OR to the ICU. Objectives: To characterize patterns of ventilator adjustments during the transition of mechanically ventilated surgical patients from the OR to the ICU and assess their impact on 28-day mortality. Methods: Hospital registry study including patients undergoing general anesthesia with continued, controlled mechanical ventilation in the ICU between 2008 and 2022. Ventilator parameters were assessed 1 hour before and 6 hours after the transition. Measurements and Main Results: Of 2,103 patients, 212 (10.1%) died within 28 days. Upon OR-to-ICU transition, VT and driving pressure decreased (-1.1 ml/kg predicted body weight [IQR, -2.0 to -0.2]; P < 0.001; and -4.3 cm H2O [-8.2 to -1.2]; P < 0.001). Concomitantly, respiratory rates increased (+5.0 breaths/min [2.0 to 7.5]; P < 0.001), resulting overall in slightly higher mechanical power (MP) in the ICU (+0.7 J/min [-1.9 to 3.0]; P < 0.001). In adjusted analysis, increases in MP were associated with a higher 28-day mortality rate (adjusted odds ratio, 1.10; 95% confidence interval, 1.06-1.14; P < 0.001; adjusted risk difference, 0.7%; 95% confidence interval, 0.4-1.0, both per 1 J/min). Conclusion: During transition of mechanically ventilated patients from the OR to the ICU, ventilator adjustments resulting in higher MP were associated with a greater risk of 28-day mortality.
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Affiliation(s)
- Dario von Wedel
- Department of Anesthesia, Critical Care and Pain Medicine
- Center for Anesthesia Research Excellence, and
| | - Simone Redaelli
- Department of Anesthesia, Critical Care and Pain Medicine
- Center for Anesthesia Research Excellence, and
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Aiman Suleiman
- Department of Anesthesia, Critical Care and Pain Medicine
- Center for Anesthesia Research Excellence, and
- Department of Anesthesia and Intensive Care, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Luca J Wachtendorf
- Department of Anesthesia, Critical Care and Pain Medicine
- Center for Anesthesia Research Excellence, and
| | - Maxime Fosset
- Department of Anesthesia, Critical Care and Pain Medicine
- Center for Anesthesia Research Excellence, and
- Medical Intensive Care Unit and PhyMedExp, Institut National de la Santé et de la Recherche Médicale, Montpellier University Hospital, Montpellier, France
| | - Peter Santer
- Department of Anesthesia, Critical Care and Pain Medicine
- Center for Anesthesia Research Excellence, and
| | - Denys Shay
- Department of Anesthesia, Critical Care and Pain Medicine
- Center for Anesthesia Research Excellence, and
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; and
| | - Ricardo Munoz-Acuna
- Department of Anesthesia, Critical Care and Pain Medicine
- Center for Anesthesia Research Excellence, and
| | - Guanqing Chen
- Department of Anesthesia, Critical Care and Pain Medicine
- Center for Anesthesia Research Excellence, and
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine
| | - Boris Jung
- Department of Anesthesia, Critical Care and Pain Medicine
- Center for Anesthesia Research Excellence, and
- Department of Pulmonary, Critical Care & Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Medical Intensive Care Unit and PhyMedExp, Institut National de la Santé et de la Recherche Médicale, Montpellier University Hospital, Montpellier, France
| | - Elias N Baedorf-Kassis
- Department of Pulmonary, Critical Care & Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine
- Center for Anesthesia Research Excellence, and
- Department of Anesthesiology, Düsseldorf University Hospital, Dusseldorf, Germany
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14
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Elefterion B, Cirenei C, Kipnis E, Cailliau E, Bruandet A, Tavernier B, Lamer A, Lebuffe G. Intraoperative Mechanical Power and Postoperative Pulmonary Complications in Noncardiothoracic Elective Surgery Patients: A 10-Year Retrospective Cohort Study. Anesthesiology 2024; 140:399-408. [PMID: 38011027 DOI: 10.1097/aln.0000000000004848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND Postoperative pulmonary complications is a major issue that affects outcomes of surgical patients. The hypothesis was that the intraoperative ventilation parameters are associated with occurrence of postoperative pulmonary complications. METHODS A single-center retrospective cohort study was conducted at the Lille University Hospital, France. The study included 33,701 adults undergoing noncardiac, nonthoracic elective surgery requiring general anesthesia with tracheal intubation between January 2010 and December 2019. Intraoperative ventilation parameters were compared between patients with and without one or more postoperative pulmonary complications (respiratory infection, respiratory failure, pleural effusion, atelectasis, pneumothorax, bronchospasm, and aspiration pneumonitis) within 7 days of surgery. RESULTS Among 33,701 patients, 2,033 (6.0%) had one or more postoperative pulmonary complications. The lower tidal volume to predicted body weight ratio (odds ratio per -1 ml·kgPBW-1, 1.08; 95% CI, 1.02 to 1.14; P < 0.001), higher mechanical power (odds ratio per 4 J·min-1, 1.37; 95% CI, 1.26 to 1.49; P < 0.001), dynamic respiratory system compliance less than 30 ml·cm H2O (1.30; 95% CI, 1.15 to 1.46; P < 0.001), oxygen saturation measured by pulse oximetry less than 96% (odds ratio, 2.42; 95% CI, 1.97 to 2.96; P < 0.001), and lower end-tidal carbon dioxide (odds ratio per -3 mmHg, 1.06; 95% CI, 1.00 to 1.13; P = 0.023) were independently associated with postoperative pulmonary complications. Patients with postoperative pulmonary complications were more likely to be admitted to the intensive care unit (odds ratio, 12.5; 95% CI, 6.6 to 10.1; P < 0.001), had longer hospital length of stay (subhazard ratio, 0.43; 95% CI, 0.40 to 0.45), and higher in-hospital (subhazard ratio, 6.0; 95% CI, 4.1 to 9.0; P < 0.001) and 1-yr mortality (subhazard ratio, 2.65; 95% CI, 2.33 to 3.02; P < 0.001). CONCLUSIONS In the study's population, decreased rather than increased tidal volume, decreased compliance, increased mechanical power, and decreased end-tidal carbon dioxide were independently associated with postoperative pulmonary complications. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Bertrand Elefterion
- Lille University Hospital, Surgical Critical Care, Department of Anesthesiology and Critical Care, Lille, France
| | - Cedric Cirenei
- Lille University Hospital, Surgical Critical Care, Department of Anesthesiology and Critical Care, Lille, France
| | - Eric Kipnis
- Lille University Hospital, Surgical Critical Care, Department of Anesthesiology and Critical Care, Lille, France
| | - Emeline Cailliau
- Lille University Hospital, Biostatistics Department, Lille, France
| | - Amélie Bruandet
- Lille University Hospital, Medical Information Department, Lille, France
| | - Benoit Tavernier
- Lille University Hospital, Surgical Critical Care, Department of Anesthesiology and Critical Care, Lille, France; and Lille University F-59000, ULR 2694-METRICS: Health Technology Assessment and Medical Practices Evaluation, Lille, France
| | - Antoine Lamer
- Lille University, Lille University Hospital, ULR 2694-METRICS: Health Technology Assessment and Medical Practices Evaluation, Lille, France
| | - Gilles Lebuffe
- Lille University Hospital, Surgical Critical Care, Department of Anesthesiology and Critical Care, Lille, France: Lille University F-59000, ULR 7365-Research Group on Injectable Forms and Associated Technologies, Lille, France
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15
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Piriyapatsom A, Trisukhonth A, Chintabanyat O, Chaiwat O, Kongsayreepong S, Thanakiattiwibun C. Adherence to lung protective mechanical ventilation in patients admitted to a surgical intensive care unit and the associated increased mortality. Heliyon 2024; 10:e26220. [PMID: 38404779 PMCID: PMC10884462 DOI: 10.1016/j.heliyon.2024.e26220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 02/05/2024] [Accepted: 02/08/2024] [Indexed: 02/27/2024] Open
Abstract
Background The adherence rate to the lung protective ventilation (LPV) strategy, which is generally accepted as a standard practice in mechanically ventilated patients, reported in the literature is approximately 40%. This study aimed to determine the adherence rate to the LPV strategy, factors associated with this adherence, and related clinical outcomes in mechanically ventilated patients admitted to the surgical intensive care unit (SICU). Methods This prospective observational study was conducted in the SICU of a tertiary university-based hospital between April 2018 and February 2019. Three hundred and six adult patients admitted to the SICU who required mechanical ventilation support for more than 12 h were included. Ventilator parameters at the initiation of mechanical ventilation support in the SICU were recorded. The LPV strategy was defined as ventilation with a tidal volume of equal or less than 8 ml/kg of predicted body weight plus positive end-expiratory pressure of at least 5 cm H2O. Demographic and clinical data were recorded and analyzed. Results There were 306 patients included in this study. The adherence rate to the LPV strategy was 36.9%. Height was the only factor associated with adherence to the LPV strategy (odds ratio for each cm, 1.10; 95% confidence interval (CI), 1.06-1.15). Cox regression analysis showed that the LPV strategy was associated with increased 90-day mortality (hazard ratio, 1.73; 95% CI, 1.02-2.94). Conclusion The adherence rate to the LPV strategy among patients admitted to the SICU was modest. Further studies are warranted to explore whether the application of the LPV strategy is simply a marker of disease severity or a causative factor for increased mortality.
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Affiliation(s)
- Annop Piriyapatsom
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700, Thailand
| | - Ajana Trisukhonth
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700, Thailand
| | - Ornin Chintabanyat
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700, Thailand
| | - Onuma Chaiwat
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700, Thailand
| | - Suneerat Kongsayreepong
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700, Thailand
| | - Chayanan Thanakiattiwibun
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700, Thailand
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16
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Rubulotta F, Blanch Torra L, Naidoo KD, Aboumarie HS, Mathivha LR, Asiri AY, Sarlabous Uranga L, Soussi S. Mechanical Ventilation, Past, Present, and Future. Anesth Analg 2024; 138:308-325. [PMID: 38215710 DOI: 10.1213/ane.0000000000006701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024]
Abstract
Mechanical ventilation (MV) has played a crucial role in the medical field, particularly in anesthesia and in critical care medicine (CCM) settings. MV has evolved significantly since its inception over 70 years ago and the future promises even more advanced technology. In the past, ventilation was provided manually, intermittently, and it was primarily used for resuscitation or as a last resort for patients with severe respiratory or cardiovascular failure. The earliest MV machines for prolonged ventilatory support and oxygenation were large and cumbersome. They required a significant amount of skills and expertise to operate. These early devices had limited capabilities, battery, power, safety features, alarms, and therefore these often caused harm to patients. Moreover, the physiology of MV was modified when mechanical ventilators moved from negative pressure to positive pressure mechanisms. Monitoring systems were also very limited and therefore the risks related to MV support were difficult to quantify, predict and timely detect for individual patients who were necessarily young with few comorbidities. Technology and devices designed to use tracheostomies versus endotracheal intubation evolved in the last century too and these are currently much more reliable. In the present, positive pressure MV is more sophisticated and widely used for extensive period of time. Modern ventilators use mostly positive pressure systems and are much smaller, more portable than their predecessors, and they are much easier to operate. They can also be programmed to provide different levels of support based on evolving physiological concepts allowing lung-protective ventilation. Monitoring systems are more sophisticated and knowledge related to the physiology of MV is improved. Patients are also more complex and elderly compared to the past. MV experts are informed about risks related to prolonged or aggressive ventilation modalities and settings. One of the most significant advances in MV has been protective lung ventilation, diaphragm protective ventilation including noninvasive ventilation (NIV). Health care professionals are familiar with the use of MV and in many countries, respiratory therapists have been trained for the exclusive purpose of providing safe and professional respiratory support to critically ill patients. Analgo-sedation drugs and techniques are improved, and more sedative drugs are available and this has an impact on recovery, weaning, and overall patients' outcome. Looking toward the future, MV is likely to continue to evolve and improve alongside monitoring techniques and sedatives. There is increasing precision in monitoring global "patient-ventilator" interactions: structure and analysis (asynchrony, desynchrony, etc). One area of development is the use of artificial intelligence (AI) in ventilator technology. AI can be used to monitor patients in real-time, and it can predict when a patient is likely to experience respiratory distress. This allows medical professionals to intervene before a crisis occurs, improving patient outcomes and reducing the need for emergency intervention. This specific area of development is intended as "personalized ventilation." It involves tailoring the ventilator settings to the individual patient, based on their physiology and the specific condition they are being treated for. This approach has the potential to improve patient outcomes by optimizing ventilation and reducing the risk of harm. In conclusion, MV has come a long way since its inception, and it continues to play a critical role in anesthesia and in CCM settings. Advances in technology have made MV safer, more effective, affordable, and more widely available. As technology continues to improve, more advanced and personalized MV will become available, leading to better patients' outcomes and quality of life for those in need.
