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Tang X, Wu Y, Chen Q, Xu Y, Wang X, Liu S. Deep Neuromuscular Block Attenuates Chronic Postsurgical Pain and Enhances Long-Term Postoperative Recovery After Spinal Surgery: A Randomized Controlled Trial. Pain Ther 2023; 12:1055-1064. [PMID: 37278923 PMCID: PMC10289993 DOI: 10.1007/s40122-023-00528-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/15/2023] [Indexed: 06/07/2023] Open
Abstract
INTRODUCTION The effects of deep neuromuscular block (DNMB) on chronic postsurgical pain (CPSP) have not been conclusively determined. Moreover, a limited number of studies have examined the impact of DNMB on long-term recovery quality after spinal surgery. We investigated the impact of DNMB on CPSP and the quality of long-term recovery in patients who had been subjected to spinal surgery. METHODS This was a randomized, controlled, double-blind, single-center study performed from May 2022 to November 2022. A total of 220 patients who underwent spinal surgery under general anesthesia were randomly assigned to receive either DNMB (post-tetanic count at 1-2) (the D group) or moderate NMB (MNMB) (train-of-four at 1-3) (the M group). The primary endpoint was the incidence of CPSP. The secondary endpoints included the visual analogue scale (VAS) score in the post-anesthesia recovery unit (PACU), at 12, 24, 48 h and 3 months after surgery; postoperative opioid consumption; quality of recovery-15 (QoR-15) scores on the second postoperative day, before discharge, and 3 months after surgery. RESULTS The incidence of CPSP was significantly lower in the D group (30/104, 28.85%) than in the M group (45/105, 42.86%) (p = 0.035). Besides, VAS scores were significantly reduced at the third month in the D group (p = 0.016). In the PACU and 12 h after surgery, VAS scores were also significantly lower in the D group than in the M group (p < 0.001, p = 0.004, respectively). The total amount of postoperative opioid consumption (expressed in total oral morphine equivalents) was significantly less in D group than M group (p = 0.027). At 3 months after surgery, QoR-15 scores were significantly higher in D group than M group (p = 0.003). CONCLUSIONS Compared with MNMB, DNMB significantly reduced CPSP and postoperative opioid consumption in spinal surgery patients. Moreover, DNMB improved the long-term recovery of patients. TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR2200058454).
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Affiliation(s)
- Xihui Tang
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, 99 Huaihai West Road, Xuzhou, Jiangsu, 221000, People's Republic of China
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Yan Wu
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, 99 Huaihai West Road, Xuzhou, Jiangsu, 221000, People's Republic of China
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Qingsong Chen
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, 99 Huaihai West Road, Xuzhou, Jiangsu, 221000, People's Republic of China
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Yuqing Xu
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, 99 Huaihai West Road, Xuzhou, Jiangsu, 221000, People's Republic of China
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Xinghe Wang
- Department of Anesthesiology, Xuzhou Central Hospital, 199 Jiefang South Road, Xuzhou, Jiangsu, 221009, People's Republic of China.
| | - Su Liu
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, 99 Huaihai West Road, Xuzhou, Jiangsu, 221000, People's Republic of China.
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, People's Republic of China.
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Fan W, Tan Q. Application of the steady-state intestinal perfusion system in measuring intestinal fluid absorption and bicarbonate secretion in vivo. Front Physiol 2023; 14:1163888. [PMID: 37497438 PMCID: PMC10366686 DOI: 10.3389/fphys.2023.1163888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/26/2023] [Indexed: 07/28/2023] Open
Abstract
Background: The steady-state intestinal perfusion system represents a tool used in measuring intestinal fluid absorption and bicarbonate secretion in vivo; however, detailed procedures and parameters were not elucidated fully. Aim: We focused on the methods of the steady-state intestinal perfusion system comprehensively including the blood pressure, hematocrit, blood gas, and heart rate of mouse. Methods: Anesthetized, tracheally intubated, and artificially ventilated mice were used for this system. The blood pressure, hematocrit, blood gas, heart rate, and rate of fluid absorption and HCO3 - secretion of the small intestine and colon at different time points were evaluated. Results: Blood pressure, hematocrit, blood gas, and heart rate became stable at the 30 min time point after completion of surgery and could be maintained for 2 h. Rates of fluid absorption and bicarbonate secretion were also kept stable during the period of steady state of mice. Rates of fluid absorption and bicarbonate secretion were different among the jejunum, ileum, proximal, and mid-distal colon. Conclusion: The steady-state intestinal perfusion system is a reliable system for measuring intestinal fluid absorption and bicarbonate secretion in vivo.
