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Abbott M, Pereira SM, Sanders N, Girard M, Sankar A, Sklar MC. Weaning from mechanical ventilation in the operating room: a systematic review. Br J Anaesth 2024; 133:424-436. [PMID: 38816331 PMCID: PMC11282496 DOI: 10.1016/j.bja.2024.03.043] [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: 11/09/2023] [Revised: 02/27/2024] [Accepted: 03/22/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Postoperative pulmonary complications (PPCs) are associated with postoperative mortality and prolonged hospital stay. Although intraoperative mechanical ventilation (MV) is a risk factor for PPCs, strategies addressing weaning from MV are understudied. In this systematic review, we evaluated weaning strategies and their effects on postoperative pulmonary outcomes. METHODS Our protocol was registered on PROSPERO (CRD42022379145). Eligible studies included randomised controlled trials and observational studies of adults weaned from MV in the operating room. Primary outcomes included atelectasis and oxygenation; secondary outcomes included lung volume changes and PPCs. Risk of bias was assessed using the Cochrane Risk of Bias (RoB2) tool, and quality of evidence with the GRADE framework. RESULTS Screening identified 14 randomised controlled trials including 1719 patients; seven studies were limited to the weaning phase and seven included interventions not restricted to the weaning phase. Strategies combining pressure support ventilation (PSV) with positive end-expiratory pressure (PEEP) and low fraction of inspired oxygen (FiO2) improved atelectasis, oxygenation, and lung volumes. Low FiO2 improved atelectasis and oxygenation but might not improve lung volumes. A fixed-PEEP strategy led to no improvement in oxygenation or atelectasis; however, individualised PEEP with low FiO2 improved oxygenation and might be associated with reduced PPCs. Half of included studies are of moderate or high risk of bias; the overall quality of evidence is low. CONCLUSIONS There is limited research evaluating weaning from intraoperative MV. Based on low-quality evidence, PSV, individualised PEEP, and low FiO2 may be associated with reduced postoperative pulmonary outcomes. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42022379145).
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Affiliation(s)
- Megan Abbott
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada
| | - Sergio M Pereira
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Noah Sanders
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada
| | - Martin Girard
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada; Division of Critical Care, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada; Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal Research Center, Montreal, QC, Canada
| | - Ashwin Sankar
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Michael C Sklar
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
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Wang X, Guo K, Sun J, Yang Y, Wu Y, Tang X, Xu Y, Chen Q, Zeng S, Wang L, Liu S. Semirecumbent Positioning During Anesthesia Recovery and Postoperative Hypoxemia: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2416797. [PMID: 38941098 PMCID: PMC11214118 DOI: 10.1001/jamanetworkopen.2024.16797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 04/09/2024] [Indexed: 06/29/2024] Open
Abstract
Importance The efficacy of a semirecumbent position (SRP) in reducing postoperative hypoxemia during anesthesia emergence is unclear despite its widespread use. Objective To determine the differences in postoperative hypoxemia between patients in an SRP and a supine position. Design, Setting, and Participants This randomized clinical trial was performed at a tertiary hospital in China between March 20, 2021, and May 10, 2022. Patients scheduled to undergo laparoscopic upper abdominal surgery under general anesthesia were enrolled. Study recruitment and follow-up are complete. Interventions Patients were randomized to 1 of the following positions at the end of the operation until leaving the postanesthesia care unit: supine (group S), 15° SRP (group F), or 30° SRP (group T). Main Outcomes and Measures The primary outcome was the incidence of postoperative hypoxemia in the postanesthesia care unit. Severe hypoxemia was also evaluated. Results Out of 700 patients (364 men [52.0%]; mean [SD] age, 47.8 [11.3] years), 233 were randomized to group S (126 men [54.1%]; mean [SD] age, 48.2 [10.9] years), 233 to group F (122 men [52.4%]; mean [SD] age, 48.1 [10.9] years), and 234 to group T (118 women [50.4%]; mean [SD] age, 47.2 [12.1] years). Postoperative hypoxemia differed significantly among the 3 groups (group S, 109 of 233 [46.8%]; group F, 105 of 233 [45.1%]; group T, 76 of 234 [32.5%]; P = .002). This difference was statistically significant for groups T vs S (risk ratio [RR], 0.69 [95% CI, 0.55-0.87]; P = .002) and groups T vs F (RR, 0.72 [95% CI, 0.57-0.91]; P = .007), but not for groups F vs S (RR, 0.96 [95% CI, 0.79-1.17]; P = .78). Severe hypoxemia also differed among the 3 groups (group S, 61 of 233 [26.2%]; group F, 53 of 233 [22.7%]; group T, 36 of 234 [15.4%]; P = .01). This difference was statistically significant for groups T vs S (RR, 0.59 [95% CI, 0.41-0.85]; P = .005). Conclusions and Relevance In this randomized clinical trial of SRP during anesthesia recovery in patients undergoing laparoscopic upper abdominal surgery, postoperative hypoxemia was significantly reduced in group T compared with group F or group S. Trial Registration Chinese Clinical Trial Registry Identifier: ChiCTR2100045087.
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Affiliation(s)
- Xinghe Wang
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
- Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
- NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, China
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, China
| | - Kedi Guo
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
- Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
- NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, China
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Jia Sun
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, China
| | - Yuping Yang
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
- Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
- NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, China
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yan Wu
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
- Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
- NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, China
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xihui Tang
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
- Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
- NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, China
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yuqing Xu
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
- Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
- NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, China
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Qingsong Chen
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
- Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
- NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, China
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Si Zeng
- Department of Anesthesiology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Liwei Wang
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, China
| | - Su Liu
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
- Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
- NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, China
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
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Kampman JM, Plasmans KYQ, Hermanides J, Hollmann MW, Repping S, Sperna Weiland NH. Influence of nitrous oxide added to general anaesthesia on postoperative mortality and morbidity: a systematic review and meta-analysis. Br J Anaesth 2024:S0007-0912(24)00073-4. [PMID: 38471989 DOI: 10.1016/j.bja.2024.02.011] [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: 10/31/2023] [Revised: 02/19/2024] [Accepted: 02/19/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Nitrous oxide (N2O) is a common adjuvant to general anaesthesia. It is also a potent greenhouse gas and causes ozone depletion. We sought to quantify the influence of N2O as an adjuvant to general anaesthesia on postoperative patient outcomes. METHODS We searched Medline, EMBASE, and Cochrane Central for works published from inception to July 6, 2023. RCTs comparing general anaesthesia with or without N2O were included. Risk ratios (RRs) and standardised mean differences (SMDs) were calculated, along with 95% confidence intervals (CIs), using a random-effects model. Outcomes were derived from the Standardised Endpoints for Perioperative Medicine (StEP) outcome set. Primary outcomes were mortality and organ-related morbidity, and secondary outcomes were anaesthetic and surgical morbidity. RESULTS Of 3305 records, 179 full-text articles were assessed, and 71 RCTs, totalling 22 147 patients, were included in the meta-analysis. Addition of N2O to general anaesthesia did not influence postoperative mortality or most morbidity outcomes. N2O increased the incidence of atelectasis (RR 1.62, 95% CI 1.24 to 2.12) and postoperative nausea and vomiting (RR 1.27, 95% CI 1.15 to 1.40), and decreased intraoperative opioid consumption (SMD -0.19, 95% CI -0.35 to -0.04) and time to extubation (MD -2.17 min, 95% CI -3.32 to -1.03 min). CONCLUSIONS N2O did not influence postoperative mortality or most morbidity outcomes. Considering the environmental effects of N2O, these findings confirm that current policy recommendations to limit its use do not affect patient safety. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42023443287.
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Affiliation(s)
- Jasper M Kampman
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam UMC Centre for Sustainable Healthcare, Amsterdam UMC, Amsterdam, The Netherlands.
| | - Kim Y Q Plasmans
- Department of Anaesthesiology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Jeroen Hermanides
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sjoerd Repping
- Healthcare Evaluation and Appropriate Use, National Healthcare Institute, Diemen, The Netherlands; Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicolaas H Sperna Weiland
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam UMC Centre for Sustainable Healthcare, Amsterdam UMC, Amsterdam, The Netherlands
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4
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Jiang Z, Liu S, Wang L, Li W, Li C, Lang F, Li R, Zhou Y, Wu J, Cai Y, Xu W, Chen Z, Bao Z, Li M, Gu W. Effects of 30% vs. 60% inspired oxygen fraction during mechanical ventilation on postoperative atelectasis: a randomised controlled trial. BMC Anesthesiol 2023; 23:265. [PMID: 37550648 PMCID: PMC10408131 DOI: 10.1186/s12871-023-02226-6] [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: 03/21/2023] [Accepted: 07/28/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND There is the ongoing debate over the effect of inspired oxygen fraction (FiO2) during mechanical ventilation on postoperative atelectasis. We aimed to compare the effects of low (30%) and moderate (60%) FiO2 on postoperative atelectasis. The hypothesis of the study was that 30% FiO2 during mechanical ventilation could reduce postoperative atelectasis volume compared with 60% FiO2. METHODS We performed a randomized controlled trial with 120 patients. Subjects were randomly assigned to receive 30% or 60% FiO2 during mechanical ventilation in a 1:1 ratio. The primary outcome was the percentage of postoperative atelectasis volume in the total lung measured using chest CT within 30 min after extubation. The secondary outcomes included different aeration region volumes, incidence of clinically significant atelectasis, and oxygenation index. RESULTS In total, 113 subjects completed the trial, including 55 and 58 subjects in the 30% and 60% FiO2 groups, respectively. The percentage of the postoperative atelectasis volume in the 30% FiO2 group did not differ from that in the 60% FiO2 group. Furthermore, there was no significant difference in the atelectasis volume between the two groups after the missing data were imputed by multiple imputation. Additionally, there were no significant differences in the volumes of the over-aeration, normal-aeration, and poor-aeration regions between the groups. No significant differences in the incidence of clinically significant atelectasis or oxygenation index at the end of surgery were observed between the groups. CONCLUSIONS Compared with 60% FiO2, the use of 30% FiO2 during mechanical ventilation does not reduce the postoperative atelectasis volume. TRIAL REGISTRATION Chinese Clinical Trial Registry ( http://www.chictr.org.cn ). Identifier: ChiCTR1900021635. Date: 2 March 2019. Principal invetigator: Weidong Gu.