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Affiliation(s)
- Francesca Rubulotta
- From the Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada
| | - Lluis Blanch Torra
- Department of Critical Care, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Kuban D Naidoo
- Division of Critical Care, University of Witwatersrand, Johannesburg, South Africa
| | - Hatem Soliman Aboumarie
- Department of Anaesthetics, Critical Care and Mechanical Circulatory Support, Harefield Hospital, Royal Brompton and Harefield Hospitals, London, United Kingdom
- School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, United Kingdom
| | - Lufuno R Mathivha
- Department of Anaesthetics, Critical Care and Mechanical Circulatory Support, The Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand
| | - Abdulrahman Y Asiri
- Department of Internal Medicine and Critical Care, King Khalid University Medical City, Abha, Saudi Arabia
- Department of Critical Care Medicine, McGill University
| | - Leonardo Sarlabous Uranga
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Sabri Soussi
- Department of Anesthesia and Pain Management, University Health Network - Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto
- UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Institut national de la santé et de la recherche médicale (INSERM), Université de Paris Cité, France
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17
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Samanta RJ, Ercole A, Harris S, Summers C. Low Tidal Volume Ventilation Is Poorly Implemented for Patients in North American and United Kingdom ICUs Using Electronic Health Records. Chest 2024; 165:333-347. [PMID: 37775039 PMCID: PMC10851261 DOI: 10.1016/j.chest.2023.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 09/09/2023] [Accepted: 09/15/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND Low tidal volume ventilation (LTVV; < 8 mL/kg predicted body weight [PBW]) is a well-established standard of care associated with improved outcomes. This study used data collated in multicenter electronic health record ICU databases from the United Kingdom and the United States to analyze the use of LTVV in routine clinical practice. RESEARCH QUESTION What factors are associated with adherence to LTVV in the United Kingdom and North America? STUDY DESIGN This was a retrospective, multicenter study across the United Kingdom and United States of patients who were mechanically ventilated. METHODS Factors associated with adherence to LTVV were assessed in all patients in both databases who were mechanically ventilated for > 48 h. We observed trends over time and investigated whether LTVV was associated with patient outcomes (30-day mortality and duration of ventilation) and identified strategies to improve adherence to LTVV. RESULTS A total of 5,466 (Critical Care Health Informatics Collaborative [CCHIC]) and 7,384 electronic ICU collaborative research database [eICU-CRD] patients were ventilated for > 48 h and had data of suitable quality for analysis. The median tidal volume (VT) values were 7.48 mL/kg PBW (CCHIC) and 7.91 mL/kg PBW (eICU-CRD). The patients at highest risk of not receiving LTVV were shorter than 160 cm (CCHIC) and 165 cm (eICU-CRD). Those with BMI > 30 kg/m2 (CCHIC OR, 1.9 [95% CI, 1.7-2.13]; eICU-CRD OR, 1.61 [95% CI, 1.49-1.75]) and female patients (CCHIC OR, 2.39 [95% CI, 2.16-2.65]; eICU-CRD OR, 2.29 [95% CI, 2.26-2.31]) were at increased risk of having median VT > 8 mL/kg PBW. Patients with median VT < 8 mL/kg PBW had decreased 30-day mortality in the CCHIC database (CCHIC cause-specific hazard ratio, 0.86 [95% CI, 0.76-0.97]; eICU-CRD cause-specific hazard ratio, 0.9 [95% CI, 0.86-1.00]). There was a significant reduction in VT over time in the CCHIC database. INTERPRETATION There has been limited implementation of LTVV in routine clinical practice in the United Kingdom and the United States. VT > 8 mL/kg PBW was associated with worse patient outcomes.
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Affiliation(s)
- Romit J Samanta
- Victor Phillip Dahdaleh Heart & Lung Research Institute, University of Cambridge, Cambridge, England
| | - Ari Ercole
- Centre for AI in Medicine, University of Cambridge, Cambridge, England
| | - Steven Harris
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, England
| | - Charlotte Summers
- Victor Phillip Dahdaleh Heart & Lung Research Institute, University of Cambridge, Cambridge, England.
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18
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Battaglini D, Delpiano L, Masuello D, Leme Silva P, Rocco PRM, Matta B, Pelosi P, Robba C. Effects of positive end-expiratory pressure on brain oxygenation, systemic oxygen cascade and metabolism in acute brain injured patients: a pilot physiological cross-sectional study. J Clin Monit Comput 2024; 38:165-175. [PMID: 37453007 DOI: 10.1007/s10877-023-01042-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/02/2023] [Indexed: 07/18/2023]
Abstract
Patients with acute brain injury (ABI) often require the application of positive end-expiratory pressure (PEEP) to optimize mechanical ventilation and systemic oxygenation. However, the effect of PEEP on cerebral function and metabolism is unclear. The primary aim of this study was to evaluate the effects of PEEP augmentation test (from 5 to 15 cmH2O) on brain oxygenation, systemic oxygen cascade and metabolism in ABI patients. Secondary aims include to determine whether changes in regional cerebral oxygenation are reflected by changes in oxygenation cascade and metabolism, and to assess the correlation between brain oxygenation and mechanical ventilation settings. Single center, pilot cross-sectional observational study in an Academic Hospital. Inclusion criteria were: adult (> 18 y/o) patients with ABI and stable intracranial pressure, available gas exchange and indirect calorimetry (IC) monitoring. Cerebral oxygenation was monitored with near-infrared spectroscopy (NIRS) and different derived parameters were collected: variation (Δ) in oxy (O2)-hemoglobin (Hb) (ΔO2Hbi), deoxy-Hb(ΔHHbi), total-Hb(ΔcHbi), and total regional oxygenation (ΔrSO2). Oxygen cascade and metabolism were monitored with arterial/venous blood gas analysis [arterial partial pressure of oxygen (PaO2), arterial saturation of oxygen (SaO2), oxygen delivery (DO2), and lactate], and IC [energy expenditure (REE), respiratory quotient (RQ), oxygen consumption (VO2), and carbon dioxide production (VCO2)]. Data were measured at PEEP 5 cmH2O and 15 cmH2O and expressed as delta (Δ) values. Ten patients with ABI [median age 70 (IQR 62-75) years, 6 (60%) were male, median Glasgow Coma Scale at ICU admission 5.5 (IQR 3-8)] were included. PEEP augmentation from 5 to 15 cmH2O did not affect cerebral oxygenation, systemic oxygen cascade parameters, and metabolism. The arterial component of cerebral oxygenation was significantly correlated with DO2 (ΔO2HBi, rho = 0.717, p = 0.037). ΔrSO2 (rho = 0.727, p = 0.032), ΔcHbi (rho = 0.797, p = 0.013), and ΔHHBi (rho = 0.816, p = 0.009) were significantly correlated with SaO2, but not ΔO2Hbi. ΔrSO2 was significantly correlated with VCO2 (rho = 0.681, p = 0.049). No correlation between brain oxygenation and ventilatory parameters was found. PEEP augmentation test did not affect cerebral and systemic oxygenation or metabolism. Changes in cerebral oxygenation significantly correlated with DO2, SaO2, and VCO2. Cerebral oxygen monitoring could be considered for individualization of mechanical ventilation setting in ABI patients without high or instable intracranial pressure.
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Affiliation(s)
| | - Lara Delpiano
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genoa, Italy
| | - Denise Masuello
- Hospital Donaciòn Francisco Santojanni, Buenos Aires, Argentina
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Centro de Ciências da Saúde, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Centro de Ciências da Saúde, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Rio de Janeiro Network on Neuroinflammation, Carlos Chagas Filho Foundation for Supporting Research in the State of Rio de Janeiro (FAPERJ), Rio de Janeiro, Brazil
| | - Basil Matta
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Paolo Pelosi
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genoa, Italy
| | - Chiara Robba
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genoa, Italy
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19
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Tartler TM, Ahrens E, Munoz-Acuna R, Azizi BA, Chen G, Suleiman A, Wachtendorf LJ, Costa ELV, Talmor DS, Amato MBP, Baedorf-Kassis EN, Schaefer MS. High Mechanical Power and Driving Pressures are Associated With Postoperative Respiratory Failure Independent From Patients' Respiratory System Mechanics. Crit Care Med 2024; 52:68-79. [PMID: 37695139 DOI: 10.1097/ccm.0000000000006038] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
OBJECTIVES High mechanical power and driving pressure (ΔP) have been associated with postoperative respiratory failure (PRF) and may be important parameters guiding mechanical ventilation. However, it remains unclear whether high mechanical power and ΔP merely reflect patients with poor respiratory system mechanics at risk of PRF. We investigated the effect of mechanical power and ΔP on PRF in cohorts after exact matching by patients' baseline respiratory system compliance. DESIGN Hospital registry study. SETTING Academic hospital in New England. PATIENTS Adult patients undergoing general anesthesia between 2008 and 2020. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS The primary exposure was high (≥ 6.7 J/min, cohort median) versus low mechanical power and the key-secondary exposure was high (≥ 15.0 cm H 2 O) versus low ΔP. The primary endpoint was PRF (reintubation or unplanned noninvasive ventilation within seven days). Among 97,555 included patients, 4,030 (4.1%) developed PRF. In adjusted analyses, high intraoperative mechanical power and ΔP were associated with higher odds of PRF (adjusted odds ratio [aOR] 1.37 [95% CI, 1.25-1.50]; p < 0.001 and aOR 1.45 [95% CI, 1.31-1.60]; p < 0.001, respectively). There was large variability in applied ventilatory parameters, dependent on the anesthesia provider. This facilitated matching of 63,612 (mechanical power cohort) and 53,260 (ΔP cohort) patients, yielding identical baseline standardized respiratory system compliance (standardized difference [SDiff] = 0.00) with distinctly different mechanical power (9.4 [2.4] vs 4.9 [1.3] J/min; SDiff = -2.33) and ΔP (19.3 [4.1] vs 11.9 [2.1] cm H 2 O; SDiff = -2.27). After matching, high mechanical power and ΔP remained associated with higher risk of PRF (aOR 1.30 [95% CI, 1.17-1.45]; p < 0.001 and aOR 1.28 [95% CI, 1.12-1.46]; p < 0.001, respectively). CONCLUSIONS High mechanical power and ΔP are associated with PRF independent of patient's baseline respiratory system compliance. Our findings support utilization of these parameters for titrating mechanical ventilation in the operating room and ICU.