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Yucepur S, Kepekci AB, Erbin A, Ozenc E. Effects of lithotomy and prone positions on hemodynamic parameters, respiratory mechanics, and arterial oxygenation in percutaneous nephrolithotomy performed under general anesthesia. Folia Med (Plovdiv) 2023; 65:427-433. [PMID: 38351819 DOI: 10.3897/folmed.65.e81068] [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: 01/23/2022] [Accepted: 06/10/2022] [Indexed: 02/16/2024] Open
Abstract
AIM The position of the body during surgery may affect the patient's body functions, especially the hemodynamic parameters. We aimed to comparatively analyze the effects of lithotomy and prone position on respiratory mechanics, arterial oxygenation, and hemodynamic parameters in patients who underwent percutaneous nephrolithotomy (PNL).
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Affiliation(s)
- Serkan Yucepur
- Bilecik Training and Research Hospital, Bilecik, Turkiye
| | | | - Akif Erbin
- Haseki Training and Research Hospital, Istanbul, Turkiye
| | - Ecder Ozenc
- Haseki Training and Research Hospital, Istanbul, Turkiye
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Surgical bleeding in patients undergoing posterior lumbar inter-body fusion surgery: a randomized clinical trial evaluating the effect of two mechanical ventilation mode types. Eur J Med Res 2023; 28:114. [PMID: 36907880 PMCID: PMC10008144 DOI: 10.1186/s40001-023-01080-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 02/27/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND The purpose of the study was to compare the effect of using volume-controlled ventilation (VCV) versus pressure-controlled ventilation (PCV) on blood loss in patients undergoing posterior lumbar inter-body fusion (PLIF) surgery. METHODS In a randomized, single-blinded, parallel design, 78 patients, candidates for PLIF surgery, were randomly allocated into two groups of 39 to be mechanically ventilated using VCV or PCV mode. All the patients were operated in prone position by one surgeon. Amount of intraoperative surgical bleeding, transfusion requirement, surgeon satisfaction, hemodynamic parameters, heart rate, and blood pressure were measured as outcomes. RESULTS PCV group showed slightly better outcomes than VCV group in terms of mean blood loss (431 cc vs. 465 cc), transfusion requirement (0.40 vs. 0.43 unit), and surgeon satisfaction (82.1% vs. 74.4%); however, the differences were not statistically significant. Diastolic blood pressure 90 and 105 min after induction were significantly lower in PCV group (P = 0.043-0.019, respectively); however, blood pressure at other times, hemoglobin levels, and mean heart rate were similar in two groups. CONCLUSIONS In patients undergoing posterior lumbar inter-body fusion surgery, mode of ventilation cannot make significant difference in terms of blood loss; however, some minor benefits in outcomes may lead to the selection of PCV rather than VCV. More studies with larger sample size, and investigating more factors may be needed.
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Han J, Hu Y, Liu S, Hu Z, Liu W, Wang H. Volume-controlled ventilation versus pressure-controlled ventilation during spine surgery in the prone position: A meta-analysis. Ann Med Surg (Lond) 2022; 78:103878. [PMID: 35734701 PMCID: PMC9207057 DOI: 10.1016/j.amsu.2022.103878] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/21/2022] [Accepted: 05/22/2022] [Indexed: 02/08/2023] Open
Abstract
Background Many studies have investigated a comparison of the potency and safety of PCV versus VCV modes in spinal surgery in prone position. However, controversy about the maximal benefits of which ventilation modes remains. The main purpose of this meta-analysis was to investigate which one is the optimal ventilation for surgery patients undergoing spine surgery in prone position between the two ventilation modes as PCV and VCV. Methods We conducted a comprehensive search of PubMed, Embase, Web of Science, the Cochrane Library, and Google Scholar for potentially eligible articles. The continuous outcomes were analyzed using the mean difference and the associated 95% confidence interval. Meta-analysis was performed using Review Manager 5.4 software. Results Our meta-analysis included 8 RCTs involving a total of 454 patients between 2012 and 2020. The results demonstrated that IOB, Ppeak and CVP for VCV are significantly superior to PCV in spinal surgery in prone position. And PCV had higher Cdyn and PaO2/FiO2 than VCV. But there was no significant difference between PCV and VCV in terms of POB, Hb, HCT, HR and MAP. Conclusions The PCV mode displayed a more satisfying effect than VCV mode. Compared to VCV mode in same preset of tidal volume, the patients with PCV mode in prone position demonstrated less IOB, lower Ppeak and CVP, and higher PaO2/FiO2 in spinal surgery. However, there is no obvious difference between PCV and VCV in terms of hemodynamics variables (HR and MAP). The PCV mode displayed a more satisfying effect than VCV mode. Compared to VCV mode, the patients with PCV mode in prone position demonstrated less IOB, lower Ppeak and CVP, and higher PaO2/FiO2 in spinal surgery. There is no obvious difference between PCV and VCV in terms of hemodynamics variables.