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Affiliation(s)
- Zhaoshun Jiang
- Department of Anesthesiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, China
| | - Songbin Liu
- Department of Anesthesiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, China
| | - Lan Wang
- Department of Anesthesiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Wanling Li
- Department of General surgery, Shanghai XuHui Central Hospital, Shanghai, China
| | - Cheng Li
- Department of Radiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Feifei Lang
- Department of Anesthesiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Ruoxi Li
- Department of Anesthesiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Yue Zhou
- Department of Anesthesiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Jiajun Wu
- Department of Anesthesiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Yuxi Cai
- Department of Anesthesiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, China
| | - Wen Xu
- Department of Anesthesiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Zhen Chen
- Department of Surgical Intensive Care Unit, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Zhijun Bao
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, China
- Department of Geriatric Medicine, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- Research Centre on Aging and Medicine, Fudan University, Shanghai, China
| | - Ming Li
- Department of Radiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China.
| | - Weidong Gu
- Department of Anesthesiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China.
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, China.
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L D, Kumar R, Patel N, Ayub A, Rewari V, Subramaniam R, Roy KK. Effect of Lung Compliance-Based Optimum Pressure Versus Fixed Positive End-Expiratory Pressure on Lung Atelectasis Assessed by Modified Lung Ultrasound Score in Laparoscopic Gynecological Surgery: A Prospective Randomized Controlled Trial. Cureus 2023; 15:e40278. [PMID: 37448389 PMCID: PMC10336472 DOI: 10.7759/cureus.40278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Lung protective ventilation during the intraoperative period is now well established. However, the additional role of positive end-expiratory pressure (PEEP) during the intraoperative period remains uncertain in major laparoscopic gynecological surgery. The authors hypothesized that compliance-based optimum PEEP titration reduces postoperative lung atelectasis and improves outcomes. METHODS Patients undergoing major laparoscopic pelvic gynecological surgeries with healthy lungs were randomized to the fixed PEEP group (PEEP 5 cm H2O and recruitment maneuver {RM}) and optimum PEEP group (compliance-based PEEP and RM). Lung ultrasound and arterial blood gas analysis were performed at four time points. Modified lung ultrasound scoring was done, and the same was used as means of assessing lung aeration and the amount of lung atelectasis. Postoperative supplemental oxygen requirement and duration were also assessed and compared. RESULTS Lung ultrasound score (LUS) 30 minutes after extubation in fixed (Group F) and optimum (Group O) PEEP groups were median (interquartile range {IQR}) 3 (2-3) versus 1 (1-2), p=0.0001. Ventilatory parameters between Group F and Group O after lung recruitment were tidal volume (mean 357 mL {SD: 35} versus 362 mL {SD: 22}, p=0.46), PEEP (median, 5 cm H2O {IQR: 5-5} versus median 16 cm H2O {IQR: 14-18}), peak airway pressure (median 26 cm H2O {IQR: 24-28} versus median 30 cm H2O {IQR: 28-32} p<0.0001), plateau pressure (median 22 cm H2O {IQR: 20-24} versus median 26 cm H2O {IQR: 24-28} p<0.0001), static compliance (32.07±8.36 mL cm H2O-1 versus 39.58±8.99 mL cm H2O-1, p=0.0002). The number of patients requiring postoperative oxygen therapy to maintain SpO2 >94% after extubation in postanesthesia care unit (PACU) was statistically significantly greater in group F (39/41 {95%} versus 30/41 {73%}, p=0.007). Median (IQR) duration of oxygenation therapy in the first 24 hours of the postoperative period between Group F and Group O differed with statistical significance, with the median (IQR) values being 25 (20-30) minutes versus 10 (0-15) minutes (p<0.0001). CONCLUSIONS The modified lung ultrasound score significantly differed intraoperatively between the two groups, with lower scores in the optimum PEEP group. This has reflected improved postoperative outcomes in optimum PEEP group patients, with fewer patients requiring postoperative oxygen supplementation and reduced supplemental oxygen requirement duration.
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Affiliation(s)
- Deeparaj L
- Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, IND
| | - Rakesh Kumar
- Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, IND
| | - Nishant Patel
- Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, IND
| | - Arshad Ayub
- Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, IND
| | - Vimi Rewari
- Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, IND
| | - Rajeshwari Subramaniam
- Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, IND
| | - Kallol Kumar Roy
- Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, IND
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Broberg E, Pierre L, Fakhro M, Malmsjö M, Lindstedt S, Hyllén S. Releasing high positive end-expiratory pressure to a low level generates a pronounced increase in particle flow from the airways. Intensive Care Med Exp 2023; 11:12. [PMID: 36929361 PMCID: PMC10020405 DOI: 10.1186/s40635-023-00498-3] [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: 06/09/2022] [Accepted: 02/04/2023] [Indexed: 03/18/2023] Open
Abstract
OBJECTIVES Detecting particle flow from the airways by a non-invasive analyzing technique might serve as an additional tool to monitor mechanical ventilation. In the present study, we used a customized particles in exhaled air (PExA) technique, which is an optical particle counter for the monitoring of particle flow in exhaled air. We studied particle flow while increasing and releasing positive end-expiratory pressure (PEEP). The aim of this study was to investigate the impact of different levels of PEEP on particle flow in exhaled air in an experimental setting. We hypothesized that gradually increasing PEEP will reduce the particle flow from the airways and releasing PEEP from a high level to a low level will result in increased particle flow. METHODS Five fully anesthetized domestic pigs received a gradual increase of PEEP from 5 cmH2O to a maximum of 25 cmH2O during volume-controlled ventilation. The particle count along with vital parameters and ventilator settings were collected continuously and measurements were taken after every increase in PEEP. The particle sizes measured were between 0.41 µm and 4.55 µm. RESULTS A significant increase in particle count was seen going from all levels of PEEP to release of PEEP. At a PEEP level of 15 cmH2O, there was a median particle count of 282 (154-710) compared to release of PEEP to a level of 5 cmH2O which led to a median particle count of 3754 (2437-10,606) (p < 0.009). A decrease in blood pressure was seen from baseline to all levels of PEEP and significantly so at a PEEP level of 20 cmH2O. CONCLUSIONS In the present study, a significant increase in particle count was seen on releasing PEEP back to baseline compared to all levels of PEEP, while no changes were seen when gradually increasing PEEP. These findings further explore the significance of changes in particle flow and their part in pathophysiological processes within the lung.
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Affiliation(s)
- Ellen Broberg
- Department of Clinical Sciences, Lund University, Lund, Sweden. .,Department of Cardiothoracic Anaesthesia and Intensive Care, Skåne University Hospital, Entrégatan 8, Level 8, 22241, Lund, Sweden.
| | - Leif Pierre
- Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Cardiothoracic Anaesthesia and Intensive Care, Skåne University Hospital, Entrégatan 8, Level 8, 22241, Lund, Sweden
| | - Mohammed Fakhro
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark
| | - Malin Malmsjö
- Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Ophthalmology, Skåne University Hospital, Lund, Sweden
| | - Sandra Lindstedt
- Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Cardiothoracic Surgery, Skåne University Hospital, Lund, Sweden.,Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
| | - Snejana Hyllén
- Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Cardiothoracic Anaesthesia and Intensive Care, Skåne University Hospital, Entrégatan 8, Level 8, 22241, Lund, Sweden
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Min WK, Jin S, Choi YJ, Won YJ, Lee K, Lim CH. Lung ultrasound score-based assessment of postoperative atelectasis in obese patients according to inspired oxygen concentration: A prospective, randomized-controlled study. Medicine (Baltimore) 2023; 102:e32990. [PMID: 36800571 PMCID: PMC9936007 DOI: 10.1097/md.0000000000032990] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND According to a recent meta-analysis, in patients with a body mass index (BMI) ≥ 30, a high fraction of inhaled oxygen (FiO2) did not increase postoperative atelectasis. However, a high FiO2 generally increases the risk of postoperative atelectasis. Therefore, this study aimed to evaluate the effect of FiO2 on the development of atelectasis in obese patients using the modified lung ultrasound score (LUSS). METHODS Patients were assigned to 4 groups: BMI ≥ 30: group A (n = 21) and group B (n = 20) and normal BMI: group C (n = 22) and group D (n = 21). Groups A and C were administered 100% O2 during preinduction and emergence and 50% O2 during anesthesia. Groups B and D received 40% O2 for anesthesia. The modified LUSS was assessed before and 20 min after arrival to the postanesthesia care unit (PACU). RESULTS The difference between the modified LUSS preinduction and PACU was significantly higher in group A with a BMI ≥ 30 (P = .006); however, there was an insignificant difference between groups C and D in the normal BMI group (P = .076). CONCLUSION High FiO2 had a greater effect on the development of atelectasis in obese patients than did low FiO2; however, in normal-weight individuals, FiO2 did not have a significant effect on postoperative atelectasis.