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Affiliation(s)
- Tim M Tartler
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Department of Anesthesia, Critical Care and Pain Medicine, Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Elena Ahrens
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Department of Anesthesia, Critical Care and Pain Medicine, Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ricardo Munoz-Acuna
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Department of Anesthesia, Critical Care and Pain Medicine, Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Basit A Azizi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Department of Anesthesia, Critical Care and Pain Medicine, Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Guanqing Chen
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Aiman Suleiman
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Luca J Wachtendorf
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Department of Anesthesia, Critical Care and Pain Medicine, Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Eduardo L V Costa
- Divisão de Pneumologia, Cardiopulmonary Department, Heart Institute (INCOR), São Paulo, SP, Brazil
| | - Daniel S Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marcelo B P Amato
- Divisão de Pneumologia, Cardiopulmonary Department, Heart Institute (INCOR), São Paulo, SP, Brazil
| | - Elias N Baedorf-Kassis
- Department of Anesthesia, Critical Care and Pain Medicine, Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Department of Anesthesia, Critical Care and Pain Medicine, Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
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20
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Ofoma UR. Mechanical Power and Safer Lung Ventilation: Not Ready for Prime Time. Crit Care Med 2024; 52:150-153. [PMID: 38095523 PMCID: PMC10751058 DOI: 10.1097/ccm.0000000000006064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Affiliation(s)
- Uchenna R Ofoma
- Division of Critical Care Medicine, Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, MO
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21
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Spraider P, Abram J, Martini J, Putzer G, Glodny B, Hell T, Barnes T, Enk D. Flow-controlled versus pressure-controlled ventilation in cardiac surgery with cardiopulmonary bypass - A single-center, prospective, randomized, controlled trial. J Clin Anesth 2023; 91:111279. [PMID: 37797394 DOI: 10.1016/j.jclinane.2023.111279] [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: 02/22/2023] [Revised: 09/16/2023] [Accepted: 09/27/2023] [Indexed: 10/07/2023]
Abstract
STUDY OBJECTIVE Multifactorial comparison of flow-controlled ventilation (FCV) to standard of pressure-controlled ventilation (PCV) in terms of oxygenation in cardiac surgery patients after chest closure. DESIGN Prospective, non-blinded, randomized, controlled trial. SETTING Operating theatre at an university hospital, Austria. PATIENTS Patients scheduled for elective, open, on-pump, cardiac surgery. INTERVENTIONS Participants were randomized to either individualized FCV (compliance guided end-expiratory and peak pressure setting) or control of PCV (compliance guided end-expiratory pressure setting and tidal volume of 6-8 ml/kg) for the duration of surgery. MEASUREMENTS The primary outcome measure was oxygenation (PaO2/FiO2) 15 min after intraoperative chest closure. Secondary endpoints included CO2-removal assessed as required minute volume to achieve normocapnia and lung tissue aeration assessed by Hounsfield unit distribution in postoperative computed tomography scans. MAIN RESULTS Between April 2020 and April 2021 56 patients were enrolled and 50 included in the primary analysis (mean age 70 years, 38 (76%) men). Oxygenation, assessed by PaO2/FiO2, was significantly higher in the FCV group (n = 24) compared to the control group (PCV, n = 26) (356 vs. 309, median difference (MD) 46 (95% CI 3 to 90) mmHg; p = 0.038). Additionally, the minute volume required to obtain normocapnia was significantly lower in the FCV group (4.0 vs. 6.1, MD -2.0 (95% CI -2.5 to -1.5) l/min; p < 0.001) and correlated with a significantly lower exposure to mechanical power (5.1 vs. 9.8, MD -5.1 (95% CI -6.2 to -4.0) J/min; p < 0.001). Evaluation of lung tissue aeration revealed a significantly reduced amount of non-aerated lung tissue in FCV compared to PCV (5 vs. 7, MD -3 (95% CI -4 to -1) %; p < 0.001). CONCLUSIONS In patients undergoing on-pump, cardiac surgery individualized FCV significantly improved oxygenation and lung tissue aeration compared to PCV. In addition, carbon dioxide removal was accomplished at a lower minute volume leading to reduced applied mechanical power.
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Affiliation(s)
- Patrick Spraider
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Julia Abram
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Judith Martini
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
| | - Gabriel Putzer
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Bernhard Glodny
- Department of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Tobias Hell
- Department of Mathematics, Faculty of Mathematics, Computer Science and Physics, University of Innsbruck, Technikerstrasse 15, 6020 Innsbruck, Austria
| | - Tom Barnes
- University of Greenwich, Old Royal Naval College, Park Row, SE109LS London, United Kingdom
| | - Dietmar Enk
- Faculty of Medicine, University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
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22
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Buonanno P, Marra A, Iacovazzo C, Vargas M, Coviello A, Squillacioti F, Nappi S, de Siena AU, Servillo G. Impact of ventilation strategies on pulmonary and cardiovascular complications in patients undergoing general anaesthesia for elective surgery: a systematic review and meta-analysis. Br J Anaesth 2023; 131:1093-1101. [PMID: 37839932 PMCID: PMC10687618 DOI: 10.1016/j.bja.2023.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/10/2023] [Accepted: 09/11/2023] [Indexed: 10/17/2023] Open
Abstract
BACKGROUND Many RCTs have evaluated the influence of intraoperative tidal volume (tV), PEEP, and driving pressure on the occurrence of postoperative pulmonary complications, cardiovascular complications, and mortality in adult patients. Our meta-analysis aimed to investigate the association between tV, PEEP, and driving pressure and the above-mentioned outcomes. METHODS We conducted a systematic review and meta-analysis of RCTs from inception to May 19, 2022. The primary outcome was the incidence of postoperative pulmonary complications; the secondary outcomes were intraoperative cardiovascular complications and 30-day mortality. Primary and secondary outcomes were evaluated stratifying patients in the following groups: (1) low tV (LV, tV 6-8 ml kg-1 and PEEP ≥5 cm H2O) vs high tV (HV, tV >8 ml kg-1 and PEEP=0 cm H2O); (2) higher PEEP (HP, ≥6 cm H2O) vs lower PEEP (LP, <6 cm H2O); and (3) driving pressure-guided PEEP (DP) vs fixed PEEP (FP). RESULTS We included 16 RCTs with a total sample size of 4993. The incidence of postoperative pulmonary complications was lower in patients treated with LV than with HV (OR=0.402, CI 0.280-0.577, P<0.001) and lower in DP than in FP group (OR=0.358, CI 0.187-0.684, P=0.002). Postoperative pulmonary complications did not differ between HP and LP groups; the incidence of intraoperative cardiovascular complications was higher in HP group (OR=1.385, CI 1.027-1.867, P=0.002). The 30-day mortality was not influenced by the ventilation strategy. CONCLUSIONS Optimal intraoperative mechanical ventilation is unclear; however, our meta-analysis showed that low tidal volume and driving pressure-guided PEEP strategies were associated with a reduction in postoperative pulmonary complications.
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Affiliation(s)
- Pasquale Buonanno
- Department of Neuroscience, Reproductive Science and Odontostomatological Science, University of Naples 'Federico II', Naples, Italy.
| | - Annachiara Marra
- Department of Neuroscience, Reproductive Science and Odontostomatological Science, University of Naples 'Federico II', Naples, Italy
| | - Carmine Iacovazzo
- Department of Neuroscience, Reproductive Science and Odontostomatological Science, University of Naples 'Federico II', Naples, Italy
| | - Maria Vargas
- Department of Neuroscience, Reproductive Science and Odontostomatological Science, University of Naples 'Federico II', Naples, Italy
| | - Antonio Coviello
- Department of Neuroscience, Reproductive Science and Odontostomatological Science, University of Naples 'Federico II', Naples, Italy
| | - Francesco Squillacioti
- Department of Neuroscience, Reproductive Science and Odontostomatological Science, University of Naples 'Federico II', Naples, Italy
| | - Serena Nappi
- Department of Neuroscience, Reproductive Science and Odontostomatological Science, University of Naples 'Federico II', Naples, Italy
| | - Andrea Uriel de Siena
- Department of Neuroscience, Reproductive Science and Odontostomatological Science, University of Naples 'Federico II', Naples, Italy
| | - Giuseppe Servillo
- Department of Neuroscience, Reproductive Science and Odontostomatological Science, University of Naples 'Federico II', Naples, Italy
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23
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Ramirez-Estrada S, Peña-Lopez Y, Vieceli T, Rello J. Ventilator-associated events: From surveillance to optimizing management. JOURNAL OF INTENSIVE MEDICINE 2023; 3:204-211. [PMID: 37533808 PMCID: PMC10391577 DOI: 10.1016/j.jointm.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/22/2022] [Accepted: 09/20/2022] [Indexed: 08/04/2023]
Abstract
Mechanical ventilation (MV) is a life-support therapy that may predispose to morbid and lethal complications, with ventilator-associated pneumonia (VAP) being the most prevalent. In 2013, the Center for Disease Control (CDC) defined criteria for ventilator-associated events (VAE). Ten years later, a growing number of studies assessing or validating its clinical applicability and the potential benefits of its inclusion have been published. Surveillance with VAE criteria is retrospective and the focus is often on a subset of patients with higher than lower severity. To date, it is estimated that around 30% of ventilated patients in the intensive care unit (ICU) develop VAE. While surveillance enhances the detection of infectious and non-infectious MV-related complications that are severe enough to impact the patient's outcomes, there are still many gaps in its classification and management. In this review, we provide an update by discussing VAE etiologies, epidemiology, and classification. Preventive strategies on optimizing ventilation, sedative and neuromuscular blockade therapy, and restrictive fluid management are warranted. An ideal VAE bundle is likely to minimize the period of intubation. We believe that it is time to progress from just surveillance to clinical care. Therefore, with this review, we have aimed to provide a roadmap for future research on the subject.
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Affiliation(s)
| | - Yolanda Peña-Lopez
- Paediatric Critical Care Department, Hospital Universitari Vall d'Hebron, Barcelona 08035, Spain
- Clinical Research/Epidemiology in Pneumonia and Sepsis (CRIPS), Vall d'Hebron Research Institute, Barcelona 08035, Spain
| | - Tarsila Vieceli
- Infectious Diseases Department, Hospital de Clínicas de Porto Alegre, Porto Alegre RS 90035-007, Brazil
| | - Jordi Rello
- Clinical Research/Epidemiology in Pneumonia and Sepsis (CRIPS), Vall d'Hebron Research Institute, Barcelona 08035, Spain
- Universitat Internacional de Catalunya, Barcelona 08195, Spain
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24
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Lim CM, Lee SJ, Kim HJ, Park DH, Jeong CY, Yang HS. Spontaneous pneumothorax after shoulder arthroscopy under general anesthesia: a case report. J Int Med Res 2023; 51:3000605231189367. [PMID: 37523598 PMCID: PMC10392293 DOI: 10.1177/03000605231189367] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023] Open
Abstract
A woman in her early 70s presented with a right fifth rib fracture along with left scapular body and glenoid fractures resulting from a traffic accident. She had no history of lung disease. The patient underwent multi-incisional video-guided arthroscopic fracture reduction and screw fixation in the right lateral decubitus position under general anesthesia, and surgery was followed by chest tube insertion. Left-sided pneumothorax was found during routine postoperative radiography despite the absence of relevant symptoms or signs such as hypoxia, chest pain, or respiratory difficulty. We herein report this unusual case with a brief literature review.