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Affiliation(s)
- Jun Han
- Department of Spine Surgery, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian, 116033, Liaoning, China
- Department of Spine Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, 116011, Liaoning, China
- Dalian Medical University, Dalian, 116044, Liaoning, China
| | - Yunxiang Hu
- Department of Spine Surgery, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian, 116033, Liaoning, China
- Dalian Medical University, Dalian, 116044, Liaoning, China
| | - Sanmao Liu
- Department of Spine Surgery, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian, 116033, Liaoning, China
- Dalian Medical University, Dalian, 116044, Liaoning, China
| | - Zhenxin Hu
- Department of Spine Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, 116011, Liaoning, China
- Dalian Medical University, Dalian, 116044, Liaoning, China
| | - Wenzhong Liu
- Department of Joint Surgery, Gaomi People's Hospital, Gaomi, 261500, Shandong, China
| | - Hong Wang
- Department of Spine Surgery, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian, 116033, Liaoning, China
- Corresponding author. Department of Spine Surgery, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian, 116021, China.
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Perioperative Care of Patients Undergoing Major Complex Spinal Instrumentation Surgery: Clinical Practice Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol 2021; 34:257-276. [PMID: 34483301 DOI: 10.1097/ana.0000000000000799] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/14/2021] [Indexed: 11/25/2022]
Abstract
Evidence-based standardization of the perioperative management of patients undergoing complex spine surgery can improve outcomes such as enhanced patient satisfaction, reduced intensive care and hospital length of stay, and reduced costs. The Society for Neuroscience in Anesthesiology and Critical Care (SNACC) tasked an expert group to review existing evidence and generate recommendations for the perioperative management of patients undergoing complex spine surgery, defined as surgery on 2 or more thoracic and/or lumbar spine levels. Institutional clinical management protocols can be constructed based on the elements included in these clinical practice guidelines, and the evidence presented.
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Kim HB, Kweon TD, Chang CH, Kim JY, Kim KS, Kim JY. Equal Ratio Ventilation Reduces Blood Loss During Posterior Lumbar Interbody Fusion Surgery. Spine (Phila Pa 1976) 2021; 46:E852-E858. [PMID: 33492083 PMCID: PMC8327934 DOI: 10.1097/brs.0000000000003957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective randomized double-blinded study. OBJECTIVE The aim of this study was to compare the effect of two different ventilator modes (inspiratory to expiratory ratio [I:E ratio] of 1:1 and 1:2) on intraoperative surgical bleeding in patients undergoing posterior lumbar interbody fusion (PLIF) surgery. SUMMARY OF BACKGROUND DATA During PLIF surgery, a considerable amount of blood loss is anticipated. In the prone position, engorgement of the vertebral vein increases surgical bleeding. We hypothesized that equal ratio ventilation (ERV) with I:E ratio of 1:1 would lower peak inspiratory pressure (PIP) in the prone position and consequentially decrease surgical bleeding. METHODS Twenty-eight patients were randomly assigned to receive either ERV (ERV group, n = 14) or conventional ventilation with I:E ratio of 1:2 (control group, n = 14). Hemodynamic and respiratory parameters were measured at 5 minutes after anesthesia induction, at 5 minutes after the prone position, at the time of skin closure, and at 5 minutes after turning to the supine position. RESULTS The amount of intraoperative surgical bleeding in the ERV group was significantly less than that in the control group (975.7 ± 349.9 mL vs. 1757.1 ± 1172.7 mL, P = 0.030). Among other hemodynamic and respiratory parameters, PIP and plateau inspiratory pressure (Pplat) were significantly lower and dynamic lung compliance (Cdyn) was significantly higher in the ERV group than those of the control group throughout the study period, respectively (all P < 0.05). CONCLUSION Compared to conventional ratio ventilation, ERV provided lower PIP and reduced intraoperative surgical blood loss in patients undergoing PLIF surgery.Level of Evidence: 2.
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Affiliation(s)
- Hye Bin Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae Dong Kweon
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chul Ho Chang
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Young Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyung Sub Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Young Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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Kundra S, Gupta R, Luthra N, Dureja M, Katyal S. Effects of ventilation mode type on intra-abdominal pressure and intra-operative blood loss in patients undergoing lumbar spine surgery: A randomised clinical study. Indian J Anaesth 2021; 65:S12-S19. [PMID: 33814585 PMCID: PMC7993040 DOI: 10.4103/ija.ija_706_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/25/2020] [Accepted: 01/07/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND AIMS The aim of the study was to evaluate the effect of mode of mechanical ventilation; pressure-controlled ventilation (PCV) vs. volume-controlled ventilation (VCV) on airway pressures, intra-abdominal pressure (IAP) and intra-operative surgical bleeding in patients undergoing lumbar spine surgery. METHODS This was a prospective, randomised study that included 50 American Society of Anesthesiologists class I and II patients undergoing lumbar spine surgery who were mechanically ventilated using PCV or VCV mode. The respiratory parameters (peak and plateau pressures) and IAP were measured after anaesthesia induction in supine position, 10 min after the patients were changed from supine to prone position, at the end of the surgery in prone position, and after the patients were changed from prone to supine position. The amount of intraoperative surgical bleeding was measured by objective and subjective methods. RESULTS The primary outcome was the amount of intraoperative surgical bleeding. It was significantly less in the PCV group than in the VCV group (137 ± 24.37 mL vs. 311 ± 66.98 mL) (P = 0.000). Similarly, on comparing other parameters like peak inspiratory pressures, plateaupressures and IAP, the patients in PCV group had significantly lower parameters than those in VCV group (P < 0.05). No harmful events were recorded. CONCLUSION In patie,nts undergoing lumbar spine surgery, use of PCV mode decreased intraoperative surgical bleeding, which may be related to lower intraoperative respiratory pressures and IAP.