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Affiliation(s)
- Won Kee Min
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Gyeonggi- do, Republic of Korea
| | - Sejong Jin
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Gyeonggi- do, Republic of Korea
- Department of Neuroscience, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yoon Ji Choi
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Gyeonggi- do, Republic of Korea
- * Correspondence: Yoon Ji Choi, Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do 15355, Republic of Korea (e-mail: )
| | - Young Ju Won
- Department of Anesthesiology and Pain Medicine, Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kaehong Lee
- Department of Anesthesiology and Pain Medicine, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Choon-Hak Lim
- Department of Anesthesiology and Pain Medicine, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
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Liu T, Huang J, Wang X, Tu J, Wang Y, Xie C. Effect of recruitment manoeuvres under lung ultrasound-guidance and positive end-expiratory pressure on postoperative atelectasis and hypoxemia in major open upper abdominal surgery: A randomized controlled trial. Heliyon 2023; 9:e13348. [PMID: 36755592 PMCID: PMC9900369 DOI: 10.1016/j.heliyon.2023.e13348] [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: 04/06/2022] [Revised: 01/11/2023] [Accepted: 01/27/2023] [Indexed: 01/31/2023] Open
Abstract
Background Postoperative pulmonary complications (PPCs) especially atelectasis and hypoxemia are common during abdominal surgery. Studies on the effect of either recruitment manoeuvres (RMs) or positive end-expiratory pressure (PEEP) on PPCs are controversial. The objective of this study is to evaluate the effect of perioperative lung ultrasound (LUS)-guided RMs combined with PEEP on the reduction of postoperative atelectasis and hypoxemia in major open upper abdominal surgery. Methods In this randomized controlled trial, 122 adult patients undergoing major open upper abdominal surgery were allocated into three groups: control (C) group (n = 42); PEEP (P) group (n = 40); RMs combined with PEEP (RP) group (n = 40). All patients were scheduled for general anaesthesia using the lung-protective ventilation (LPV) strategy. The levels of PEEP in the three groups were 0 cmH2O, 5 cmH2O and 5 cmH2O. LUS examination was carried out at 3 predetermined time points in each group: 5 min after intubation (T1), at the end of surgery (T2) and 15 min after extubation (T3). Patients with atelectasis on the sonogram in the RP group received LUS-guided RMs at point T2. LUS scores were used to estimate the severity of aeration loss. The P/F ratio (PaO2/FiO2) at 15min after extubation was used to assess the incidence of postoperative hypoxemia. Primary outcomes were the incidences of postoperative atelectasis and hypoxemia (PaO2/FiO2 < 300 mmHg). The secondary outcome was the distribution of LUS scores in each lung area. Results From July 2021 to December 2021, 122 consecutive patients were enrolled. No typical atelectasis was observed 5 min after intubation. The incidence of atelectasis was 52.4%, 50.0% and 42.5% in the C group, P group and RP group at the end of surgery, respectively. The rate of atelectasis in the C group, P group and RP group (after RMs) was 52.4%, 50.0% and 17.5%, respectively, 15 min after extubation (P < 0.01). The frequency of postoperative hypoxemia was 27.5%, 15.0% and 5.0% in the C group, P group and RP group, respectively (P < 0.017). The increased LUS scores mainly occurred in the superoposterior and inferoposterior quadrants at the end of surgery. Only in the RP group demonstrated a decreased LUS score in the posteriorquadrants after extubation. Conclusions In patients undergoing major open upper abdominal surgery, an intraoperative mechanical ventilation strategy without PEEP or with PEEP alone did not reduce PPCs. However, PEEP of 5 cmH2O combined with LUS-guided RMs proved feasible and beneficial to decrease the occurrence of postoperative atelectasis and hypoxemia in major open upper abdominal surgeries.
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Affiliation(s)
- Tao Liu
- Department of Anesthesiology, The First People's Hospital of Huzhou, The Affiliated Hospital of Huzhou Teachers College, Guangchanghou Road 158th, Huzhou, 313000, PR China
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY, 40202, USA
| | - Xinqiang Wang
- Department of Anesthesiology, The First People's Hospital of Huzhou, The Affiliated Hospital of Huzhou Teachers College, Guangchanghou Road 158th, Huzhou, 313000, PR China
| | - Jiahui Tu
- Department of Anesthesiology, The First People's Hospital of Huzhou, The Affiliated Hospital of Huzhou Teachers College, Guangchanghou Road 158th, Huzhou, 313000, PR China
| | - Yahong Wang
- Department of Anesthesiology, The First People's Hospital of Huzhou, The Affiliated Hospital of Huzhou Teachers College, Guangchanghou Road 158th, Huzhou, 313000, PR China
| | - Chen Xie
- Department of Anesthesiology, The First People's Hospital of Huzhou, The Affiliated Hospital of Huzhou Teachers College, Guangchanghou Road 158th, Huzhou, 313000, PR China,Corresponding author.
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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: 17] [Impact Index Per Article: 8.5] [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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Nair PR, Ramachandran R, Trikha A, Anand RK, Rewari V. Effect of positive end expiratory pressure on atelectasis in patients undergoing major upper abdominal surgery under general anaesthesia: A lung ultrasonography study. J Perioper Pract 2022; 33:99-106. [PMID: 35322693 DOI: 10.1177/17504589211045218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Postoperative pulmonary complications vary in major upper abdominal surgery. The objective of this study was to assess the effect of positive end expiratory pressure on the incidence of atelectasis in patients undergoing major upper abdominal surgery under general anaesthesia using lung ultrasound. The patients were randomised into receiving either no positive end expiratory pressure (Group I) or positive end expiratory pressure of 5cm H2O (Group II). Lung ultrasound was performed at various time points - baseline, 10 minutes, 2 hours after induction, during closure of skin and 30 minutes post extubation. The lung aeration as assessed by Total Modified Lung Ultrasound Score was worse in the Group I as compared to the Group II at 2 hours post induction. Driving pressure in Group II was significantly reduced compared to Group I. Application of positive end expiratory pressure, as minimal as 5cm H2O, as a single intervention, helps in significantly reducing the Total Modified Lung Ultrasound Score after a duration of more than 2 hours and also attaining low driving pressures during intraoperative mechanical ventilation.
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Affiliation(s)
- Parvathy Ramachandran Nair
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Rashmi Ramachandran
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Anjan Trikha
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Rahul Kumar Anand
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Vimi Rewari
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi 110029, India
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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: 50] [Impact Index Per Article: 25.0] [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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Ferrando C, Librero J, Tusman G, Serpa‐Neto A, Villar J, Belda FJ, Costa E, Amato MBP, Suarez‐Sipmann F. Intraoperative open lung condition and postoperative pulmonary complications. A secondary analysis of iPROVE and iPROVE-O2 trials. Acta Anaesthesiol Scand 2022; 66:30-39. [PMID: 34460936 DOI: 10.1111/aas.13979] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/09/2021] [Accepted: 08/16/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND The preventive role of an intraoperative recruitment maneuver plus open lung approach (RM + OLA) ventilation on postoperative pulmonary complications (PPC) remains unclear. We aimed at investigating whether an intraoperative open lung condition reduces the risk of developing a composite of PPCs. METHODS Post hoc analysis of two randomized controlled trials including patients undergoing abdominal surgery. Patients were classified according to the intraoperative lung condition as "open" (OL) or "non-open" (NOL) if PaO2 /FIO2 ratio was ≥ or <400 mmHg, respectively. We used a multivariable logistic regression model that included potential confounders selected with directed acyclic graphs (DAG) using Dagitty software built with variables that were considered clinically relevant based on biological mechanism or evidence from previously published data. PPCs included severe acute respiratory failure, acute respiratory distress syndrome, and pneumonia. RESULTS A total of 1480 patients were included in the final analysis, with 718 (49%) classified as OL. The rate of severe PPCs during the first seven postoperative days was 6.0% (7.9% in the NOL and 4.4% in the OL group, p = .007). OL was independently associated with a lower risk for severe PPCs during the first 7 and 30 postoperative days [odds ratio of 0.58 (95% CI 0.34-0.99, p = .04) and 0.56 (95% CI 0.34-0.94, p = .03), respectively]. CONCLUSIONS An intraoperative open lung condition was associated with a reduced risk of developing severe PPCs in intermediate-to-high risk patients undergoing abdominal surgery. TRIAL REGISTRATION Registered at clinicaltrials.gov NCT02158923 (iPROVE), NCT02776046 (iPROVE-O2).