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Affiliation(s)
- Chang Mook Lim
- Department of Anesthesiology and Pain Medicine, Daejeon Eulji University Medical Center, Eulji University School of Medicine, Daejeon, Korea
| | - Seok Jin Lee
- Department of Anesthesiology and Pain Medicine, Daejeon Eulji University Medical Center, Eulji University School of Medicine, Daejeon, Korea
| | - Hyo June Kim
- Department of Orthopedic Surgery, Daejeon Eulji University Medical Center, Eulji University School of Medicine, Daejeon, Korea
| | - Dong Ho Park
- Department of Anesthesiology and Pain Medicine, Daejeon Eulji University Medical Center, Eulji University School of Medicine, Daejeon, Korea
| | - Chang Young Jeong
- Department of Anesthesiology and Pain Medicine, Daejeon Eulji University Medical Center, Eulji University School of Medicine, Daejeon, Korea
| | - Hong Seuk Yang
- Department of Anesthesiology and Pain Medicine, Daejeon Eulji University Medical Center, Eulji University School of Medicine, Daejeon, Korea
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25
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Giardina A, Cardim D, Ciliberti P, Battaglini D, Ball L, Kasprowicz M, Beqiri E, Smielewski P, Czosnyka M, Frisvold S, Groznik M, Pelosi P, Robba C. Effects of positive end-expiratory pressure on cerebral hemodynamics in acute brain injury patients. Front Physiol 2023; 14:1139658. [PMID: 37200838 PMCID: PMC10185889 DOI: 10.3389/fphys.2023.1139658] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 04/14/2023] [Indexed: 05/20/2023] Open
Abstract
Background: Cerebral autoregulation is the mechanism that allows to maintain the stability of cerebral blood flow despite changes in cerebral perfusion pressure. Maneuvers which increase intrathoracic pressure, such as the application of positive end-expiratory pressure (PEEP), have been always challenged in brain injured patients for the risk of increasing intracranial pressure (ICP) and altering autoregulation. The primary aim of this study is to assess the effect of PEEP increase (from 5 to 15 cmH2O) on cerebral autoregulation. Secondary aims include the effect of PEEP increase on ICP and cerebral oxygenation. Material and Methods: Prospective, observational study including adult mechanically ventilated patients with acute brain injury requiring invasive ICP monitoring and undergoing multimodal neuromonitoring including ICP, cerebral perfusion pressure (CPP) and cerebral oxygenation parameters obtained with near-infrared spectroscopy (NIRS), and an index which expresses cerebral autoregulation (PRx). Additionally, values of arterial blood gases were analyzed at PEEP of 5 and 15 cmH2O. Results are expressed as median (interquartile range). Results: Twenty-five patients were included in this study. The median age was 65 years (46-73). PEEP increase from 5 to 15 cmH2O did not lead to worsened autoregulation (PRx, from 0.17 (-0.003-0.28) to 0.18 (0.01-0.24), p = 0.83). Although ICP and CPP changed significantly (ICP: 11.11 (6.73-15.63) to 13.43 (6.8-16.87) mm Hg, p = 0.003, and CPP: 72.94 (59.19-84) to 66.22 (58.91-78.41) mm Hg, p = 0.004), these parameters did not reach clinically relevant levels. No significant changes in relevant cerebral oxygenation parameters were observed. Conclusion: Slow and gradual increases of PEEP did not alter cerebral autoregulation, ICP, CPP and cerebral oxygenation to levels triggering clinical interventions in acute brain injury patients.
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Affiliation(s)
- Alberto Giardina
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
| | - Danilo Cardim
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, TX, United States
| | - Pietro Ciliberti
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
| | | | - Lorenzo Ball
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
- IRCCS Policlinico San Martino, Genova, Italy
| | - Magdalena Kasprowicz
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - Erta Beqiri
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Peter Smielewski
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Shirin Frisvold
- Anesthesia and Intensive Care, University Hospital of Northern Norway, Tromsø, Norway
| | - Matjaž Groznik
- Traumatology Department of the University Clinical Center Ljubljana, Ljubljana, Slovenia
| | - Paolo Pelosi
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
- IRCCS Policlinico San Martino, Genova, Italy
| | - Chiara Robba
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
- IRCCS Policlinico San Martino, Genova, Italy
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26
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Grieco DL, Russo A, Anzellotti GM, Romanò B, Bongiovanni F, Dell'Anna AM, Mauti L, Cascarano L, Gallotta V, Rosà T, Varone F, Menga LS, Polidori L, D'Indinosante M, Cappuccio S, Galletta C, Tortorella L, Costantini B, Gueli Alletti S, Sollazzi L, Scambia G, Antonelli M. Lung-protective ventilation during Trendelenburg pneumoperitoneum surgery: A randomized clinical trial. J Clin Anesth 2023; 85:111037. [PMID: 36495775 DOI: 10.1016/j.jclinane.2022.111037] [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: 08/29/2022] [Revised: 10/31/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
Study objective To assess the effects of a protective ventilation strategy during Trendelenburg pneumoperitoneum surgery on postoperative oxygenation. DESIGNS Parallel-group, randomized trial. SETTING Operating room of a university hospital, Italy. PATIENTS Morbidly obese patients undergoing Trendelenburg pneumoperitoneum gynaecological surgery. INTERVENTIONS Participants were randomized to standard (SV: tidal volume = 10 ml/kg of predicted body weight, PEEP = 5 cmH2O) or protective (PV: tidal volume = 6 ml/kg of predicted body weight, PEEP = 10 cmH2O, recruitment maneuvers) ventilation during anesthesia. MEASUREMENTS Primary outcome was PaO2/FiO2 one hour after extubation. Secondary outcomes included day-1 PaO2/FiO2, day-2 respiratory function and intraoperative respiratory/lung mechanics, assessed through esophageal manometry, end-expiratory lung volume (EELV) measurement and pressure-volume curves. MAIN RESULTS Sixty patients were analyzed (31 in SV group, 29 in PV group). Median [IqR] tidal volume was 350 ml [300-360] in PV group and 525 [500-575] in SV group. Median PaO2/FiO2 one hour after extubation was 280 mmHg [246-364] in PV group vs. 298 [250-343] in SV group (p = 0.64). Day-1 PaO2/FiO2, day-2 forced vital capacity, FEV-1 and Tiffenau Index were not different between groups (all p > 0.10). Intraoperatively, 59% of patients showed complete airway closure during pneumoperitoneum, without difference between groups: median airway opening pressure was 17 cmH2O. In PV group, airway and transpulmonary driving pressure were lower (12 ± 5 cmH2O vs. 17 ± 7, p < 0.001; 9 ± 4 vs. 13 ± 7, p < 0.001), PaCO2 and respiratory rate were higher (48 ± 8 mmHg vs. 42 ± 12, p < 0.001; 23 ± 5 breaths/min vs. 16 ± 4, p < 0.001). Intraoperative EELV was similar between PV and SV group (1193 ± 258 ml vs. 1207 ± 368, p = 0.80); ratio of tidal volume to EELV was lower in PV group (0.45 ± 0.12 vs. 0.32 ± 0.09, p < 0.001). CONCLUSIONS In obese patients undergoing Trendelenburg pneumoperitoneum surgery, PV did not improve postoperative oxygenation nor day-2 respiratory function. PV was associated with intraoperative respiratory mechanics indicating less injurious ventilation. The high prevalence of complete airway closure may have affected study results. TRIAL REGISTRATION Prospectively registered on http://clinicaltrials.govNCT03157479 on May 17th, 2017.
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Affiliation(s)
- Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Andrea Russo
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gian Marco Anzellotti
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Bruno Romanò
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Filippo Bongiovanni
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio M Dell'Anna
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Mauti
- Department of Internal medicine, Catholic University of The Sacred Heart, Rome, Italy; Respiratory Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Laura Cascarano
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Valerio Gallotta
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Tommaso Rosà
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Varone
- Department of Internal medicine, Catholic University of The Sacred Heart, Rome, Italy; Respiratory Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luca S Menga
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lorenzo Polidori
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco D'Indinosante
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Serena Cappuccio
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Claudia Galletta
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lucia Tortorella
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Barbara Costantini
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Salvatore Gueli Alletti
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Liliana Sollazzi
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Scambia
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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27
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Henricks EM, Pfeifer KJ. Pulmonary assessment and optimization for older surgical patients. Int Anesthesiol Clin 2023; 61:8-15. [PMID: 36794803 DOI: 10.1097/aia.0000000000000398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Affiliation(s)
- Evan M Henricks
- Division of Geriatric and Palliative Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kurt J Pfeifer
- Department of Medicine, Section of Perioperative & Consultative Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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28
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Ko E, Yoo KY, Lim CH, Jun S, Lee K, Kim YH. Is atelectasis related to the development of postoperative pneumonia? a retrospective single center study. BMC Anesthesiol 2023; 23:77. [PMID: 36906539 PMCID: PMC10007747 DOI: 10.1186/s12871-023-02020-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/14/2023] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND Atelectasis may play a substantial role in the development of pneumonia. However, pneumonia has never been evaluated as an outcome of atelectasis in surgical patients. We aimed to determine whether atelectasis is related to an increased risk of postoperative pneumonia, intensive care unit (ICU) admission and hospital length of stay (LOS). METHODS The electronic medical records of adult patients who underwent elective non-cardiothoracic surgery under general anesthesia between October 2019 and August 2020 were reviewed. They were divided into two groups: one who developed postoperative atelectasis (atelectasis group) and the other who did not (non-atelectasis group). The primary outcome was the incidence of pneumonia within 30 days after the surgery. The secondary outcomes were ICU admission rate and postoperative LOS. RESULTS Patients in the atelectasis group were more likely to have risk factors for postoperative pneumonia including age, body mass index, a history of hypertension or diabetes mellitus and duration of surgery, compared with those in the non-atelectasis. Among 1,941 patients, 63 (3.2%) developed postoperative pneumonia; 5.1% in the atelectasis group and 2.8% in the non-atelectasis (P = 0.025). In multivariable analysis, atelectasis was associated with an increased risk of pneumonia (adjusted odds ratio, 2.33; 95% CI: 1.24 - 4.38; P = 0.008). Median postoperative LOS was significantly longer in the atelectasis group (7 [interquartile range: 5-10 days]) than in the non-atelectasis (6 [3-8] days) (P < 0.001). Adjusted median duration was also 2.19 days longer in the atelectasis group (β, 2.19; 95% CI: 0.821 - 2.834; P < 0.001). ICU admission rate was higher in the atelectasis group (12.1% vs. 6.5%; P < 0.001), but it did not differ between the groups after adjustment for confounders (adjusted odds ratio, 1.52; 95% CI: 0.88 - 2.62; P = 0.134). CONCLUSION Among patients undergoing elective non-cardiothoracic surgery, patients with postoperative atelectasis were associated with a 2.33-fold higher incidence of pneumonia and a longer LOS than those without atelectasis. This finding alerts the need for careful management of perioperative atelectasis to prevent or reduce the adverse events including pneumonia and the burden of hospitalizations. TRIAL REGISTRATION None.