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Affiliation(s)
- Sandeep Kundra
- Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Rekha Gupta
- Department of Anaesthesia, PGIMER, Chandigarh, India
| | - Neeru Luthra
- Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Mehak Dureja
- Department of Anaesthesia, Maharishi Markandeshwar (Deemed University), Mullana, Ambala, Haryana, India
| | - Sunil Katyal
- Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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Neuroanesthesiology Update. J Neurosurg Anesthesiol 2021; 33:107-136. [PMID: 33480638 DOI: 10.1097/ana.0000000000000757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 12/18/2020] [Indexed: 11/27/2022]
Abstract
This review summarizes the literature published in 2020 that is relevant to the perioperative care of neurosurgical patients and patients with neurological diseases as well as critically ill patients with neurological diseases. Broad topics include general perioperative neuroscientific considerations, stroke, traumatic brain injury, monitoring, anesthetic neurotoxicity, and perioperative disorders of cognitive function.
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Palmer AJR, Gagné S, Fergusson DA, Murphy MF, Grammatopoulos G. Blood Management for Elective Orthopaedic Surgery. J Bone Joint Surg Am 2020; 102:1552-1564. [PMID: 32558663 DOI: 10.2106/jbjs.19.01417] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Antony J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, United Kingdom
| | | | | | - Michael F Murphy
- NHS Blood and Transplant and Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
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Kang WS, Kim SH. Reply to: deep neuromuscular blockade reduces intra-operative blood loss. Eur J Anaesthesiol 2020; 37:820-821. [PMID: 32769510 DOI: 10.1097/eja.0000000000001276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Woon-Seok Kang
- From the Department of Anaesthesiology and Pain Medicine, Konkuk University Medical Center (W-SK, S-HK), Department of Medicine, Institute of Biomedical Science and Technology (S-HK) and Department of Infection and Immunology, Konkuk University School of Medicine, Seoul, South Korea (S-HK)
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Robba C, Hemmes SNT, Serpa Neto A, Bluth T, Canet J, Hiesmayr M, Hollmann MW, Mills GH, Vidal Melo MF, Putensen C, Jaber S, Schmid W, Severgnini P, Wrigge H, Battaglini D, Ball L, Gama de Abreu M, Schultz MJ, Pelosi P. Intraoperative ventilator settings and their association with postoperative pulmonary complications in neurosurgical patients: post-hoc analysis of LAS VEGAS study. BMC Anesthesiol 2020; 20:73. [PMID: 32241266 PMCID: PMC7114790 DOI: 10.1186/s12871-020-00988-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 03/20/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Limited information is available regarding intraoperative ventilator settings and the incidence of postoperative pulmonary complications (PPCs) in patients undergoing neurosurgical procedures. The aim of this post-hoc analysis of the 'Multicentre Local ASsessment of VEntilatory management during General Anaesthesia for Surgery' (LAS VEGAS) study was to examine the ventilator settings of patients undergoing neurosurgical procedures, and to explore the association between perioperative variables and the development of PPCs in neurosurgical patients. METHODS Post-hoc analysis of LAS VEGAS study, restricted to patients undergoing neurosurgery. Patients were stratified into groups based on the type of surgery (brain and spine), the occurrence of PPCs and the assess respiratory risk in surgical patients in Catalonia (ARISCAT) score risk for PPCs. RESULTS Seven hundred eighty-four patients were included in the analysis; 408 patients (52%) underwent spine surgery and 376 patients (48%) brain surgery. Median tidal volume (VT) was 8 ml [Interquartile Range, IQR = 7.3-9] per predicted body weight; median positive end-expiratory pressure (PEEP) was 5 [3 to 5] cmH20. Planned recruitment manoeuvres were used in the 6.9% of patients. No differences in ventilator settings were found among the sub-groups. PPCs occurred in 81 patients (10.3%). Duration of anaesthesia (odds ratio, 1.295 [95% confidence interval 1.067 to 1.572]; p = 0.009) and higher age for the brain group (odds ratio, 0.000 [0.000 to 0.189]; p = 0.031), but not intraoperative ventilator settings were independently associated with development of PPCs. CONCLUSIONS Neurosurgical patients are ventilated with low VT and low PEEP, while recruitment manoeuvres are seldom applied. Intraoperative ventilator settings are not associated with PPCs.