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Affiliation(s)
- Carlos Ferrando
- Department of Anesthesiology and Critical Care Hospital Clínic Institut D'investigació August Pi i Sunyer Barcelona Spain
- CIBER de Enfermedades Respiratorias Instituto de Salud Carlos III Madrid Spain
| | - Julian Librero
- Navarrabiomed Complejo Hospitalario de Navarra UPNA REDISSEC (Red de Investigación en Servicios de Salud) La Palma de Cervelló Spain
| | - Gerardo Tusman
- Department of Anesthesiology Hospital Privado de Comunidad Mar de Plata Argentina
| | - Ary Serpa‐Neto
- Australian and New Zealand Intensive Care‐Research Centre (ANZIC‐RC) Monash University Melbourne Vic. Australia
- Department of Critical Care Medicine Hospital Israelita Albert Einstein Sao Paulo Brazil
- Department of Critical Care Melbourne Medical School University of Melbourne Austin Hospital Melbourne Vic. Australia
| | - Jesús Villar
- CIBER de Enfermedades Respiratorias Instituto de Salud Carlos III Madrid Spain
- Multidisciplinary Organ Dysfunction Evaluation Research Network Research Unit Hospital Universitario Dr. Negrín Las Palmas de Gran Canaria Spain
- Keenan Research Center for Biomedical Science at the Li Ka Shing Knowledge Institute St. Michael’s Hospital Toronto Ontario Canada
| | - Francisco J. Belda
- Department of Critical Care Medicine Hospital Israelita Albert Einstein Sao Paulo Brazil
| | - Eduardo Costa
- Cardio‐Pulmonary Department Pulmonary Division Heart Institute (Incor) University of São Paulo Sao Paulo Brazil
- Research and Education Institute Hospital Sirio‐Libanês Sao Paulo Brazil
| | - Marcelo B. P. Amato
- Cardio‐Pulmonary Department Pulmonary Division Heart Institute (Incor) University of São Paulo Sao Paulo Brazil
| | - Fernando Suarez‐Sipmann
- CIBER de Enfermedades Respiratorias Instituto de Salud Carlos III Madrid Spain
- Department of Surgical Sciences Hedenstierna Laboratory Uppsala University Hospital Uppsala Sweden
- Department of Intensive Care Hospital Universitario La Princesa Madrid Spain
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Pressure Support versus Spontaneous Ventilation during Anesthetic Emergence-Effect on Postoperative Atelectasis: A Randomized Controlled Trial. Anesthesiology 2021; 135:1004-1014. [PMID: 34610099 DOI: 10.1097/aln.0000000000003997] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Despite previous reports suggesting that pressure support ventilation facilitates weaning from mechanical ventilation in the intensive care unit, few studies have assessed its effects on recovery from anesthesia. The authors hypothesized that pressure support ventilation during emergence from anesthesia reduces postoperative atelectasis in patients undergoing laparoscopic surgery using the Trendelenburg position. METHODS In this randomized controlled double-blinded trial, adult patients undergoing laparoscopic colectomy or robot-assisted prostatectomy were assigned to either the pressure support (n = 50) or the control group (n = 50). During emergence (from the end of surgery to extubation), pressure support ventilation was used in the pressure support group versus intermittent manual assistance in the control group. The primary outcome was the incidence of atelectasis diagnosed by lung ultrasonography at the postanesthesia care unit (PACU). The secondary outcomes were Pao2 at PACU and oxygen saturation measured by pulse oximetry less than 92% during 48 h postoperatively. RESULTS Ninety-seven patients were included in the analysis. The duration of emergence was 9 min and 8 min in the pressure support and control groups, respectively. The incidence of atelectasis at PACU was lower in the pressure support group compared to that in the control group (pressure support vs. control, 16 of 48 [33%] vs. 28 of 49 [57%]; risk ratio, 0.58; 95% CI, 0.35 to 0.91; P = 0.024). In the PACU, Pao2 in the pressure support group was higher than that in the control group (92 ± 26 mmHg vs. 83 ± 13 mmHg; P = 0.034). The incidence of oxygen saturation measured by pulse oximetry less than 92% during 48 h postoperatively was not different between the groups (9 of 48 [19%] vs. 11 of 49 [22%]; P = 0.653). There were no adverse events related to the study protocol. CONCLUSIONS The incidence of postoperative atelectasis was lower in patients undergoing either laparoscopic colectomy or robot-assisted prostatectomy who received pressure support ventilation during emergence from general anesthesia compared to those receiving intermittent manual assistance. EDITOR’S PERSPECTIVE
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Respiratory Prehabilitation for the Prevention of Postoperative Pulmonary Complications after Major Surgery. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00495-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Li H, Zheng ZN, Zhang NR, Guo J, Wang K, Wang W, Li LG, Jin J, Tang J, Liao YJ, Jin SQ. Intra-operative open-lung ventilatory strategy reduces postoperative complications after laparoscopic colorectal cancer resection: A randomised controlled trial. Eur J Anaesthesiol 2021; 38:1042-1051. [PMID: 34366425 PMCID: PMC8452317 DOI: 10.1097/eja.0000000000001580] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The role of the positive end-expiratory pressure (PEEP) and lung recruitment manoeuvre (LRM) combination (termed open-lung strategy, OLS) during intra-operative mechanical ventilation is not clear. OBJECTIVE To determine whether an open-lung strategy constituting medium PEEP (6-8 cmH2O) and repeated LRMs protects against postoperative complications in at-risk patients undergoing laparoscopic colorectal cancer resection under low-tidal-volume ventilation. DESIGN A prospective, assessor-blinded, randomised controlled trial. SETTING Single university-affiliated hospital, conducted from January 2017 to October 2018. PATIENTS A total of 280 patients at risk of pulmonary complications, scheduled for laparoscopic colorectal cancer resection under general anaesthesia and low-tidal-volume (6-8 ml kg-1 predicted body weight) ventilation. INTERVENTION The patients were randomly assigned (1 : 1) to a PEEP of 6-8 cmH2O with LRMs repeated every 30 min (OLS group) or a zero PEEP without LRMs (non-OLS group). MAIN OUTCOME MEASURES The primary outcome was a composite of major pulmonary and extrapulmonary complications occurring within 7 days after surgery. The secondary outcomes included intra-operative potentially harmful hypotension and the need for vasopressors. RESULTS A total of 130 patients from each group were included in the primary outcome analysis. Primary outcome events occurred in 24 patients (18.5%) in the OLS group and 43 patients (33.1%) in the non-OLS group [relative risk, 0.46; 95% confidence interval (CI), 0.26 to 0.82; P = 0.009). More patients in the OLS group developed potentially harmful hypotension (OLS vs. non-OLS, 15% vs. 4.3%; P = 0.004) and needed vasopressors (25% vs. 8.6%; P < 0.001). CONCLUSION Among at-risk patients undergoing laparoscopic colorectal cancer resection under low-tidal-volume ventilation, an open-lung strategy with a PEEP of 6-8 cmH2O and repeated LRMs reduced postoperative complications compared with a strategy using zero PEEP without LRMs. Of note, LRMs should be used with caution in patients with haemodynamic instability. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT03160144.
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Affiliation(s)
- Hong Li
- From the Department of Anaesthesia, the Sixth Affiliated Hospital, Sun Yat-sen University, No. 26 Yuancun Erheng Road, Tianhe District, Guangzhou, China (HL, Z-NZ, N-RZ, JG, KW, WW, L-GL, JJ, JT, Y-JL, S-QJ)
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Zhu C, Zhang S, Dong J, Wei R. Effects of positive end-expiratory pressure/recruitment manoeuvres compared with zero end-expiratory pressure on atelectasis in children: A randomised clinical trial. Eur J Anaesthesiol 2021; 38:1026-1033. [PMID: 33534267 PMCID: PMC8452313 DOI: 10.1097/eja.0000000000001451] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
BACKGROUND Atelectasis is a common postoperative complication. Peri-operative lung protection can reduce atelectasis; however, it is not clear whether this persists into the postoperative period. OBJECTIVE To evaluate to what extent lung-protective ventilation reduces peri-operative atelectasis in children undergoing nonabdominal surgery. DESIGN Randomised, controlled, double-blind study. SETTING Single tertiary hospital, 25 July 2019 to 18 January 2020. PATIENTS A total of 60 patients aged 1 to 6 years, American Society of Anesthesiologists physical status 1 or 2, planned for nonabdominal surgery under general anaesthesia (≤2 h) with mechanical ventilation. INTERVENTIONS The patients were assigned randomly into either the lung-protective or zero end-expiratory pressure with no recruitment manoeuvres (control) group. Lung protection entailed 5 cmH2O positive end-expiratory pressure and recruitment manoeuvres every 30 min. Both groups received volume-controlled ventilation with a tidal volume of 6 ml kg-1 body weight. Lung ultrasound was conducted before anaesthesia induction, immediately after induction, surgery and tracheal extubation, and 15 min, 3 h, 12 h and 24 h after extubation. MAIN OUTCOME MEASURES The difference in lung ultrasound score between groups at each interval. A higher score indicates worse lung aeration. RESULTS Patients in the lung-protective group exhibited lower median [IQR] ultrasound scores compared with the control group immediately after surgery, 4 [4 to 5] vs. 8 [4 to 6], (95% confidence interval for the difference between group values -4 to -4, Z = -6.324) and after extubation 3 [3 to 4] vs. 4 [4 to 4], 95% CI -1 to 0, Z = -3.161. This did not persist from 15 min after extubation onwards. Lung aeration returned to normal in both groups 3 h after extubation. CONCLUSIONS The reduced atelectasis provided by lung-protective ventilation does not persist from 15 min after extubation onwards. Further studies are needed to determine if it yields better results in other types of surgery. TRIAL REGISTRATION Chictr.org.cn (ChiCTR2000033469).
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Affiliation(s)
- Change Zhu
- From the Department of Anaesthesiology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China (CZ, SZ, JD, RW)
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Park S, Lee JH, Kim HJ, Choi H, Lee JR. Optimal positive end-expiratory pressure to prevent anaesthesia-induced atelectasis in infants: A prospective, randomised, double-blind trial. Eur J Anaesthesiol 2021; 38:1019-1025. [PMID: 33720065 DOI: 10.1097/eja.0000000000001483] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Paediatric patients have a particularly high incidence of anaesthesia-induced atelectasis. Applying positive end-expiratory pressure (PEEP) with an alveolar recruitment manoeuvre has been substantially studied and adopted in adults; however, few studies have been conducted in children. OBJECTIVE We compared the effects of three levels of PEEP (3, 6 and 9 cmH2O) on anaesthesia-induced atelectasis measured by ultrasound in infants between 6 and 12 months of age who were undergoing general anaesthesia. DESIGN A prospective, randomised, double-blind trial. SETTING Department of Anaesthesia, single centre, South Korea, from May 2019 to March 2020. PATIENTS Children who were 6 to 12 months of age, whose American Society of Anesthesiologists (ASA) physical status was 1 or 2, whose height and weight were within two standard deviations of those of their peers, and who were scheduled for elective urological or general surgery were included in the study. MAIN OUTCOME MEASURES The primary outcome was the lung ultrasound score at the end of the procedure. The secondary outcomes included dynamic compliance, peak inspiratory pressure, driving pressure, cardiac index, mean arterial pressure and heart rate before and after applying PEEP. RESULTS The mean lung ultrasound score at the end of operation was 12.8 at PEEP 6 cmH2O and 12.1 at PEEP 9 cmH2O. Both were significantly lower than 18.4 at PEEP 3 cmH2O (P = 0.0002 and 0.00003, respectively). However, there was no significant difference between the scores of PEEP 6 cmH2O and PEEP 9 cmH2O. The Δ cardiac index (the cardiac index after PEEP - the cardiac index at 3 cmH2O of PEEP) was comparable among the three groups. CONCLUSION To reduce anaesthesia-induced atelectasis measured by ultrasound in healthy infants undergoing low abdominal, genitourinary or superficial regional operations, 6 cmH2O of PEEP was more effective than 3 cmH2O. PEEP of 9 cmH2O was comparable with 6 cmH2O. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT03969173.