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Affiliation(s)
- Eunji Ko
- grid.411134.20000 0004 0474 0479Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, 73, Goryeodae-ro, Seongbuk-gu, Seoul, 02841 Republic of Korea
| | - Kyung Yeon Yoo
- grid.411597.f0000 0004 0647 2471Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital, 42 , Jebong-ro, Dong-gu, Gwangju, 58128 Republic of Korea
| | - Choon Hak Lim
- grid.222754.40000 0001 0840 2678Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University, 73, Goryeodae-ro, Seongbuk-gu, Seoul, 02841 Republic of Korea
| | - Seungwoo Jun
- grid.411134.20000 0004 0474 0479Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, 73, Goryeodae-ro, Seongbuk-gu, Seoul, 02841 Republic of Korea
| | - Kaehong Lee
- grid.411134.20000 0004 0474 0479Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, 73, Goryeodae-ro, Seongbuk-gu, Seoul, 02841 Republic of Korea
| | - Yun Hee Kim
- grid.49606.3d0000 0001 1364 9317Department of Anesthesiology and Pain Medicine, Hanyang University Changwon Hanmaeum Hospital, 57, Yongdong-Ro, Uichang-Gu, Gyeongsangnam-Do, Changwon-Si, 51139 Republic of Korea
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29
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Low tidal volume ventilation for patients undergoing laparoscopic surgery: a secondary analysis of a randomised clinical trial. BMC Anesthesiol 2023; 23:71. [PMID: 36882701 PMCID: PMC9990198 DOI: 10.1186/s12871-023-01998-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 01/30/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND We recently reported the results for a large randomized controlled trial of low tidal volume ventilation (LTVV) versus conventional tidal volume (CTVV) during major surgery when positive end expiratory pressure (PEEP) was equal between groups. We found no difference in postoperative pulmonary complications (PPCs) in patients who received LTVV. However, in the subgroup of patients undergoing laparoscopic surgery, LTVV was associated with a numerically lower rate of PPCs after surgery. We aimed to further assess the relationship between LTVV versus CTVV during laparoscopic surgery. METHODS We conducted a post-hoc analysis of this pre-specified subgroup. All patients received volume-controlled ventilation with an applied PEEP of 5 cmH2O and either LTVV (6 mL/kg predicted body weight [PBW]) or CTVV (10 mL/kg PBW). The primary outcome was the incidence of a composite of PPCs within seven days. RESULTS Three hundred twenty-eight patients (27.2%) underwent laparoscopic surgeries, with 158 (48.2%) randomised to LTVV. Fifty two of 157 patients (33.1%) assigned to LTVV and 72 of 169 (42.6%) assigned to conventional tidal volume developed PPCs within 7 days (unadjusted absolute difference, - 9.48 [95% CI, - 19.86 to 1.05]; p = 0.076). After adjusting for pre-specified confounders, the LTVV group had a lower incidence of the primary outcome than patients receiving CTVV (adjusted absolute difference, - 10.36 [95% CI, - 20.52 to - 0.20]; p = 0.046). CONCLUSION In this post-hoc analysis of a large, randomised trial of LTVV we found that during laparoscopic surgeries, LTVV was associated with a significantly reduced PPCs compared to CTVV when PEEP was applied equally between both groups. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry no: 12614000790640.
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30
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Hennessey E, Bittner E, White P, Kovar A, Meuchel L. Intraoperative Ventilator Management of the Critically Ill Patient. Anesthesiol Clin 2023; 41:121-140. [PMID: 36871995 PMCID: PMC9985493 DOI: 10.1016/j.anclin.2022.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Strategies for the intraoperative ventilator management of the critically ill patient focus on parameters used for lung protective ventilation with acute respiratory distress syndrome, preventing or limiting the deleterious effects of mechanical ventilation, and optimizing anesthetic and surgical conditions to limit postoperative pulmonary complications for patients at risk. Patient conditions such as obesity, sepsis, the need for laparoscopic surgery, or one-lung ventilation may benefit from intraoperative lung protective ventilation strategies. Anesthesiologists can use risk evaluation and prediction tools, monitor advanced physiologic targets, and incorporate new innovative monitoring techniques to develop an individualized approach for patients.
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Affiliation(s)
- Erin Hennessey
- Stanford University - School of Medicine Department of Anesthesiology, Perioperative and Pain Medicine, 300 Pasteur Drive, Room H3580, Stanford, CA 94305, USA.
| | - Edward Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Peggy White
- University of Florida College of Medicine, Department of Anesthesiology, 1500 SW Archer Road, PO Box 100254, Gainesville, FL 32610, USA
| | - Alan Kovar
- Oregon Health and Science University, 3161 SW Pavilion Loop, Portland, OR 97239, USA
| | - Lucas Meuchel
- Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
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Papastefanou A, Rioja E. Severe Hypercapnia during Anaesthesia under Mechanical Ventilation in Two Paediatric Patients. Animals (Basel) 2023; 13:ani13040663. [PMID: 36830450 PMCID: PMC9951664 DOI: 10.3390/ani13040663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/07/2023] [Accepted: 02/11/2023] [Indexed: 02/17/2023] Open
Abstract
A 2-month-old male 1.56 kg Yorkshire terrier (Case No. 1) and a 3-month-old male 2.3 kg Jack Russell Terrier (Case No. 2) were scheduled for ophthalmological surgery under general anaesthesia and neuromuscular blockade. For both patients, volume-controlled ventilation (VCV) was used with set tidal volumes (VT) of 13 mL/kg and 20 mL/kg for cases No. 1 and 2, respectively. The type of ventilator used did not take into account the intrinsic compliance of the breathing system; therefore, a significant part of the delivered VT was wasted in the expansion of the breathing system, and did not reach the patients, causing alveolar hypoventilation. Both cases developed low dynamic compliance (CD), and after a recruitment manoeuvre, EtCO2 of up to 116 mmHg and 197 mmHg were revealed for cases No. 1 and 2, respectively. The two cases had to be ventilated manually, using positive inspiratory pressures (PIP) of 20-25 mmHg, in order to improve alveolar ventilation and reduce the EtCO2, as adjustments to the VCV were ineffective. Both patients maintained an oxygen haemoglobin saturation between 94% and 100% throughout the procedure and they recovered well. Using a higher VT from the beginning, to compensate for the compliance of the breathing system, or the use of pressure-controlled ventilation (PCV), could have potentially helped to avoid these two incidences of severe hypercapnia.
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Qian X, Jiang Y, Jia J, Shen W, Ding Y, He Y, Xu P, Pan Q, Xu Y, Ge H. PEEP application during mechanical ventilation contributes to fibrosis in the diaphragm. Respir Res 2023; 24:46. [PMID: 36782202 PMCID: PMC9926671 DOI: 10.1186/s12931-023-02356-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 02/01/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Positive end-expiratory airway pressure (PEEP) is a potent component of management for patients receiving mechanical ventilation (MV). However, PEEP may cause the development of diaphragm remodeling, making it difficult for patients to be weaned from MV. The current study aimed to explore the role of PEEP in VIDD. METHODS Eighteen adult male New Zealand rabbits were divided into three groups at random: nonventilated animals (the CON group), animals with volume-assist/control mode without/ with PEEP 8 cmH2O (the MV group/ the MV + PEEP group) for 48 h with mechanical ventilation. Ventilator parameters and diaphragm were collected during the experiment for further analysis. RESULTS There was no difference among the three groups in arterial blood gas and the diaphragmatic excursion during the experiment. The tidal volume, respiratory rate and minute ventilation were similar in MV + PEEP group and MV group. Airway peak pressure in MV + PEEP group was significantly higher than that in MV group (p < 0.001), and mechanical power was significantly higher (p < 0.001). RNA-seq showed that genes associated with fibrosis were enriched in the MV + PEEP group. This results were further confirmed on mRNA expression. As shown by Masson's trichrome staining, there was more collagen fiber in the MV + PEEP group than that in the MV group (p = 0.001). Sirius red staining showed more positive staining of total collagen fibers and type I/III fibers in the MV + PEEP group (p = 0.001; p = 0.001). The western blot results also showed upregulation of collagen types 1A1, III, 6A1 and 6A2 in the MV + PEEP group compared to the MV group (p < 0.001, all). Moreover, the positive immunofluorescence of COL III in the MV + PEEP group was more intense (p = 0.003). Furthermore, the expression of TGF-β1, one of the most potent fibrogenic factors, was upregulated at both the mRNA and protein levels in the MV + PEEP group (mRNA: p = 0.03; protein: p = 0.04). CONCLUSIONS We demonstrated that PEEP application for 48 h in mechanically ventilated rabbits will cause collagen deposition and fibrosis in the diaphragm. Moreover, activation of the TGF-β1 signaling pathway and myofibroblast differentiation may be the potential mechanism of this diaphragmatic fibrosis. These findings might provide novel therapeutic targets for PEEP application-induced diaphragm dysfunction.
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Affiliation(s)
- Xiaoli Qian
- grid.13402.340000 0004 1759 700XDepartment of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016 China
| | - Ye Jiang
- grid.13402.340000 0004 1759 700XDepartment of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016 China
| | - Jianwei Jia
- grid.13402.340000 0004 1759 700XDepartment of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016 China
| | - Weimin Shen
- grid.13402.340000 0004 1759 700XDepartment of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016 China
| | - Yuejia Ding
- grid.13402.340000 0004 1759 700XDepartment of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016 China
| | - Yuhan He
- grid.13402.340000 0004 1759 700XDepartment of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016 China
| | - Peifeng Xu
- grid.13402.340000 0004 1759 700XDepartment of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016 China
| | - Qing Pan
- grid.469325.f0000 0004 1761 325XCollege of Information Engineering, Zhejiang University of Technology, Liuhe Rd. 288, Hangzhou, 310023 China
| | - Ying Xu
- Department of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016, China.
| | - Huiqing Ge
- Department of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016, China.
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Intermediate tidal volume is an acceptable option for ventilated patients with acute respiratory distress syndrome. Med Intensiva 2022; 46:609-618. [PMID: 36313965 PMCID: PMC9597521 DOI: 10.1016/j.medin.2022.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/25/2022] [Indexed: 01/05/2023]
Abstract
Objective Evidence only proves low surpasses high tidal volume (V T) for acute respiratory distress syndrome (ARDS). Intermediate V T is a common setting for ARDS patients and has been demonstrated as effective as low V T in non-ARDS patients. The effectiveness of intermediate V T in ARDS has not been studied and is the objective of this study. Design A retrospective cohort study. Setting Five ICUs with their totally 130 beds in Taiwan. Patients or participants ARDS patients under invasive ventilation. Interventions No. Main variables of interest 28-D mortality. Result Totally 382 patients, with 6958 ventilator settings eligible for lung protection, were classified into low (mean V T = 6.7 ml/kg), intermediate (mean V T = 8.9 ml/kg) and high (mean V T = 11.2 ml/kg) V T groups. With similar baseline ARDS and ICU severities, intermediate and low V T groups did not differ in 28-D mortality (47% vs. 63%, P = 0.06) or other outcomes such as 90-D mortality, ventilator-free days, ventilator-dependence rate. Multivariate analysis revealed high V T was independently associated with 28-D and 90-D mortality, but intermediate V T was not significantly associated with 28-D mortality (HR 1.34, CI 0.92-1.97, P = 0.13) or 90-D mortality. When the intermediate and low V T groups were matched in propensity scores (n = 66 for each group), their outcomes were also not significantly different. Conclusion Intermediate V T, with its outcomes similar to small V T, is an acceptable option for ventilated ARDS patients. This conclusion needs verification through clinical trials.
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Intermediate tidal volume is an acceptable option for ventilated patients with acute respiratory distress syndrome. MEDICINA INTENSIVA (ENGLISH EDITION) 2022; 46:609-618. [PMCID: PMC9633924 DOI: 10.1016/j.medine.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/25/2022] [Indexed: 11/06/2022]
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Affiliation(s)
- Guido Musch
- Department of Anesthesiology and Perioperative Medicine, UMass Chan Medical School, Worcester, Massachusetts
| | - Marcos F Vidal Melo
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York
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Yueyi J, Jing T, Lianbing G. A structured narrative review of clinical and experimental studies of the use of different positive end-expiratory pressure levels during thoracic surgery. THE CLINICAL RESPIRATORY JOURNAL 2022; 16:717-731. [PMID: 36181340 PMCID: PMC9629996 DOI: 10.1111/crj.13545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/03/2022] [Accepted: 09/12/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES This study aimed to present a review on the general effects of different positive end-expiratory pressure (PEEP) levels during thoracic surgery by qualitatively categorizing the effects into detrimental, beneficial, and inconclusive. DATA SOURCE Literature search of Pubmed, CNKI, and Wanfang was made to find relative articles about PEEP levels during thoracic surgery. We used the following keywords as one-lung ventilation, PEEP, and thoracic surgery. RESULTS We divide the non-individualized PEEP value into five grades, that is, less than 5, 5, 5-10, 10, and more than 10 cmH2 O, among which 5 cmH2 O is the most commonly used in clinic at present to maintain alveolar dilatation and reduce the shunt fraction and the occurrence of atelectasis, whereas individualized PEEP, adjusted by test titration or imaging method to adapt to patients' personal characteristics, can effectively ameliorate intraoperative oxygenation and obtain optimal pulmonary compliance and better indexes relating to respiratory mechanics. CONCLUSIONS Available data suggest that PEEP might play an important role in one-lung ventilation, the understanding of which will help in exploring a simple and economical method to set the appropriate PEEP level.