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Affiliation(s)
- Chiara Robba
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Largo Rosanna Benzi 8, 16131, Genoa, Italy.
| | - Sabrine N T Hemmes
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands.,Department of Anaesthesiology, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Thomas Bluth
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary engineering group, University Hospital Carl Gustav Carus, Technische Universitat Dresden, Dresden, Germany
| | - Jaume Canet
- Department of Anaesthesiology and Postoperative Care, Hospital Universitari Germans Trials I Pujol, Barcelona, Spain
| | - Michael Hiesmayr
- Division Cardiac, Thoracic, Vascular Anesthesia and Intensive Care, Medical University Vienna, Vienna, Austria
| | - M Wiersma Hollmann
- Department of Anaesthesiology, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands
| | - Gary H Mills
- Operating Services, Critical Care and Anaesthesia, Sheffield Teaching Hospitals and University of Sheffield, Sheffield, UK
| | - Marcos F Vidal Melo
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachussetts General Hospital, Boston, MA, USA
| | - Christian Putensen
- Department of Anesthesiology and Intenisve Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Samir Jaber
- Department of Anaesthesia and Intensive Care, Saint Eloi Montpellier University Hospital, and PhyMedExp, University of Montpellier, Montpellier, France
| | - Werner Schmid
- Division Cardiac, Thoracic, Vascular Anesthesia and Intensive Care, Medical University Vienna, Vienna, Austria
| | - Paolo Severgnini
- Department of Biotechnology and Sciences of Life, ASST-Setteleghi Ospedale di circolo e Fondazione Macchi, University of Insubria, Varese, Italy
| | - Hermann Wrigge
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Denise Battaglini
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Largo Rosanna Benzi 8, 16131, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Lorenzo Ball
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Largo Rosanna Benzi 8, 16131, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Marcelo Gama de Abreu
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary engineering group, University Hospital Carl Gustav Carus, Technische Universitat Dresden, Dresden, Germany
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Paolo Pelosi
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Largo Rosanna Benzi 8, 16131, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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Deep neuromuscular blockade during spinal surgery reduces intra-operative blood loss. Eur J Anaesthesiol 2020; 37:187-195. [DOI: 10.1097/eja.0000000000001135] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Messina A, Montagnini C, Cammarota G, Giuliani F, Muratore L, Baggiani M, Bennett V, Della Corte F, Navalesi P, Cecconi M. Assessment of Fluid Responsiveness in Prone Neurosurgical Patients Undergoing Protective Ventilation. Anesth Analg 2020; 130:752-761. [DOI: 10.1213/ane.0000000000004494] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Xu D, Chen X, Li Z, Ren Z, Zhuang Q, Li S. Tranexamic acid reduce hidden blood loss in posterior lumbar interbody fusion (PLIF) surgery. Medicine (Baltimore) 2020; 99:e19552. [PMID: 32176112 PMCID: PMC7440332 DOI: 10.1097/md.0000000000019552] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 01/28/2020] [Accepted: 02/13/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Posterior lumbar interbody fusion (PLIF) surgery is associated with significant blood loss; however, few studies have focused on hidden blood loss (HBL) in PLIF or its regulatory factors. The purpose of this study was to explore the HBL in PLIF surgery as well as the influence of tranexamic acid (TXA) on blood loss in PLIF. METHODS We performed a randomized controlled trial (RCT) and recruited patients undergoing PLIF into the study from November 2013 to April 2017. All participants were assigned to one of 2 groups according to a simple equal probability randomization scheme. At the end of PLIF surgery, for patients in the TXA group, the surgical field was immersed in TXA (1 g in 100 mL of saline solution) for 5 min before stitching the wound. For the control group, the surgical field was immersed in the same volume of normal saline. RESULTS In our study, the drainage volume during the first 24 h and the total postoperative drainage volume were significantly lower in patients in the TXA group than in the control group (P = .001). The hematocrit (Hct) of the drainage and calculation of blood contained in the drainage showed similar results. The mean length of hospital stay and rate of blood transfusion in the TXA group were less than those in the control group (P < .05). HBL was responsible for 45.6% of the total blood loss in PLIF, and both of the indicators in the TXA group were much lower than those in the control group. CONCLUSIONS PLIF is associated with massive perioperative HBL, but the application of topical TXA leads to less postoperative blood loss including less HBL, a lower blood product transfusion rate, and a shorter hospital stay for PLIF.