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Affiliation(s)
- Sujung Park
- From the Department of Anaesthesiology and Pain Medicine, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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Zanza C, Longhitano Y, Leo M, Romenskaya T, Franceschi F, Piccioni A, Pabon IM, Santarelli MT, Racca F. Practical Review of Mechanical Ventilation in Adults and Children in The Operating Room and Emergency Department. Rev Recent Clin Trials 2021; 17:20-33. [PMID: 34387167 DOI: 10.2174/1574887116666210812165615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/03/2021] [Accepted: 05/24/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND During general anesthesia, mechanical ventilation can cause pulmonary damage through mechanism of ventilator-induced lung injury which is a major cause of postoperative pulmonary complications, which varies between 5 and 33% and increases significantly the 30-day mortality of the surgical patient. OBJECTIVE The aim of this review is to analyze different variables which played key role in safe application of mechanical ventilation in the operating room and emergency setting. METHOD Also, we wanted to analyze different types of population that underwent intraoperative mechanical ventilation like obese patients, pediatric and adult population and different strategies such as one lung ventilation and ventilation in trendelemburg position. The peer-reviewed articles analyzed were selected according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) from Pubmed/Medline, Ovid/Wiley and Cochrane Library, combining key terms such as: "pulmonary post-operative complications", "protective ventilation", "alveolar recruitment maneuvers", "respiratory compliance", "intraoperative paediatric ventilation", "best peep", "types of ventilation". Among the 230 papers identified, 150 articles were selected, after title - abstract examination and removing the duplicates, resulting in 94 articles related to mechanical ventilation in operating room and emergency setting that were analyzed. RESULTS Careful preoperative patient's evaluation and protective ventilation (i.e. use of low tidal volumes, adequate PEEP and alveolar recruitment maneuvers) has been shown to be effective not only in limiting alveolar de-recruitment, alveolar overdistension and lung damage, but also in reducing the onset of pulmonary post-operative complications (PPCs). CONCLUSION Mechanical ventilation is like "Janus Bi-front" because it is essential for surgical procedures, for the care of critical care patients and in life-threatening conditions but it can be harmful to the patient if continued for a long time and where an excessive dose of oxygen is administered into the lungs. Low tidal volume is associated with minor rate of PPCs and other complications and every complication can increase length of Stay, adding cost to NHS between 1580 € and 1650 € per day in Europe and currently the prevention of PPCS is only weapon that we possess.
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Affiliation(s)
| | | | - Mirco Leo
- Department of Anesthesiology and Critical Care Medicine - AON SS Antonio e Biagio e Cesare Arrigo -Alessandria. Italy
| | - Tatsiana Romenskaya
- Department of Anesthesiology and Critical Care Medicine - AON SS Antonio e Biagio e Cesare Arrigo -Alessandria. Italy
| | - Francesco Franceschi
- Department of Emergency Medicine - Fondazione Policlinico A.Gemelli/Catholic University of Sacred Heart-Rome. Italy
| | - Andrea Piccioni
- Department of Emergency Medicine - Fondazione Policlinico A.Gemelli/Catholic University of Sacred Heart-Rome. Italy
| | - Ingrid Marcela Pabon
- Department of Emergency Medicine, Anesthesia and Critical Care Medicine- Michele and Pietro Ferrero Hospital- Verduno. Italy
| | | | - Fabrizio Racca
- Department of Anesthesiology and Critical Care Medicine - AON SS Antonio e Biagio e Cesare Arrigo -Alessandria. Italy
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Griffiths M, Everson J, Mandour Y. Should positive end-expiratory pressure be used during elective general anaesthesia with supraglottic airway devices? Br J Hosp Med (Lond) 2021; 82:1-2. [PMID: 34431349 DOI: 10.12968/hmed.2021.0178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Anaesthetists' use of positive end-expiratory pressure during elective general anaesthesia via supraglottic airway devices varies. Positive end-expiratory pressure may help to maintain oxygenation and prevent atelectasis, but could worsen the risk of air leak, gastric insufflation and catastrophic aspiration.
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Affiliation(s)
| | - James Everson
- Department of Anaesthesia, University College Hospital, London, UK
| | - Yasser Mandour
- Department of Anaesthesia, University College Hospital, London, UK
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Zhang C, Xu F, Li W, Tong X, Xia R, Wang W, Du J, Shi X. Driving Pressure-Guided Individualized Positive End-Expiratory Pressure in Abdominal Surgery: A Randomized Controlled Trial. Anesth Analg 2021; 133:1197-1205. [PMID: 34125080 DOI: 10.1213/ane.0000000000005575] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The optimal positive end-expiratory pressure (PEEP) to prevent postoperative pulmonary complications (PPCs) remains unclear. Recent evidence showed that driving pressure was closely related to PPCs. In this study, we tested the hypothesis that an individualized PEEP guided by minimum driving pressure during abdominal surgery would reduce the incidence of PPCs. METHODS This single-centered, randomized controlled trial included a total of 148 patients scheduled for open upper abdominal surgery. Patients were randomly assigned to receive an individualized PEEP guided by minimum driving pressure or an empiric fixed PEEP of 6 cm H2O. The primary outcome was the incidence of clinically significant PPCs within the first 7 days after surgery, using a χ2 test. Secondary outcomes were the severity of PPCs, the area of atelectasis, and pleural effusion. Other outcomes, such as the incidence of different types of PPCs (including hypoxemia, atelectasis, pleural effusion, dyspnea, pneumonia, pneumothorax, and acute respiratory distress syndrome), intensive care unit (ICU) admission rate, length of hospital stay, and 30-day mortality were also explored. RESULTS The median value of PEEP in the individualized group was 10 cm H2O. The incidence of clinically significant PPCs was significantly lower in the individualized PEEP group compared with that in the fixed PEEP group (26 of 67 [38.8%] vs 42 of 67 [62.7%], relative risk = 0.619, 95% confidence intervals, 0.435-0.881; P = .006). The overall severity of PPCs and the area of atelectasis were also significantly diminished in the individualized PEEP group. Higher respiratory compliance during surgery and improved intra- and postoperative oxygenation was observed in the individualized group. No significant differences were found in other outcomes between the 2 groups, such as ICU admission rate or 30-day mortality. CONCLUSIONS The application of individualized PEEP based on minimum driving pressure may effectively decrease the severity of atelectasis, improve oxygenation, and reduce the incidence of clinically significant PPCs after open upper abdominal surgery.
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Affiliation(s)
- Chengmi Zhang
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Fengying Xu
- Department of Anesthesiology, No. 971 Hospital of People's Liberation Army Navy, Qingdao, China
| | - Weiwei Li
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xingyu Tong
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ran Xia
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wei Wang
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jianer Du
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xueyin Shi
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
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Zhang Y, Zhang M, Wang X, Shang G, Dong Y. Individualized positive end-expiratory pressure in patients undergoing thoracoscopic lobectomy: a randomized controlled trial. Braz J Anesthesiol 2021; 71:565-571. [PMID: 33895220 PMCID: PMC9373519 DOI: 10.1016/j.bjane.2021.04.001] [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: 12/23/2019] [Revised: 03/21/2021] [Accepted: 04/02/2021] [Indexed: 11/29/2022] Open
Abstract
Background and objectives With the intensive study of lung protective ventilation strategies, people begin to advocate the individualized application of positive end-expiratory pressure (PEEP). This study investigated the optimal PEEP in patients during one-lung ventilation (OLV) and its effects on pulmonary mechanics and oxygenation. Methods Fifty-eight patients who underwent elective thoracoscopic lobectomy were randomly divided into two groups. Both groups received an alveolar recruitment maneuver (ARM) after OLV. Patients in Group A received optimal PEEP followed by PEEP decremental titration, while Group B received standard 5 cmH2O PEEP until the end of OLV. Relevant indexes of respiratory mechanics, pulmonary oxygenation and hemodynamics were recorded after entering the operating room (T0), 10 minutes after intubation (T1), pre-ARM (T2), 20 minutes after the application of optimal PEEP (T3), at the end of OLV (T4) and at the end of surgery (T5). Postoperative outcomes were also assessed. Results The optimal PEEP obtained in Group A was 8.8 ± 2.4 cmH2O, which positively correlated with BMI and forced vital capacity (FVC). Group A had a higher CPAT than Group B at T3, T4, T5 (p < 0.05) and a smaller ΔP than Group B at T3, T4 (p < 0.01). At T4, PaO2 was significantly higher in Group A (p < 0.01). At T3, stroke volume variation was higher in Group A (p < 0.01). Postoperative outcomes did not differ between the two groups. Conclusions Our findings suggest that the individualized PEEP can increase lung compliance, reduce driving pressure, and improve pulmonary oxygenation in patients undergoing thoracoscopic lobectomy, with little effect on hemodynamics.
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Affiliation(s)
- Yuying Zhang
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Meng Zhang
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xu'an Wang
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Gaocheng Shang
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Youjing Dong
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China.
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A Lower Tidal Volume Regimen during One-lung Ventilation for Lung Resection Surgery Is Not Associated with Reduced Postoperative Pulmonary Complications. Anesthesiology 2021; 134:562-576. [PMID: 33635945 DOI: 10.1097/aln.0000000000003729] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Protective ventilation may improve outcomes after major surgery. However, in the context of one-lung ventilation, such a strategy is incompletely defined. The authors hypothesized that a putative one-lung protective ventilation regimen would be independently associated with decreased odds of pulmonary complications after thoracic surgery. METHODS The authors merged Society of Thoracic Surgeons Database and Multicenter Perioperative Outcomes Group intraoperative data for lung resection procedures using one-lung ventilation across five institutions from 2012 to 2016. They defined one-lung protective ventilation as the combination of both median tidal volume 5 ml/kg or lower predicted body weight and positive end-expiratory pressure 5 cm H2O or greater. The primary outcome was a composite of 30-day major postoperative pulmonary complications. RESULTS A total of 3,232 cases were available for analysis. Tidal volumes decreased modestly during the study period (6.7 to 6.0 ml/kg; P < 0.001), and positive end-expiratory pressure increased from 4 to 5 cm H2O (P < 0.001). Despite increasing adoption of a "protective ventilation" strategy (5.7% in 2012 vs. 17.9% in 2016), the prevalence of pulmonary complications did not change significantly (11.4 to 15.7%; P = 0.147). In a propensity score matched cohort (381 matched pairs), protective ventilation (mean tidal volume 6.4 vs. 4.4 ml/kg) was not associated with a reduction in pulmonary complications (adjusted odds ratio, 0.86; 95% CI, 0.56 to 1.32). In an unmatched cohort, the authors were unable to define a specific alternative combination of positive end-expiratory pressure and tidal volume that was associated with decreased risk of pulmonary complications. CONCLUSIONS In this multicenter retrospective observational analysis of patients undergoing one-lung ventilation during thoracic surgery, the authors did not detect an independent association between a low tidal volume lung-protective ventilation regimen and a composite of postoperative pulmonary complications. EDITOR’S PERSPECTIVE
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Mini G, Ray BR, Anand RK, Muthiah T, Baidya DK, Rewari V, Sahni P, Maitra S. Effect of driving pressure-guided positive end-expiratory pressure (PEEP) titration on postoperative lung atelectasis in adult patients undergoing elective major abdominal surgery: A randomized controlled trial. Surgery 2021; 170:277-283. [PMID: 33771357 DOI: 10.1016/j.surg.2021.01.047] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/22/2021] [Accepted: 01/28/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND As respiratory system compliances are heterogenous, we hypothesized that individualized intraoperative positive end-expiratory pressure titration on the basis of lowest driving pressure can reduce postoperative atelectasis and improve intraoperative oxygenation and postoperative lung functions. METHODS Eighty-two adult patients undergoing major abdominal surgery were recruited in this randomized trial. In the titrated positive end-expiratory pressure group, positive end-expiratory pressure was titrated incrementally until lowest driving pressure was achieved, and the same procedure was repeated in every 2 hours. In the fixed positive end-expiratory pressure group, a positive end-expiratory pressure of 5 cmH2O was used throughout the surgery. The primary objective of this study was lung ultrasound score noted at the completion of surgery and 5 minutes after extubation at 12 lung areas bilaterally. RESULTS Mean (standard deviation) age of the recruited patients were 43.8 (17.3) years, and 50% of all patients (41 of 82) were women. Lung ultrasound aeration scores were significantly higher in the fixed positive end-expiratory pressure group both before and after extubation (median [interquartile range] 7 [5-8] vs 4 [2-6] before extubation and 8 [6-9] vs 5 [3-7] after extubation; P = .0004 and P = .0011, respectively). Incidence of postoperative pulmonary complications was significantly lower in the titrated positive end-expiratory pressure group (absolute risk difference [95% CI] 17.1% [32.5%-1.7%]; P = .034). The number of patients requiring postoperative supplemental oxygen therapy to maintain SpO2 >95%, the requirement of intraoperative rescue therapy, and the duration of hospital stay were similar in both of the groups. CONCLUSION Intraoperative titrated positive end-expiratory pressure reduced postoperative lung atelectasis in adult patients undergoing major abdominal surgery. Further large clinical trials are required to know its effect on postoperative pulmonary complications.