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Affiliation(s)
- Jiang Yueyi
- The Affiliated Cancer Hospital of Nanjing Medical UniversityNanjingChina
| | - Tan Jing
- Department of AnesthesiologyJiangsu Cancer HospitalNanjingChina
| | - Gu Lianbing
- The Affiliated Cancer Hospital of Nanjing Medical UniversityNanjingChina,Department of AnesthesiologyJiangsu Cancer HospitalNanjingChina
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Akkermans A, van Waes JA, Kheterpal S, Pasma W, Saager L, Thompson A, van Klei WA. Outlying End-Tidal Carbon Dioxide During General Anesthesia Is Associated With Postoperative Pulmonary Complications: A Multicenter Retrospective Observational Study From US Hospitals Between 2010 and 2017. Anesth Analg 2022; 135:341-353. [PMID: 35839498 DOI: 10.1213/ane.0000000000006062] [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
BACKGROUND Postoperative pulmonary complications (PPCs) occur in up to 33% of patients who undergo noncardiothoracic surgery. Emerging evidence suggests that permissive hypercapnia may reduce the risk of lung injury. We hypothesized that higher intraoperative end-tidal carbon dioxide (Etco2) concentrations would be associated with a decreased risk of PPCs. METHODS This retrospective, observational, multicenter study included patients undergoing general anesthesia for noncardiothoracic procedures (January 2010-December 2017). The primary outcome was PPC within 30 postoperative days. Secondary outcomes were PPC within 1 week, postoperative length of stay, and inhospital 30-day mortality. The association between these outcomes, median Etco2, and 4 time-weighted average area-under-the-curve (TWA-AUC) thresholds (<28, <35, <45, and >45 mm Hg) was explored using a multivariable mixed-effect model and by plotting associated risks. RESULTS Among 143,769 cases across 11 hospitals, 10,276 (7.1%) experienced a PPC. When compared to a baseline median Etco2 of 35 to 40 mm Hg, a median Etco2 >40 mm Hg was associated with an increase in PPCs within 30 days (median Etco2, 40-45 mm Hg; adjusted OR, 1.16 [99% confidence interval {CI}, 1.00-1.33]; P value = .008 and median Etco2, >45 mm Hg; OR, 1.64 [99% CI, 1.33-2.02]; P value < .001). The occurrence of any Etco2 value <28 mm Hg (ie, a positive TWA-AUC < 28 mm Hg) was associated with PPCs (OR, 1.40 [95% CI, 1.33-1.49]; P value < .001), mortality, and length of stay. Any Etco2 value >45 mm Hg (ie, a positive TWA-AUC >45 mm Hg) was also associated with PPCs (OR, 1.24 [95% CI, 1.17-1.31]; P < .001). The Etco2 range with the lowest incidence of PPCs was 35 to 38 mm Hg. CONCLUSIONS Both a very low (<28 mm Hg) and a high Etco2 (>45 mm Hg) were associated with PPCs within 30 days. The lowest PPC incidence was found in patients with an Etco2 of 35 to 38 mm Hg. Prospective studies are needed to clarify the relationship between postoperative PPCs and intraoperative Etco2.
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Affiliation(s)
- Annemarie Akkermans
- From the Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Judith A van Waes
- From the Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Wietze Pasma
- From the Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Leif Saager
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan.,Department of Anesthesiology, University Medical Center Goettingen, Goettingen, Germany
| | - Aleda Thompson
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Wilton A van Klei
- From the Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Rezoagli E, Laffey JG, Bellani G. Monitoring Lung Injury Severity and Ventilation Intensity during Mechanical Ventilation. Semin Respir Crit Care Med 2022; 43:346-368. [PMID: 35896391 DOI: 10.1055/s-0042-1748917] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a severe form of respiratory failure burden by high hospital mortality. No specific pharmacologic treatment is currently available and its ventilatory management is a key strategy to allow reparative and regenerative lung tissue processes. Unfortunately, a poor management of mechanical ventilation can induce ventilation induced lung injury (VILI) caused by physical and biological forces which are at play. Different parameters have been described over the years to assess lung injury severity and facilitate optimization of mechanical ventilation. Indices of lung injury severity include variables related to gas exchange abnormalities, ventilatory setting and respiratory mechanics, ventilation intensity, and the presence of lung hyperinflation versus derecruitment. Recently, specific indexes have been proposed to quantify the stress and the strain released over time using more comprehensive algorithms of calculation such as the mechanical power, and the interaction between driving pressure (DP) and respiratory rate (RR) in the novel DP multiplied by four plus RR [(4 × DP) + RR] index. These new parameters introduce the concept of ventilation intensity as contributing factor of VILI. Ventilation intensity should be taken into account to optimize protective mechanical ventilation strategies, with the aim to reduce intensity to the lowest level required to maintain gas exchange to reduce the potential for VILI. This is further gaining relevance in the current era of phenotyping and enrichment strategies in ARDS.
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Affiliation(s)
- Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo University Hospital, Monza, Italy
| | - John G Laffey
- School of Medicine, National University of Ireland, Galway, Ireland.,Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,Lung Biology Group, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo University Hospital, Monza, Italy
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Spassov SG, Faller S, Goeft A, von Itter MNA, Birkigt A, Meyerhoefer P, Ihle A, Seiler R, Schumann S, Hoetzel A. Profiling Distinctive Inflammatory and Redox Responses to Hydrogen Sulfide in Stretched and Stimulated Lung Cells. Antioxidants (Basel) 2022; 11:1001. [PMID: 35624865 PMCID: PMC9137934 DOI: 10.3390/antiox11051001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/11/2022] [Accepted: 05/18/2022] [Indexed: 11/16/2022] Open
Abstract
Hydrogen sulfide (H2S) protects against stretch-induced lung injury. However, the impact of H2S on individual cells or their crosstalk upon stretch remains unclear. Therefore, we addressed this issue in vitro using relevant lung cells. We have explored (i) the anti-inflammatory properties of H2S on epithelial (A549 and BEAS-2B), macrophage (RAW264.7) and endothelial (HUVEC) cells subjected to cycling mechanical stretch; (ii) the intercellular transduction of inflammation by co-culturing epithelial cells and macrophages (A549 and RAW264.7); (iii) the effect of H2S on neutrophils (Hoxb8) in transmigration (co-culture setup with HUVECs) and chemotaxis experiments. In stretched epithelial cells (A549, BEAS-2B), the release of interleukin-8 was not prevented by H2S treatment. However, H2S reduced macrophage inflammatory protein-2 (MIP-2) release from unstretched macrophages (RAW264.7) co-cultured with stretched epithelial cells. In stretched macrophages, H2S prevented MIP-2 release by limiting nicotinamide adenine dinucleotide phosphate oxidase-derived superoxide radicals (ROS). In endothelial cells (HUVEC), H2S inhibited interleukin-8 release and preserved endothelial integrity. In neutrophils (Hoxb8), H2S limited MIP-2-induced transmigration through endothelial monolayers, ROS formation and their chemotactic movement. H2S induces anti-inflammatory effects in a cell-type specific manner. H2S limits stretch- and/or paracrine-induced inflammatory response in endothelial, macrophage, and neutrophil cells by maintaining redox homeostasis as underlying mechanism.
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Affiliation(s)
- Sashko G. Spassov
- Department of Anesthesiology and Critical Care, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; (S.F.); (A.G.); (M.-N.A.v.I.); (A.B.); (P.M.); (A.I.); (R.S.); (S.S.); (A.H.)
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Khaled L, Godet T, Jaber S, Chanques G, Asehnoune K, Bourdier J, Araujo L, Futier E, Pereira B. Intraoperative protective mechanical ventilation in patients requiring emergency abdominal surgery: the multicentre prospective randomised IMPROVE-2 study protocol. BMJ Open 2022; 12:e054823. [PMID: 35523498 PMCID: PMC9083403 DOI: 10.1136/bmjopen-2021-054823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 04/07/2022] [Indexed: 12/02/2022] Open
Abstract
IntroductionEmergency abdominal surgery is associated with a high risk of postoperative complications. One of the most serious is postoperative respiratory failure (PRF), with reported rates up to 20%-30% and attributable 30-day mortality that can exceed 20%.Lung-protective ventilation, especially the use of low tidal volume, may help reducing the risk of lung injury. The role of positive end-expiratory pressure (PEEP) and recruitment manoeuvre (RM) remains however debated. We aim to evaluate whether a strategy aimed at increasing alveolar recruitment by using higher PEEP levels and RM could be more effective at reducing PRF and mortality after emergency abdominal surgery than a strategy aimed at minimising alveolar distension by using lower PEEP levels without RM. METHODS AND ANALYSIS The IMPROVE-2 study is a multicentre randomised, parallel-group clinical trial of 680 patients requiring emergency abdominal surgery under general anaesthesia. Patients will be randomly allocated in a 1:1 ratio to receive either low PEEP levels (≤5 cm H2O) without RM or high PEEP levels individually adjusted according to driving pressure in addition to RM, stratified by centre and according to the presence of shock and hypoxaemia at randomisation. The primary endpoint is a composite of PRF and all-cause mortality by day 30 or hospital discharge. Data will be analysed on the intention-to-treat principle and a per-protocol basis. ETHICS AND DISSEMINATION IMPROVE-2 trial has been approved by an independent ethics committee for all study centres. Participant recruitment began in February 2021. Results will be submitted for publication in international peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03987789.
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Affiliation(s)
- Louisa Khaled
- Departement Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Clermont-Ferrand, France
| | - Thomas Godet
- Departement Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Clermont-Ferrand, France
| | - Samir Jaber
- Département Anesthésie Réanimation B (DAR B), Centre Hospitalier Universitaire (CHU) Montpellier, Montpellier, France
| | - Gerald Chanques
- Département Anesthésie Réanimation B (DAR B), Centre Hospitalier Universitaire (CHU) Montpellier, Montpellier, France
| | - Karim Asehnoune
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Nantes, Nantes, France
| | - Justine Bourdier
- Direction de la Recherche Clinique & Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Lynda Araujo
- Direction de la Recherche Clinique & Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Emmanuel Futier
- Departement Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Clermont-Ferrand, France
- Inserm U-1103, Université Clermont Auvergne (UCA), Clermont-Ferrand, France
| | - Bruno Pereira
- Direction de la Recherche Clinique & Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
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Schuijt MT, Hol L, Nijbroek SG, Ahuja S, van Meenen D, Mazzinari G, Hemmes S, Bluth T, Ball L, Gama–de Abreu M, Pelosi P, Schultz MJ, Serpa Neto A. Associations of dynamic driving pressure and mechanical power with postoperative pulmonary complications-posthoc analysis of two randomised clinical trials in open abdominal surgery. EClinicalMedicine 2022; 47:101397. [PMID: 35480074 PMCID: PMC9035701 DOI: 10.1016/j.eclinm.2022.101397] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/19/2022] [Accepted: 03/30/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND While an association of the intraoperative driving pressure with postoperative pulmonary complications has been described before, it is uncertain whether the intraoperative mechanical power is associated with postoperative pulmonary complications. METHODS Posthoc analysis of two international, multicentre randomised clinical trials (ISRCTN70332574 and NCT02148692) conducted between 2011-2013 and 2014-2018, in patients undergoing open abdominal surgery comparing the effect of two different positive end-expiratory pressure (PEEP) levels on postoperative pulmonary complications. Time-weighted average dynamic driving pressure and mechanical power were calculated for individual patients. A multivariable logistic regression model adjusted for confounders was used to assess the independent associations of driving pressure and mechanical power with the occurrence of a composite of postoperative pulmonary complications, the primary endpoint of this posthoc analysis. FINDINGS In 1191 patients included, postoperative pulmonary complications occurrence was 35.9%. Median time-weighted average driving pressure and mechanical power were 14·0 [11·0-17·0] cmH2O, and 7·6 [5·1-10·0] J/min, respectively. While driving pressure was not independently associated with postoperative pulmonary complications (odds ratio, 1·06 [95% CI 0·88-1·28]; p=0.534), the mechanical power had an independent association with the occurrence of postoperative pulmonary complications (odds ratio, 1·28 [95% CI 1·05-1·57]; p=0.016). These findings were independent of body mass index or the level of PEEP used, i.e., independent of the randomisation arm. INTERPRETATION In this merged cohort of surgery patients, higher intraoperative mechanical power was independently associated with postoperative pulmonary complications. Mechanical power could serve as a summary ventilatory biomarker for the risk for postoperative pulmonary complications in these patients, but our findings need confirmation in other, preferably prospective studies. FUNDING The two original studies were supported by unrestricted grants from the European Society of Anaesthesiology and the Amsterdam University Medical Centers, Location AMC. For this current analysis, no additional funding was requested. The funding sources had neither a role in the design, collection of data, statistical analysis, interpretation of data, writing of the report, nor in the decision to submit the paper for publication.