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Affiliation(s)
- Derong Xu
- Department of Orthorpaedic Surgery, Peking Union Medical College Hospital, Beijing
- The Affiliated Hospital of Qingdao University, Shandong Province, China
| | - Xin Chen
- Department of Orthorpaedic Surgery, Peking Union Medical College Hospital, Beijing
| | - Zheng Li
- Department of Orthorpaedic Surgery, Peking Union Medical College Hospital, Beijing
| | - Zhinan Ren
- Department of Orthorpaedic Surgery, Peking Union Medical College Hospital, Beijing
| | - Qianyu Zhuang
- Department of Orthorpaedic Surgery, Peking Union Medical College Hospital, Beijing
| | - Shugang Li
- Department of Orthorpaedic Surgery, Peking Union Medical College Hospital, Beijing
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Abstract
BACKGROUND Airway closure causes lack of communication between proximal airways and alveoli, making tidal inflation start only after a critical airway opening pressure is overcome. The authors conducted a matched cohort study to report the existence of this phenomenon among obese patients undergoing general anesthesia. METHODS Within the procedures of a clinical trial during gynecological surgery, obese patients underwent respiratory/lung mechanics and lung volume assessment both before and after pneumoperitoneum, in the supine and Trendelenburg positions, respectively. Among patients included in this study, those exhibiting airway closure were compared to a control group of subjects enrolled in the same trial and matched in 1:1 ratio according to body mass index. RESULTS Eleven of 50 patients (22%) showed airway closure after intubation, with a median (interquartile range) airway opening pressure of 9 cm H2O (6 to 12). With pneumoperitoneum, airway opening pressure increased up to 21 cm H2O (19 to 28) and end-expiratory lung volume remained unchanged (1,294 ml [1,154 to 1,363] vs. 1,160 ml [1,118 to 1,256], P = 0.155), because end-expiratory alveolar pressure increased consistently with airway opening pressure and counterbalanced pneumoperitoneum-induced increases in end-expiratory esophageal pressure (16 cm H2O [15 to 19] vs. 27 cm H2O [23 to 30], P = 0.005). Conversely, matched control subjects experienced a statistically significant greater reduction in end-expiratory lung volume due to pneumoperitoneum (1,113 ml [1,040 to 1,577] vs. 1,000 ml [821 to 1,061], P = 0.006). With airway closure, static/dynamic mechanics failed to measure actual lung/respiratory mechanics. When patients with airway closure underwent pressure-controlled ventilation, no tidal volume was inflated until inspiratory pressure overcame airway opening pressure. CONCLUSIONS In obese patients, complete airway closure is frequent during anesthesia and is worsened by Trendelenburg pneumoperitoneum, which increases airway opening pressure and alveolar pressure: besides preventing alveolar derecruitment, this yields misinterpretation of respiratory mechanics and generates a pressure threshold to inflate the lung that can reach high values, spreading concerns on the safety of pressure-controlled modes in this setting.
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Dunn LK, Taylor DG, Chen CJ, Singla P, Fernández L, Wiedle CH, Hanak MF, Tsang S, Smith JS, Shaffrey CI, Nemergut EC, Durieux ME, Blank RS, Naik BI. Ventilator Mode Does Not Influence Blood Loss or Transfusion Requirements During Major Spine Surgery. Anesth Analg 2020; 130:100-110. [DOI: 10.1213/ane.0000000000004322] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Le Guen M, Paternot A, Declerck A, Feliot E, Gayat E, Gaillard S, Fischler M. Impact of the modality of mechanical ventilation on bleeding during pituitary surgery: A single blinded randomized trial. Medicine (Baltimore) 2019; 98:e17254. [PMID: 31567997 PMCID: PMC6756699 DOI: 10.1097/md.0000000000017254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Bleeding modifies the surgeon's view of the field during transsphenoidal endoscopic pituitary surgery. Since ventilation can alter venous return, we compared the effect of volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV) on intraoperative bleeding. METHODS Eighty-six patients were randomized to VCV or PCV in this single blinded study; comparisons concerned 42 in the PCV group and 43 in the VCV group. RESULTS Intraoperative bleeding, the primary endpoint, did not differ between groups whether analysis focused on 7 levels of the score, from minimal bleeding to bleeding with significant change in the conduct of surgical procedure (P = .89) or on a stratification into 3 categories, mild, moderate, and major (P = .47). Median [interquartile range] peak airway pressure was lower in the PCV group (13.5 [12.5-15] vs 16.3 [14.4-19.1] cm H2O, P < .001) while mean airway pressures were similar (P = .08). Means ± SD of tidal volumes were lower in the VCV group when expressed as absolute values (470.6 ± 84 vs 434.7 ± 71.7 ml, P = .05) or as tidal volume/theoretical ideal weight ratio (6.7 [6.5-7] vs 7.2 [6.9-7.9], P < .001). The 2 groups were similar for postoperative complications and number of patients cured. CONCLUSION In conclusion, ventilation mode does not influence intraoperative bleeding during transsphenoidal pituitary surgery. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT01891838; July 3, 2013.