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Affiliation(s)
- Gouri Mini
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Bikash R Ray
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Rahul K Anand
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Thilaka Muthiah
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Dalim K Baidya
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Vimi Rewari
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Peush Sahni
- Department of GI Surgery & Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Souvik Maitra
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India.
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Yoon HK, Kim BR, Yoon S, Jeong YH, Ku JH, Kim WH. The Effect of Ventilation with Individualized Positive End-Expiratory Pressure on Postoperative Atelectasis in Patients Undergoing Robot-Assisted Radical Prostatectomy: A Randomized Controlled Trial. J Clin Med 2021; 10:jcm10040850. [PMID: 33669526 PMCID: PMC7922101 DOI: 10.3390/jcm10040850] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 02/04/2021] [Accepted: 02/16/2021] [Indexed: 01/06/2023] Open
Abstract
For patients undergoing robot-assisted radical prostatectomy, the pneumoperitoneum with a steep Trendelenburg position could worsen intraoperative respiratory mechanics and result in postoperative atelectasis. We investigated the effects of individualized positive end-expiratory pressure (PEEP) on postoperative atelectasis, evaluated using lung ultrasonography. Sixty patients undergoing robot-assisted radical prostatectomy were randomly allocated into two groups. Individualized groups (n = 30) received individualized PEEP determined by a decremental PEEP trial using 20 to 7 cm H2O, aiming at maximizing respiratory compliance, whereas standardized groups (n = 30) received a standardized PEEP of 7 cm H2O during the pneumoperitoneum. Ultrasound examination was performed on 12 sections of thorax, and the lung ultrasound score was measured as 0–3 by considering the number of B lines and the degree of subpleural consolidation. The primary outcome was the difference between the lung ultrasound scores measured before anesthesia induction and just after extubation in the operating room. An increase in the difference means the development of atelectasis. The optimal PEEP in the individualized group was determined as the median (interquartile range) 14 (12–18) cm H2O. Compared with the standardized group, the difference in the lung ultrasound scores was significantly smaller in the individualized group (−0.5 ± 2.7 vs. 6.0 ± 2.9, mean difference −6.53, 95% confidence interval (−8.00 to −5.07), p < 0.001), which means that individualized PEEP was effective to reduce atelectasis. The lung ultrasound score measured after surgery was significantly lower in the individualized group than the standardized group (8.1 ± 5.7 vs. 12.2 ± 4.2, mean difference −4.13, 95% confidence interval (−6.74 to −1.53), p = 0.002). However, the arterial partial pressure of the oxygen/fraction of inspired oxygen levels during the surgery showed no significant time-group interaction between the two groups in repeated-measures analysis of variance (p = 0.145). The incidence of a composite of postoperative respiratory complications was comparable between the two groups. Individualized PEEP determined by maximal respiratory compliance during the pneumoperitoneum and steep Trendelenburg position significantly reduced postoperative atelectasis, as evaluated using lung ultrasonography. However, the clinical significance of this finding should be evaluated by a larger clinical trial.
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Affiliation(s)
- Hyun-Kyu Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, #101 Daehak-ro, Jongno-gu, Seoul 03080, Korea; (H.-K.Y.); (B.R.K.); (S.Y.); (Y.H.J.)
| | - Bo Rim Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, #101 Daehak-ro, Jongno-gu, Seoul 03080, Korea; (H.-K.Y.); (B.R.K.); (S.Y.); (Y.H.J.)
| | - Susie Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, #101 Daehak-ro, Jongno-gu, Seoul 03080, Korea; (H.-K.Y.); (B.R.K.); (S.Y.); (Y.H.J.)
| | - Young Hyun Jeong
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, #101 Daehak-ro, Jongno-gu, Seoul 03080, Korea; (H.-K.Y.); (B.R.K.); (S.Y.); (Y.H.J.)
| | - Ja Hyeon Ku
- Department of Urology, Seoul National University Hospital, Seoul National University College of Medicine, #101 Daehak-ro, Jongno-gu, Seoul 03080, Korea;
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, #101 Daehak-ro, Jongno-gu, Seoul 03080, Korea; (H.-K.Y.); (B.R.K.); (S.Y.); (Y.H.J.)
- Correspondence:
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Perioperative Open-lung Approach, Regional Ventilation, and Lung Injury in Cardiac Surgery. Anesthesiology 2020; 133:1029-1045. [PMID: 32902561 DOI: 10.1097/aln.0000000000003539] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND In the Protective Ventilation in Cardiac Surgery (PROVECS) randomized, controlled trial, an open-lung ventilation strategy did not improve postoperative respiratory outcomes after on-pump cardiac surgery. In this prespecified subanalysis, the authors aimed to assess the regional distribution of ventilation and plasma biomarkers of lung epithelial and endothelial injury produced by that strategy. METHODS Perioperative open-lung ventilation consisted of recruitment maneuvers, positive end-expiratory pressure (PEEP) = 8 cm H2O, and low-tidal volume ventilation including during cardiopulmonary bypass. Control ventilation strategy was a low-PEEP (2 cm H2O) low-tidal volume approach. Electrical impedance tomography was used serially throughout the perioperative period (n = 56) to compute the dorsal fraction of ventilation (defined as the ratio of dorsal tidal impedance variation to global tidal impedance variation). Lung injury was assessed serially using biomarkers of epithelial (soluble form of the receptor for advanced glycation end-products, sRAGE) and endothelial (angiopoietin-2) lung injury (n = 30). RESULTS Eighty-six patients (age = 64 ± 12 yr; EuroSCORE II = 1.65 ± 1.57%) undergoing elective on-pump cardiac surgery were studied. Induction of general anesthesia was associated with ventral redistribution of tidal volumes and higher dorsal fraction of ventilation in the open-lung than the control strategy (0.38 ± 0.07 vs. 0.30 ± 0.10; P = 0.004). No effect of the open-lung strategy on the dorsal fraction of ventilation was noted at the end of surgery after median sternotomy closure (open-lung = 0.37 ± 0.09 vs. control = 0.34 ± 0.11; P = 0.743) or in extubated patients at postoperative day 2 (open-lung = 0.63 ± 0.18 vs. control = 0.59 ± 0.11; P > 0.999). Open-lung ventilation was associated with increased intraoperative plasma sRAGE (7,677 ± 3,097 pg/ml vs. 6,125 ± 1,400 pg/ml; P = 0.037) and had no effect on angiopoietin-2 (P > 0.999). CONCLUSIONS In cardiac surgery patients, open-lung ventilation provided larger dorsal lung ventilation early during surgery without a maintained benefit as compared with controls at the end of surgery and postoperative day 2 and was associated with higher intraoperative plasma concentration of sRAGE suggesting lung overdistension. EDITOR’S PERSPECTIVE
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Effects of high-flow nasal oxygen during prolonged deep sedation on postprocedural atelectasis: A randomised controlled trial. Eur J Anaesthesiol 2020; 37:1025-1031. [PMID: 32890016 DOI: 10.1097/eja.0000000000001324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Atelectasis is common in patients undergoing prolonged deep sedation outside the operating theatre. High-flow nasal oxygen (HFNO) produces positive airway pressure which, hypothetically, should improve lung atelectasis, but this has not been investigated. OBJECTIVE We investigated whether HFNO ameliorates postprocedural atelectasis and compared the influences of HFNO and facial oxygen by mask on postprocedural outcomes. DESIGN A single-blind, open-label single-institution randomised controlled trial. SETTING A single university hospital, from February 2017 to July 2019. PATIENTS A total of 59 patients undergoing computed tomography (CT)-guided hepatic tumour radiofrequency ablation were randomly allocated to two groups. INTERVENTION These patients randomly received HFNO (oxygen flow 10 l min before sedation and 50 l min during the procedure) or a conventional oxygen face mask (oxygen flow 10 l min) during the procedure. MAIN OUTCOME MEASURES Changes in the area of lung atelectasis calculated on the basis of chest CT images and also recovery profiles were compared between the two groups. RESULTS The two groups had comparable procedural profiles, but the HFNO group exhibited less postprocedural atelectasis than the face mask group (median [IQR] 7.4 [3.9 to 11.4%] vs. 10.5 [7.2 to 14.6%]; P = 0.0313). However, the numbers of patients requiring oxygen supplementation in the recovery room and during transport from the recovery room to the ward did not differ significantly between groups (24.1 vs. 50.0%; P = 0.0596). CONCLUSION Our results suggested that HFNO ameliorates lung atelectasis after prolonged deep sedation in patients receiving CT-guided hepatic tumour radiofrequency ablation. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT03019354.