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Affiliation(s)
- Michiel T.U. Schuijt
- Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
- Department of Anaesthesiology, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
- Correspondence: M.T.U. Schuijt, MD, Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands.
| | - Liselotte Hol
- Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Sunny G. Nijbroek
- Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Sanchit Ahuja
- Department of Anaesthesiology, Pain Management & Perioperative Medicine, & Outcomes Research Consortium Cleveland Clinic, Henry Ford Health System, Detroit, Michigan, The United States of America
| | - David van Meenen
- Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
- Department of Anaesthesiology, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Guido Mazzinari
- Department of Anaesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Sabrine Hemmes
- Department of Anaesthesiology, Pain Management & Perioperative Medicine, & Outcomes Research Consortium Cleveland Clinic, Henry Ford Health System, Detroit, Michigan, The United States of America
| | - Thomas Bluth
- Department of Anaesthesiology and Critical Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- Department of Anaesthesia and Critical Care, San Martino Policlinico Hospital – IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Marcelo Gama–de Abreu
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, Ohio, The United States of America
- Department of Outcomes Research, Anaesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, The United States of America
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- Department of Anaesthesia and Critical Care, San Martino Policlinico Hospital – IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, The United Kingdom
- Department of Medical Affairs, Hamilton Medical AG, Bonaduz, Switzerland
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
- Australian and New Zealand Intensive Care Research Centre (ANZIC–RC), Monash University, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Cardio–Pulmonary Department, Pulmonary Division, Faculdade de Medicina, Instituto do Coração, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
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Martins ARC, Ambrósio AM, Fantoni DT, Pinto ACBCF, Villamizar-Martinez LA, Soares JHN, Otsuki DA, Malbouisson LMS. Computed Tomography Assessment of Tidal Lung Overinflation in Domestic Cats Undergoing Pressure-Controlled Mechanical Ventilation During General Anesthesia. Front Vet Sci 2022; 9:842528. [PMID: 35433898 PMCID: PMC9011143 DOI: 10.3389/fvets.2022.842528] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 03/04/2022] [Indexed: 11/22/2022] Open
Abstract
Objective This study aimed to evaluate lung overinflation at different airway inspiratory pressure levels using computed tomography in cats undergoing general anesthesia. Study Design Prospective laboratory study. Animals A group of 17 healthy male cats, aged 1.9–4.5 years and weighing 3.5 ± 0.5 kg. Methods Seventeen adult male cats were ventilated in pressure-controlled mode with airway pressure stepwise increased from 5 to 15 cmH2O in 2 cmH2O steps every 5 min and then stepwise decreased. The respiratory rate was set at 15 movements per min and end-expiratory pressure at zero (ZEEP). After 5 min in each inspiratory pressure step, a 4 s inspiratory pause was performed to obtain a thoracic juxta-diaphragmatic single slice helical CT image and to collect respiratory mechanics data and an arterial blood sample. Lung parenchyma aeration was defined as overinflated, normally-aerated, poorly-aerated, and non-aerated according to the CT attenuation number (−1,000 to −900 HU, −900 to −500 HU, −500 to −100 HU, and −100 to +100 HU, respectively). Result At 5 cmH2O airway pressure, tidal volume was 6.7± 2.2 ml kg−1, 2.1% (0.3–6.3%) of the pulmonary parenchyma was overinflated and 84.9% (77.6%−87.6%) was normally inflated. Increases in airway pressure were associated with progressive distention of the lung parenchyma. At 15 cmH2O airway pressure, tidal volume increased to 31.5± 9.9 ml kg−1 (p < 0.001), overinflated pulmonary parenchyma increased to 28.4% (21.2–30.6%) (p < 0.001), while normally inflated parenchyma decreased 57.9% (53.4–62.8%) (p < 0.001). Tidal volume and overinflated lung fraction returned to baseline when airway pressure was decreased. A progressive decrease was observed in arterial carbon dioxide partial pressure (PaCO2) and end-tidal carbon dioxide (ETCO2) when the airway pressures were increased above 9 cmH2O (p < 0.001). The increase in airway pressure promoted an elevation in pH (p < 0.001). Conclusions and Clinical Relevance Ventilation with 5 and 7 cmH2O of airway pressure prevents overinflation in healthy cats with highly compliant chest walls, despite presenting acidemia by respiratory acidosis. This fact can be controlled by increasing or decreasing respiratory rate and inspiratory time.
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Affiliation(s)
| | - Aline M. Ambrósio
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, Brazil
| | - Denise T. Fantoni
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, Brazil
| | - Ana Carolina B. C. F. Pinto
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, Brazil
| | | | - João H. N. Soares
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California Davis, Davis, CA, United States
| | - Denise A. Otsuki
- Discipline of Anesthesiology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- *Correspondence: Denise A. Otsuki
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Intraoperative positive end-expiratory pressure and postoperative pulmonary complications: a patient-level meta-analysis of three randomised clinical trials. Br J Anaesth 2022; 128:1040-1051. [PMID: 35431038 DOI: 10.1016/j.bja.2022.02.039] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/03/2022] [Accepted: 02/13/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND High intraoperative PEEP with recruitment manoeuvres may improve perioperative outcomes. We re-examined this question by conducting a patient-level meta-analysis of three clinical trials in adult patients at increased risk for postoperative pulmonary complications who underwent non-cardiothoracic and non-neurological surgery. METHODS The three trials enrolled patients at 128 hospitals in 24 countries from February 2011 to February 2018. All patients received volume-controlled ventilation with low tidal volume. Analyses were performed using one-stage, two-level, mixed modelling (site as a random effect; trial as a fixed effect). The primary outcome was a composite of postoperative pulmonary complications within the first week, analysed using mixed-effect logistic regression. Pre-specified subgroup analyses of nine patient characteristics and seven procedure and care-delivery characteristics were also performed. RESULTS Complete datasets were available for 1913 participants ventilated with high PEEP and recruitment manoeuvres, compared with 1924 participants who received low PEEP. The primary outcome occurred in 562/1913 (29.4%) participants randomised to high PEEP, compared with 620/1924 (32.2%) participants randomised to low PEEP (unadjusted odds ratio [OR]=0.87; 95% confidence interval [95% CI], 0.75-1.01; P=0.06). Higher PEEP resulted in 87/1913 (4.5%) participants requiring interventions for desaturation, compared with 216/1924 (11.2%) participants randomised to low PEEP (OR=0.34; 95% CI, 0.26-0.45). Intraoperative hypotension was associated more frequently (784/1913 [41.0%]) with high PEEP, compared with low PEEP (579/1924 [30.1%]; OR=1.87; 95% CI, 1.60-2.17). CONCLUSIONS High PEEP combined with recruitment manoeuvres during low tidal volume ventilation in patients undergoing major surgery did not reduce postoperative pulmonary complications. CLINICAL TRIAL REGISTRATION NCT03937375 (Clinicaltrials.gov).
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Jabaudon M, Neto AS. Open the lungs, keep them open and… take a break? Anaesth Crit Care Pain Med 2022; 41:101057. [PMID: 35523479 PMCID: PMC9062598 DOI: 10.1016/j.accpm.2022.101057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Matthieu Jabaudon
- Inserm, Department of Perioperative Medicine, GReD, CNRS, CHU de Clermont-Ferrand, Université Clermont Auvergne, Clermont-Ferrand, France.
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Intensive Care and Data Analytics Research and Evaluation (DARE) Centre, Department of Critical Care, Melbourne Medical School, Monash University, University of Melbourne, Austin Hospital, Melbourne, VIC, Australia; Department of Intensive Care, Austin Hospital, Melbourne, Australia; Honorary Senior Clinical Fellow, Department of Critical Care, University of Melbourne, Melbourne, Australia; Department of Critical Care Medicine, Hospital Israelita Albert-Einstein, São Pãulo, Brazil
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Swart P, Nijbroek SGLH, Paulus F, Neto AS, Schultz MJ. Sex Differences in Use of Low Tidal Volume Ventilation in COVID-19-Insights From the PRoVENT-COVID Study. Front Med (Lausanne) 2022; 8:780005. [PMID: 35300177 PMCID: PMC8923734 DOI: 10.3389/fmed.2021.780005] [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: 09/20/2021] [Accepted: 11/30/2021] [Indexed: 12/12/2022] Open
Abstract
The purpose of this study was to compare and understand differences in the use of low tidal volume ventilation (LTVV) between females and males with acute respiratory distress syndrome (ARDS) related to coronavirus disease 2019 (COVID-19). This is a post-hoc analysis of an observational study in invasively ventilated patients with ARDS related to COVID-19 in 22 ICUs in the Netherlands. The primary endpoint was the use of LTVV, defined as having received a median tidal volume (VT) ≤6 ml/kg predicted body weight (PBW) during controlled ventilation. A mediation analysis was used to investigate the impact of anthropometric factors, next to the impact of sex per se. The analysis included 934 patients, 251 females and 683 males. All the patients had ARDS, and there were no differences in ARDS severity between the sexes. On the first day of ventilation, females received ventilation with a higher median VT compared with males [6.8 (interquartile range (IQR) 6.0–7.6 vs. 6.3 (IQR 5.8–6.9) ml/kg PBW; p < 0.001]. Consequently, females received LTVV less often than males (23 vs. 34%; p = 0.003). The difference in the use of LTVV became smaller but persisted over the next days (27 vs. 36%; p = 0.046 at day 2 and 28 vs. 38%; p = 0.030 at day 3). The difference in the use LTVV was significantly mediated by sex per se [average direct effect of the female sex, 7.5% (95% CI, 1.7–13.3%); p = 0.011] and by differences in the body height [average causal mediation effect, −17.5% (−21.5 to −13.5%); p < 0.001], but not by the differences in actual body weight [average causal mediation effect, 0.2% (−0.8 to 1.2%); p = 0.715]. In conclusion, in this cohort of patients with ARDS related to COVID-19, females received LTVV less often than males in the first days of invasive ventilation. The difference in the use of LTVV was mainly driven by an anthropometric factor, namely, body height. Use of LTVV may improve by paying attention to correct titration of VT, which should be based on PBW, which is a function of body height.