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Affiliation(s)
- Morgan Le Guen
- Department of Anesthesiology, Hôpital Foch, 92150 Suresnes
- University Versailles Saint-Quentin en Yvelines, 78180 Montigny-Le-Bretonneux
| | - Alexis Paternot
- University Versailles Saint-Quentin en Yvelines, 78180 Montigny-Le-Bretonneux
- Department of Critical Care Medicine, Hôpital Ambroise Paré, 92100 Boulogne-Billancourt
| | - Agnes Declerck
- Department of Anesthesiology, Hôpital Foch, 92150 Suresnes
| | - Elodie Feliot
- Department of Anesthesiology and Critical Care Medicine, Hôpital Saint Louis-Lariboisière, AP-HP, Paris
- INSERM UMR-S 942, Paris, France
| | - Etienne Gayat
- Department of Anesthesiology and Critical Care Medicine, Hôpital Saint Louis-Lariboisière, AP-HP, Paris
- INSERM UMR-S 942, Paris, France
| | - Stephan Gaillard
- Department of Neurosurgery, Hôpital Foch, 92150 Suresnes, France
| | - Marc Fischler
- Department of Anesthesiology, Hôpital Foch, 92150 Suresnes
- University Versailles Saint-Quentin en Yvelines, 78180 Montigny-Le-Bretonneux
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Jin SJ, Park YS, Kim SH, Kim D, Shim WH, Jang DM, Shaffrey CI, Naik BI. Effect of Prone Positional Apparatus on the Occurrence of Acute Kidney Injury After Spine Surgery. World Neurosurg 2019; 128:e597-e602. [DOI: 10.1016/j.wneu.2019.04.216] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 11/30/2022]
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Lee JM, Lee SK, Kim KM, Kim YJ, Park EY. Comparison of volume-controlled ventilation mode and pressure-controlled ventilation with volume-guaranteed mode in the prone position during lumbar spine surgery. BMC Anesthesiol 2019; 19:133. [PMID: 31351445 PMCID: PMC6661081 DOI: 10.1186/s12871-019-0806-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 07/18/2019] [Indexed: 11/29/2022] Open
Abstract
Background During lumbar spine surgery, patients are placed in the prone position for surgical access. The prone position has various effects on cardiac and pulmonary function, including a decreased cardiac index (CI), decreased dynamic lung compliance (Cdyn), and increased peak inspiratory pressure (Ppeak). In this study, we compared the volume-controlled ventilation mode (VCV) and pressure-controlled ventilation with volume guaranteed mode (PCV-VG) based on hemodynamic and pulmonary variables in the prone position during lumbar spine surgery. Methods Thirty-six patients scheduled for lumbar spine surgery in the prone position were enrolled in this prospective, randomized clinical trial. The patients were randomly assigned to receive VCV or PCV-VG. Hemodynamic variables, respiratory variables, and arterial blood gases were measured in the supine position 15 min after the induction of anesthesia, 15 min after placement in the prone position, 30 min after placement in the prone position, and 15 min after placement in the supine position at the end of anesthesia. Results The hemodynamic variables and arterial blood gas results did not differ significantly between the two groups. Lower Ppeak values were observed in the PCV-VG group than in the VCV group (p = 0.045). The Cdyn values in the VCV group were lower than those in the PCV-VG group (p = 0.040). Conclusion PCV-VG led to lower Ppeak and improved Cdyn values compared with VCV, showing that it may be a favorable alternative mode of mechanical ventilation for patients in the prone position during lumbar spine surgery. Trial registration The study was retrospectively registered at ClinicalTrials.gov (NCT 03571854). The initial registration date was 6/18/2018.
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Affiliation(s)
- Jung Min Lee
- Department of Anesthesiology and Pain Medicine, Hallym University Sacred Heart Hospital, College of Medicine, Hallym University, 22, Gwanpyeong-ro 170beon-gil, Dongan-gu, Gyeonggi-do, 14068, Anyang-si, Republic of Korea
| | - Soo Kyung Lee
- Department of Anesthesiology and Pain Medicine, Hallym University Sacred Heart Hospital, College of Medicine, Hallym University, 22, Gwanpyeong-ro 170beon-gil, Dongan-gu, Gyeonggi-do, 14068, Anyang-si, Republic of Korea
| | - Kyung Mi Kim
- Department of Anesthesiology and Pain Medicine, Hallym University Sacred Heart Hospital, College of Medicine, Hallym University, 22, Gwanpyeong-ro 170beon-gil, Dongan-gu, Gyeonggi-do, 14068, Anyang-si, Republic of Korea
| | - You Jung Kim
- Department of Anesthesiology and Pain Medicine, Hallym University Sacred Heart Hospital, College of Medicine, Hallym University, 22, Gwanpyeong-ro 170beon-gil, Dongan-gu, Gyeonggi-do, 14068, Anyang-si, Republic of Korea
| | - Eun Young Park
- Department of Anesthesiology and Pain Medicine, Hallym University Sacred Heart Hospital, College of Medicine, Hallym University, 22, Gwanpyeong-ro 170beon-gil, Dongan-gu, Gyeonggi-do, 14068, Anyang-si, Republic of Korea.