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Xie C, Sun K, You Y, Ming Y, Yu X, Yu L, Huang J, Yan M. Feasibility and efficacy of lung ultrasound to investigate pulmonary complications in patients who developed postoperative Hypoxaemia-a prospective study. BMC Anesthesiol 2020; 20:220. [PMID: 32873237 PMCID: PMC7461251 DOI: 10.1186/s12871-020-01123-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 08/09/2020] [Indexed: 12/18/2022] Open
Abstract
Background Postoperative pulmonary complications (PPCs) and hypoxaemia are associated with morbidity and mortality. We aimed to evaluate the feasibility and efficacy of lung ultrasound (LUS) to diagnose PPCs in patients suffering from hypoxaemia after general anaesthesia and compare the results to those of thoracic computed tomography (CT). Methods Adult patients who received general anaesthesia and suffered from hypoxaemia in the postanaesthesia care unit (PACU) were analysed. Hypoxaemia was defined as an oxygen saturation measured by pulse oximetry (SPO2) less than 92% for more than 30 s under ambient air conditions. LUS was performed by two trained anaesthesiologists once hypoxaemia occurred. After LUS examination, each patient was transported to the radiology department for thoracic CT scan within 1 h before returning to the ward. Results From January 2019 to May 2019, 113 patients (61 men) undergoing abdominal surgery (45 patients, 39.8%), video-assisted thoracic surgery (31 patients, 27.4%), major orthopaedic surgery (17 patients, 15.0%), neurosurgery (10 patients, 8.8%) or other surgery (10 patients, 8.8%) were included. CT diagnosed 327 of 1356 lung zones as atelectasis, while LUS revealed atelectasis in 311 of the CT-confirmed zones. Pneumothorax was detected by CT scan in 75 quadrants, 72 of which were detected by LUS. Pleural effusion was diagnosed in 144 zones on CT scan, and LUS detected 131 of these zones. LUS was reliable in diagnosing atelectasis (sensitivity 98.0%, specificity 96.7% and diagnostic accuracy 97.2%), pneumothorax (sensitivity 90.0%, specificity 98.9% and diagnostic accuracy 96.7%) and pleural effusion (sensitivity 92.9%, specificity 96.0% and diagnostic accuracy 95.1%). Conclusions Lung ultrasound is feasible, efficient and accurate in diagnosing different aetiologies of postoperative hypoxia in healthy-weight patients in the PACU. Trial registration Current Controlled Trials NCT03802175, 2018/12/05, www.ClinicalTrials.gov
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Affiliation(s)
- Chen Xie
- Department of Anesthesiology and Pain Medicine, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou, 310016, People's Republic of China
| | - Kai Sun
- Department of Anesthesiology and Pain Medicine, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou, 310016, People's Republic of China
| | - Yueyang You
- Department of Anesthesiology and Pain Medicine, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou, 310016, People's Republic of China
| | - Yue Ming
- Department of Anesthesiology and Pain Medicine, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou, 310016, People's Republic of China
| | - Xiaoling Yu
- Department of Anesthesiology and Pain Medicine, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou, 310016, People's Republic of China
| | - Lina Yu
- Department of Anesthesiology and Pain Medicine, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou, 310016, People's Republic of China
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY, 40202, USA
| | - Min Yan
- Department of Anesthesiology and Pain Medicine, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou, 310016, People's Republic of China. .,Department of Anesthesiology and Pain Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, NO, China.
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Individualized PEEP ventilation between tumor resection and dural suture in craniotomy. Clin Neurol Neurosurg 2020; 196:106027. [PMID: 32673939 DOI: 10.1016/j.clineuro.2020.106027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/03/2020] [Accepted: 06/14/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Atelectasis, which affects oxygenation, is always occurred after craniotomy under general anesthesia. The commonly used protective ventilation strategy, which includes recruitment maneuver and higher level of positive end-expiratory pressure (PEEP), can effectively reduce atelectasis after heart and abdominal surgery, but increase intracranial pressure and reduce cerebral perfusion in patients undergoing craniotomy. We hypothesized individualized PEEP ventilation between tumor resection and dural suture in craniotomy could effectively reduce postoperative atelectasis, improve PaO2/FiO2 ratio, and without reducing the regional cerebral oxygen saturation (rScO2). PATIENTS AND METHODS 96 patients underwent tumor craniotomy in supine position were randomized into the control group (C group) and individualized PEEP group (P group). In the C group, the tidal volume (VT) was set at 8 mL/kg of predicted body weight, but PEEP were not used. In the P group, VT was set at 6 mL/kg of predicted body weight combined with individualized PEEP between tumor resection and dural suture, while in other periods of general anesthesia, VT was set at 8 mL/kg of predicted body weight. PaO2/FiO2 ratio, lung ultrasound score (LUS) and rScO2 were measured before induction, 1 h and 24 h after extubation. RESULTS Individual PEEP in the P group was 7.0 (4.0-9.0). The PaO2/FiO2 ratio and rScO2 in the P group were significantly higher than that of the C group (395 ± 62 vs. 344 ± 40, 67 ± 5 vs. 61 ± 4, respectively, p < 0.05) and the LUS of the experimental group was significantly lower than that of the C group [7.5 (5.3-8.3) vs. 10.0 (9.0-12.0), p < 0.05] 1 h after extubation. CONCLUSION Mechanical ventilation with individualized PEEP between tumor resection and dural suture in craniotomy can reduce atelectasis, improve PaO2/FiO2 ratio and rScO2 1 h after extubation.
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Fernandez-Bustamante A, Sprung J, Parker RA, Bartels K, Weingarten TN, Kosour C, Thompson BT, Vidal Melo MF. Individualized PEEP to optimise respiratory mechanics during abdominal surgery: a pilot randomised controlled trial. Br J Anaesth 2020; 125:383-392. [PMID: 32682559 DOI: 10.1016/j.bja.2020.06.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 05/24/2020] [Accepted: 06/10/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Higher intraoperative driving pressures (ΔP) are associated with increased postoperative pulmonary complications (PPC). We hypothesised that dynamic adjustment of PEEP throughout abdominal surgery reduces ΔP, maintains positive end-expiratory transpulmonary pressures (Ptp_ee) and increases respiratory system static compliance (Crs) with PEEP levels that are variable between and within patients. METHODS In a prospective multicentre pilot study, adults at moderate/high risk for PPC undergoing elective abdominal surgery were randomised to one of three ventilation protocols: (1) PEEP≤2 cm H2O, compared with periodic recruitment manoeuvres followed by individualised PEEP to either optimise respiratory system compliance (PEEPmaxCrs) or maintain positive end-expiratory transpulmonary pressure (PEEPPtp_ee). The composite primary outcome included intraoperative ΔP, Ptp_ee, Crs, and PEEP values (median (interquartile range) and coefficients of variation [CVPEEP]). RESULTS Thirty-seven patients (48.6% female; age range: 47-73 yr) were assigned to control (PEEP≤2 cm H2O; n=13), PEEPmaxCrs (n=16), or PEEPPtp_ee (n=8) groups. The PEEPPtp_ee intervention could not be delivered in two patients. Subjects assigned to PEEPmaxCrs had lower ΔP (median8 cm H2O [7-10]), compared with the control group (12 cm H2O [10-15]; P=0.006). PEEPmaxCrs was also associated with higher Ptp_ee (2.0 cm H2O [-0.7 to 4.5] vs controls: -8.3 cm H2O [-13.0 to -4.0]; P≤0.001) and higher Crs (47.7 ml cm H2O [43.2-68.8] vs controls: 39.0 ml cm H2O [32.9-43.4]; P=0.009). Individualised PEEP (PEEPmaxCrs and PEEPPtp_ee combined) varied widely (median: 10 cm H2O [8-15]; CVPEEP=0.24 [0.14-0.35]), both between, and within, subjects throughout surgery. CONCLUSIONS This pilot study suggests that individualised PEEP management strategies applied during abdominal surgery reduce driving pressure, maintain positive Ptp_ee and increase static compliance. The wide range of PEEP observed suggests that an individualised approach is required to optimise respiratory mechanics during abdominal surgery. CLINICAL TRIAL REGISTRATION NCT02671721.
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Affiliation(s)
- Ana Fernandez-Bustamante
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA; Webb-Waring Center, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Robert A Parker
- Department of Medicine, Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Karsten Bartels
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Carolina Kosour
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Department of 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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Effect of positive end-expiratory pressure on gastric insufflation during induction of anaesthesia when using pressure-controlled ventilation via a face mask: A randomised controlled trial. Eur J Anaesthesiol 2020; 36:625-632. [PMID: 31116114 PMCID: PMC6688779 DOI: 10.1097/eja.0000000000001016] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Face mask ventilation (FMV) during induction of anaesthesia is associated with risk of gastric insufflation that may lead to gastric regurgitation and pulmonary aspiration. A continuous positive airway pressure (CPAP) has been shown to reduce gastric regurgitation. We therefore hypothesised that CPAP followed by FMV with positive end-expiratory pressure (PEEP) during induction of anaesthesia would reduce the risk of gastric insufflation. OBJECTIVE The primary aim was to compare the incidence of gastric insufflation during FMV with a fixed PEEP level or zero PEEP (ZEEP) after anaesthesia induction. A secondary aim was to investigate the effects of FMV with or without PEEP on upper oesophageal sphincter (UES), oesophageal body and lower oesophageal sphincter (LES) pressures. DESIGN A randomised controlled trial. SETTING Single centre, Department of Anaesthesia and Intensive Care, Örebro University Hospital, Sweden. PARTICIPANTS Thirty healthy volunteers. INTERVENTIONS Pre-oxygenation without or with CPAP 10 cmH2O, followed by pressure-controlled FMV with either ZEEP or PEEP 10 cmH2O after anaesthesia induction. MAIN OUTCOME MEASURES A combined impedance/manometry catheter was used to detect the presence of gas and to measure oesophageal pressures. The primary outcome measure was the cumulative incidence of gastric insufflation, defined as a sudden anterograde increase in impedance of more than 1 kΩ over the LES. Secondary outcome measures were UES, oesophageal body and LES pressures. RESULTS The cumulative incidence of gastric insufflation related to peak inspiratory pressure (PIP), was significantly higher in the PEEP group compared with the ZEEP group (log-rank test P < 0.01). When PIP reached 30 cmH2O, 13 out of 15 in the PEEP group compared with five out of 15 had shown gastric insufflation. There was a significant reduction of oesophageal sphincter pressures within groups comparing pre-oxygenation to after anaesthesia induction, but there were no significant differences in oesophageal sphincter pressures related to the level of PEEP. CONCLUSION Contrary to the primary hypothesis, with increasing PIP the tested PEEP level did not protect against but facilitated gastric insufflation during FMV. This result suggests that PEEP should be used with caution after anaesthesia induction during FMV, whereas CPAP during pre-oxygenation seems to be safe. TRIAL REGISTRATION ClinicalTrials.gov, identifier: NCT02238691.