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Affiliation(s)
- Pien Swart
- Department of Intensive Care, Amsterdam University Medical Center, Location 'Academic Medical Center', Amsterdam, Netherlands
| | - Sunny G L H Nijbroek
- Department of Intensive Care, Amsterdam University Medical Center, Location 'Academic Medical Center', Amsterdam, Netherlands.,Department of Anaesthesiology, Amsterdam University Medical Center, Location 'Academic Medical Center', Amsterdam, Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Center, Location 'Academic Medical Center', Amsterdam, Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam University Medical Center, Location 'Academic Medical Center', Amsterdam, Netherlands.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Center, Location 'Academic Medical Center', Amsterdam, Netherlands.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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Rodrigues RR, Ambrósio AM, Engbruch AM, Gonçalves LA, Villela PA, Sanchez AF, Fantoni DT. Intraoperative Protective Mechanical Ventilation in Dogs: A Randomized Clinical Trial. Front Vet Sci 2022; 9:842613. [PMID: 35372547 PMCID: PMC8964628 DOI: 10.3389/fvets.2022.842613] [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] [Received: 12/23/2021] [Accepted: 02/17/2022] [Indexed: 12/16/2022] Open
Abstract
Objective To evaluate gas exchange, respiratory mechanics, and hemodynamic impact of mechanical ventilation with low tidal volume (VT) in dogs with the use of positive end-expiratory pressure (PEEP) or preceded by alveolar recruitment maneuver (ARM). Study Design Prospective randomized clinical trial. Animals Twenty-one healthy client-owned mesocephalic healthy dogs, 1-7 years old, weighing 10-20 kg, and body condition scores 4-6/9 admitted for periodontal treatment. Methods Isoflurane-anesthetized dogs in dorsal recumbency were ventilated until 1 h with a volume-controlled ventilation mode using 8 mL kg-1 of VT. The dogs were distributed in 2 groups: in the ARM group, PEEP starts in 0 cmH2O, increasing gradually 5 cmH2O every 3 min, until reach 15 cmH2O and decreasing in the same steps until 5 cmH2O, maintaining this value until the end; and PEEP group, in which the pressure 5 cmH2O was instituted from the beginning of anesthesia and maintained the same level up to the end of the anesthesia. Cardiopulmonary, metabolic, oxygenation parameters, and respiratory mechanics were recorded after the anesthesia induction (baseline-BL), 15, 45, and 75 min after BL and during the recovery. Results The ARM increased the static compliance (Cst) (15 min after baseline) when compared with baseline moment (24.9 ± 5.8 mL cmH20-1 vs. 20.7 ± 5.4 mL cmH20-1-p = 0.0364), oxygenation index (PaO2/FIO2) (505.6 ± 59.2 mmHg vs. 461.2 ± 41.0 mmHg-p = 0.0453) and reduced the shunt fraction (3.4 ± 2.4% vs. 5.5 ± 1.6%-p = 0.062). In the PEEP group, no statistical differences were observed concerning the variables evaluated. At the beginning of the evaluation, the driving pressure (DP) before ARM was significantly greater than all other evaluation time points (6.9 ± 1.8 cmH20). Conclusions and Clinical Relevance The use of 8 mL kg-1 of VT and 5 cmH20 PEEP without ARM maintain adequate oxygenation and mechanical ventilation in dental surgeries for up to 1 h. The use of ARM slightly improved compliance and oxygenation during the maneuver.
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Joshi M, Dhakane P, Bhosale SJ, Phulambrikar R, Kulkarni AP. Correlation between Carotid and Brachial Artery Velocity Time Integral and Their Comparison to Pulse Pressure Variation and Stroke Volume Variation for Assessing Fluid Responsiveness. Indian J Crit Care Med 2022; 26:179-184. [PMID: 35712738 PMCID: PMC8857717 DOI: 10.5005/jp-journals-10071-24115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Fluid boluses are used in hemodynamically unstable patients with presumed hypovolemia, to improve tissue perfusion, in the perioperative period. Now less invasive methods, such as pulse pressure variation (PPV) and stroke volume variation (SVV) are increasingly being used. We investigated correlation between carotid and brachial artery velocity time integral (VTI) and compared both with PPV and SVV. Methods We recruited 27 patients undergoing supra-major abdominal surgeries. When indicated (hypotension or increased lactate), a fluid bolus was given after measuring carotid and brachial artery VTI, PPV, and SVV. The change in SV was noted and patients were categorized as responders if the SV increased by >15%. We performed Bland Altman Agreement and calculated best sensitivity and specificity for the parameters. Results Patients were found to be fluid responders on 29 instances. The correlation between PPV, SVV, carotid and brachial artery VTI was poor and the limits of agreement between them were wide. The Area under Curve (AUC) for PPV was 0.69, for SVV was 0.63, while those of Carotid and Brachial artery VTI (TAP and flow) were (0.53 and 0.54 for carotid) and (0.51 and 0.56 for brachial) respectively. Conclusion We found poor agreement and weak correlation between both VTi (TAP and flow) measured at carotid and brachial arteries, suggesting that the readings at brachial vessel cannot be used interchangeably with those at carotid artery. The PPV and SVV were better than these parameters for predicting fluid responsiveness; however, their predictive ability (AUROC), sensitivity and specificity were much lower than previously reported. Further studies in this area are therefore required (CTRI Reg No: CTRI/2017/08/009243). How to cite this article Joshi M, Dhakane P, Bhosale SJ, Phulambrikar R, Kulkarni AP. Correlation between Carotid and Brachial Artery Velocity Time Integral and Their Comparison to Pulse Pressure Variation and Stroke Volume Variation for Assessing Fluid Responsiveness. Indian J Crit Care Med 2022;26(2):179–184.
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Affiliation(s)
- Malini Joshi
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Praveen Dhakane
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Shilpushp J Bhosale
- Department of Critical Care Medicine, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Rutuja Phulambrikar
- Department of Community Medicine, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Atul P Kulkarni
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
- Atul P Kulkarni, Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India, Phone: +91 9869077526, e-mail:
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Hol L, Nijbroek SGLH, Neto AS, Hemmes SNT, Hedenstierna G, Hiesmayr M, Hollmann MW, Mills GH, Vidal Melo MF, Putensen C, Schmid W, Severgnini P, Wrigge H, de Abreu MG, Pelosi P, Schultz MJ. Geo-economic variations in epidemiology, ventilation management and outcome of patients receiving intraoperative ventilation during general anesthesia- posthoc analysis of an observational study in 29 countries. BMC Anesthesiol 2022; 22:15. [PMID: 34996361 PMCID: PMC8740416 DOI: 10.1186/s12871-021-01560-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this analysis is to determine geo-economic variations in epidemiology, ventilator settings and outcome in patients receiving general anesthesia for surgery. METHODS Posthoc analysis of a worldwide study in 29 countries. Lower and upper middle-income countries (LMIC and UMIC), and high-income countries (HIC) were compared. The coprimary endpoint was the risk for and incidence of postoperative pulmonary complications (PPC); secondary endpoints were intraoperative ventilator settings, intraoperative complications, hospital stay and mortality. RESULTS Of 9864 patients, 4% originated from LMIC, 11% from UMIC and 85% from HIC. The ARISCAT score was 17.5 [15.0-26.0] in LMIC, 16.0 [3.0-27.0] in UMIC and 15.0 [3.0-26.0] in HIC (P = .003). The incidence of PPC was 9.0% in LMIC, 3.2% in UMIC and 2.5% in HIC (P < .001). Median tidal volume in ml kg- 1 predicted bodyweight (PBW) was 8.6 [7.7-9.7] in LMIC, 8.4 [7.6-9.5] in UMIC and 8.1 [7.2-9.1] in HIC (P < .001). Median positive end-expiratory pressure in cmH2O was 3.3 [2.0-5.0]) in LMIC, 4.0 [3.0-5.0] in UMIC and 5.0 [3.0-5.0] in HIC (P < .001). Median driving pressure in cmH2O was 14.0 [11.5-18.0] in LMIC, 13.5 [11.0-16.0] in UMIC and 12.0 [10.0-15.0] in HIC (P < .001). Median fraction of inspired oxygen in % was 75 [50-80] in LMIC, 50 [50-63] in UMIC and 53 [45-70] in HIC (P < .001). Intraoperative complications occurred in 25.9% in LMIC, in 18.7% in UMIC and in 37.1% in HIC (P < .001). Hospital mortality was 0.0% in LMIC, 1.3% in UMIC and 0.6% in HIC (P = .009). CONCLUSION The risk for and incidence of PPC is higher in LMIC than in UMIC and HIC. Ventilation management could be improved in LMIC and UMIC. TRIAL REGISTRATION Clinicaltrials.gov , identifier: NCT01601223.
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Affiliation(s)
- Liselotte Hol
- Department of Anesthesiology, Amsterdam UMC, location AMC, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands. .,Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands.
| | - Sunny G L H Nijbroek
- Department of Anesthesiology, Amsterdam UMC, location AMC, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.,Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands.,Department of Critical Care Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia
| | - Sabrine N T Hemmes
- Department of Anesthesiology, Amsterdam UMC, location AMC, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Goran Hedenstierna
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Michael Hiesmayr
- Division Cardiac, Thoracic, Vascular Anesthesia and Intensive Care, Medical University Vienna, Vienna, Austria
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam UMC, location AMC, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Gary H Mills
- Operating Services, Critical Care and Anaesthesia, Sheffield Teaching Hospitals, Sheffield and University of Sheffield, Sheffield, UK
| | - Marcos F Vidal Melo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Werner Schmid
- Division Cardiac, Thoracic, Vascular Anesthesia and Intensive Care, Medical University Vienna, Vienna, Austria
| | - Paolo Severgnini
- Department of Biotechnology and Life, ASST Sette Laghi Ospedale di Circolo e Fondazio Macchi, University of Insubria, Varese, Italy
| | - Hermann Wrigge
- Department of Anaesthesiology, Intensive Care Medicine and Emergency Medicine, Pain Therapy, Bermannstrost Hospital Halle, Halle, Germany
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany.,Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, OH, USA.,Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, Università degli Studi di Genova, Genova, Italy.,Anesthesia and Critical Care, IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genova, Italy
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
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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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Lagier D, Zeng C, Fernandez-Bustamante A, Melo MFV. Perioperative Pulmonary Atelectasis: Part II. Clinical Implications. Anesthesiology 2022; 136:206-236. [PMID: 34710217 PMCID: PMC9885487 DOI: 10.1097/aln.0000000000004009] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The development of pulmonary atelectasis is common in the surgical patient. Pulmonary atelectasis can cause various degrees of gas exchange and respiratory mechanics impairment during and after surgery. In its most serious presentations, lung collapse could contribute to postoperative respiratory insufficiency, pneumonia, and worse overall clinical outcomes. A specific risk assessment is critical to allow clinicians to optimally choose the anesthetic technique, prepare appropriate monitoring, adapt the perioperative plan, and ensure the patient's safety. Bedside diagnosis and management have benefited from recent imaging advancements such as lung ultrasound and electrical impedance tomography, and monitoring such as esophageal manometry. Therapeutic management includes a broad range of interventions aimed at promoting lung recruitment. During general anesthesia, these strategies have consistently demonstrated their effectiveness in improving intraoperative oxygenation and respiratory compliance. Yet these same intraoperative strategies may fail to affect additional postoperative pulmonary outcomes. Specific attention to the postoperative period may be key for such outcome impact of lung expansion. Interventions such as noninvasive positive pressure ventilatory support may be beneficial in specific patients at high risk for pulmonary atelectasis (e.g., obese) or those with clinical presentations consistent with lung collapse (e.g., postoperative hypoxemia after abdominal and cardiothoracic surgeries). Preoperative interventions may open new opportunities to minimize perioperative lung collapse and prevent pulmonary complications. Knowledge of pathophysiologic mechanisms of atelectasis and their consequences in the healthy and diseased lung should provide the basis for current practice and help to stratify and match the intensity of selected interventions to clinical conditions.
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Affiliation(s)
- David Lagier
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Congli Zeng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Marcos F. Vidal Melo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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