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Comparison of Operating Conditions, Postoperative Pain and Recovery, and Overall Satisfaction of Surgeons with Deep vs. No Neuromuscular Blockade for Spinal Surgery under General Anesthesia: A Prospective Randomized Controlled Trial. J Clin Med 2019; 8:jcm8040498. [PMID: 31013693 PMCID: PMC6518127 DOI: 10.3390/jcm8040498] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/02/2019] [Accepted: 04/09/2019] [Indexed: 02/07/2023] Open
Abstract
We aimed to investigate operating conditions, postoperative pain, and overall satisfaction of surgeons using deep neuromuscular blockade (NMB) vs. no NMB in patients undergoing lumbar spinal surgery under general anesthesia. Eighty-three patients undergoing lumbar fusion were randomly assigned to receive deep NMB (n = 43) or no NMB (n = 40). In the deep-NMB group, rocuronium was administered to maintain deep NMB (train-of-four count 0, post-tetanic count 1–2) until the end of surgery. In the no-NMB group, sugammadex 4 mg/kg at train-of-four (TOF) count 0–1 or sugammadex 2 mg/kg at TOF count ≥2 was administered to reverse the NMB 10 min after placing the patient prone. Peak inspiratory airway pressure, plateau airway pressure, lumbar retractor pressure significantly were lower in the deep-NMB group. Degree of surgical field bleeding (0–5), muscle tone (1–3), and satisfaction (1–10) rated by the surgeon were all superior in the deep-NMB group. Pain scores, rescue fentanyl consumption in post-anesthesia care unit (PACU), and postoperative patient-controlled analgesia consumption were significantly lower in the deep-NMB group, and this group had a shorter length of stay in PACU. Compared to no NMB, deep NMB provides better operating conditions, reduced postoperative pain and higher overall satisfaction in lumbar spinal surgery.
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El-Sayed AA, Arafa SK, El-Demerdash AM. Pressure-controlled ventilation could decrease intraoperative blood loss and improve airway pressure measures during lumbar discectomy in the prone position: A comparison with volume-controlled ventilation mode. J Anaesthesiol Clin Pharmacol 2019; 35:468-474. [PMID: 31920229 PMCID: PMC6939555 DOI: 10.4103/joacp.joacp_288_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Prone positioning may induce alterations of hemodynamic and airway pressure parameters that may affect intraoperative (IO) blood loss. Pressure-controlled ventilation (PCV) may modify these alterations. To observe the relation between ventilation mode and hemodynamic, airway pressure changes, and blood loss during lumbar discectomy performed in the prone position. Material and Methods Volume-controlled ventilation (VCV) patients were using tidal volume (TV) of 8-10 ml/Kg, but for pressure-controlled ventilation (PCV) patients peak inspiratory pressure (PIP) was adjusted to provide the same TV according to ideal body weight. Respiratory and hemodynamic parameters were recorded in supine (T1), on turning to prone (T2), and on returning to the supine position (T3). Primary outcome included amount of IO blood loss; Secondary outcome included need for blood transfusion, IO hemodynamics, and airway pressure changes. Results IO blood loss and central venous pressure (CVP) were significantly higher with VCV than PCV patients. Heart rate and blood pressure were significantly reduced in the prone position with little impact of ventilation mode. Prone positioning resulted in significant increase of P-peak and non-significant decrease of P-mean pressure with VCV, while with PCV resulted in a significantly increased airway pressures. P-peak pressure was significantly lower with PCV in supine and prone positions than VCV. P-mean pressure was significantly lower in supine but significantly higher in the prone position with PCV than VCV. Conclusions Prone positioning and VCV were associated with increased CVP and IO blood loss, while PCV could lessen these effects and significantly improve airway pressures.
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Affiliation(s)
- Amir Abouzkry El-Sayed
- Department of Anaesthesia and Intensive Care, Faculty of Medicine, Aswan University, Aswan, Egypt
| | - Sherif Kamal Arafa
- Department of Anaesthesia and Intensive Care, Faculty of Medicine, Aswan University, Aswan, Egypt
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Abstract
PURPOSE OF REVIEW The main objective of this article is to present the updated data regarding the perioperative management of patients undergoing major spine surgery in an era where the surgical techniques are changing and there is a high demand for these surgeries in older and high-risk patients. RECENT FINDINGS Preoperative assessment and stabilization is now more structured protocol and it is based on a multidisciplinary approach to the patient. The Enhanced Recovery After Surgery (ERAS) programs and the Perioperative Surgical Home on major spine surgery are not yet fully evidence based but it seems that the use of a perioperative optimization of patients and use of a drugs' bundle is more effective than using single drugs or interventions on the postoperative pain reduction and faster recovery from surgery. Fluid and pain-control protocols combined with an accurate blood management represent the key to success. SUMMARY A tailored approach to patients undergoing major spine surgeries seems to be effective improving the outcome and quality of life of patients. Future studies should aim to understand which elements of the ERAS can be improved to allow the patient to have a long-term good outcome. VIDEO ABSTRACT.
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Naik BI, Nemergut EC, Durieux ME. Complexities of Bleeding During Spine Surgery: It'll Take Your (Mechanical) Breath Away. Anesthesiology 2017; 126:195. [PMID: 27977458 DOI: 10.1097/aln.0000000000001411] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Bhiken I Naik
- University of Virginia, Charlottesville, Virginia (B.I.N.).
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In Reply. Anesthesiology 2017; 126:196. [DOI: 10.1097/aln.0000000000001412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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