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Effects of intra-operative positive end-expiratory pressure setting guided by oesophageal pressure measurement on oxygenation and respiratory mechanics during laparoscopic gynaecological surgery: A randomised controlled trial. Eur J Anaesthesiol 2020; 37:1032-1039. [PMID: 32371830 DOI: 10.1097/eja.0000000000001204] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The creation of pneumoperitoneum during laparoscopic surgery can lead to adverse effects on the respiratory system. Positive end-expiratory pressure (PEEP) plays an important role in mechanical ventilation during laparoscopic surgery. OBJECTIVE To evaluate whether PEEP setting guided by oesophageal pressure (Poeso) measurement would affect oxygenation and respiratory mechanics during laparoscopic gynaecological surgery. DESIGN A randomised controlled study. SETTING A single-centre trial from March 2018 to June 2018. PATIENTS Forty-four adult patients undergoing laparoscopic gynaecological surgery with anticipated duration of surgery more than 2 h. INTERVENTION PEEP set according to Poeso measurement (intervention group) versus PEEP constantly set at 5 cmH2O (control group). MAIN OUTCOME MEASURES Gas exchange and respiratory mechanics after induction and intubation (T0) and at 15 and 60 min after initiation of pneumoperitoneum (T1 and T2, respectively). RESULTS PEEP during pneumoperitoneum was significantly higher in the intervention group than in the control group (T1, 12.5 ± 1.9 vs. 5.0 ± 0.0 cmH2O and T2, 12.4 ± 1.9 vs. 5.0 ± 0.0 cmH2O, both P < 0.001). Partial pressures of oxygen decreased significantly from baseline during pneumoperitoneum in the control group but not in the intervention group. Nevertheless, the changes in partial pressures of oxygen did not differ between groups. Compliance of the respiratory system (CRS) significantly decreased and driving pressure significantly increased during pneumoperitoneum in both groups. However, the changes in CRS and driving pressure were significantly less in the intervention group. Transpulmonary pressure during expiration was maintained in the intervention group while it decreased significantly in the control group. CONCLUSION PEEP setting guided by Poeso measurement showed no beneficial effects in terms of oxygenation but respiratory mechanics were better during laparoscopic gynaecological surgery. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03256396.
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Hedenstierna G, Tokics L, Reinius H, Rothen HU, Östberg E, Öhrvik J. Higher age and obesity limit atelectasis formation during anaesthesia: an analysis of computed tomography data in 243 subjects. Br J Anaesth 2020; 124:336-344. [DOI: 10.1016/j.bja.2019.11.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 10/29/2019] [Accepted: 11/23/2019] [Indexed: 11/30/2022] Open
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Nekhendzy V, Saxena A, Mittal B, Sun E, Sung K, Dewan K, Damrose EJ. The Safety and Efficacy of Transnasal Humidified Rapid-Insufflation Ventilatory Exchange for Laryngologic Surgery. Laryngoscope 2020; 130:E874-E881. [PMID: 32078170 DOI: 10.1002/lary.28562] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 01/22/2020] [Accepted: 01/26/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) is an intraoperative ventilatory technique that allows avoidance of tracheal intubation (TI) or jet ventilation (JV) in selected laryngologic surgical cases. Unimpeded access to all parts of the glottis may improve surgical precision, decrease operative time, and potentially improve patient outcomes. The objective of this prospective, randomized, patient-blinded, 2-arm parallel pilot trial was to investigate the safety and efficacy of THRIVE use for adult patients undergoing nonlaser laryngologic surgery of short-to-intermediate duration. METHODS Twenty adult, American society of anesthesiology class 1-3 patients with body mass index (BMI) < 35 kg/m2 were randomly assigned to either an experimental THRIVE group or active comparator conventional ventilation group (TI or supraglottic high-frequency JV [SHFJV]). Primary outcomes included intraoperative oxygenation, anesthesia awakening/extubation time, time to laryngoscopic suspension, number of intraoperative suspension adjustments, and operative time. Secondary patient outcomes including postanesthesia and functional patient recovery were investigated. RESULTS Compared to TI/SHFJV, THRIVE use was associated with significantly lower intraoperative oxygenation (SpO2 93.0 ± 5.6% vs. 98.7 ± 1.6%), shorter time to suspension (1.8 ± 1.1 minutes vs. 4.3 ± 2.1 minutes), fewer suspension adjustments (0.4 ± 0.5 vs. 1.7 ± 0.9), and lower postoperative pain scores on recovery room admission (1.3 ± 1.9 vs. 3.7 ± 2.9) and discharge (0.9 ± 1.3 vs. 2.7 ± 1.8). The study was underpowered to detect other possible outcome differences. CONCLUSION We confirm the safe intraoperative oxygenation profile of THRIVE for selected patients undergoing nonlaser laryngologic surgery of short-to-intermediate duration. THRIVE facilitated surgical exposure and improved early patient recovery, suggesting a potential economic benefit for outpatient laryngologic procedures. The results of this exploratory study provide a framework for designing future adequately powered THRIVE trials. TRIAL REGISTER ClinicalTrials.gov (NCT03091179). LEVEL OF EVIDENCE II Laryngoscope, 2020.
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Affiliation(s)
- Vladimir Nekhendzy
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Stanford, CA, USA.,Otolaryngology-Head and Neck Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Amit Saxena
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Stanford, CA, USA
| | - Brita Mittal
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Stanford, CA, USA
| | - Eric Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Stanford, CA, USA
| | - Kwang Sung
- Otolaryngology-Head and Neck Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Karuna Dewan
- Otolaryngology-Head and Neck Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Edward J Damrose
- Otolaryngology-Head and Neck Surgery, Stanford University Medical Center, Stanford, CA, USA
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Généreux V, Chassé M, Girard F, Massicotte N, Chartrand-Lefebvre C, Girard M. Effects of positive end-expiratory pressure/recruitment manoeuvres compared with zero end-expiratory pressure on atelectasis during open gynaecological surgery as assessed by ultrasonography: a randomised controlled trial. Br J Anaesth 2020; 124:101-109. [DOI: 10.1016/j.bja.2019.09.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 09/17/2019] [Accepted: 09/23/2019] [Indexed: 12/22/2022] Open
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Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations. Br J Anaesth 2019; 123:898-913. [DOI: 10.1016/j.bja.2019.08.017] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/22/2019] [Accepted: 08/04/2019] [Indexed: 12/16/2022] Open
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García-Sanz V, Aguado D, Gómez de Segura IA, Canfrán S. Comparative effects of open-lung positive end-expiratory pressure (PEEP) and fixed PEEP on respiratory system compliance in the isoflurane anaesthetised healthy dog. Res Vet Sci 2019; 127:91-98. [PMID: 31683197 DOI: 10.1016/j.rvsc.2019.10.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 12/18/2022]
Abstract
This study was performed to assess the effects of open-lung positive end-expiratory pressure (OL-PEEP) following stepwise recruitment manoeuvre (RM) and those of a fixed PEEP of 5 cm H2O without previous RM on respiratory system compliance (Crs) and selected cardiovascular variables in healthy dogs under general anaesthesia. Forty-five healthy client-owned dogs undergoing surgery were anaesthetised and mechanically ventilated (tidal volume, VT = 10-12 mL/kg; PEEP = 0 cm H2O) for 1 min (baseline) and randomly allocated into zero positive end-expiratory pressure (ZEEP), PEEP (5 cm H2O) and OL-PEEP treatment groups. In the OL-PEEP group, a stepwise RM was performed and the individual OL-PEEP was subsequently applied. The Crs, heart rate (HR) and non-invasive mean arterial pressure (NIMAP) were registered at baseline and then every 10 min during 60 min. In the ZEEP group, Crs decreased from baseline. In the PEEP group, Crs was not different from either baseline or ZEEP group values. In the OL-PEEP group, Crs was higher than both baseline and ZEEP group values at all time points as well as of those in the PEEP group during at least 20 min after RM. There were no differences for HR and NIMAP between groups. A clinically relevant hypotension following RM was observed in 40% of dogs. Therefore, an individually set OL-PEEP following stepwise RM improved Crs in anaesthetised healthy dogs, although transient but clinically relevant hypotension was observed during RM in some dogs. Fixed PEEP of 5 cm H2O without previous RM did not improve Crs, although it prevented it from decreasing.
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Affiliation(s)
- Virginia García-Sanz
- Anaesthesiology Service, Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Avda. Puerta de Hierro s/n, 28040 Madrid, Spain.
| | - Delia Aguado
- Anaesthesiology Service, Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Avda. Puerta de Hierro s/n, 28040 Madrid, Spain.
| | - Ignacio A Gómez de Segura
- Anaesthesiology Service, Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Avda. Puerta de Hierro s/n, 28040 Madrid, Spain.
| | - Susana Canfrán
- Anaesthesiology Service, Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Avda. Puerta de Hierro s/n, 28040 Madrid, Spain.
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Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Positive end-expiratory pressure (PEEP) increases lung volume and protects against alveolar collapse during anesthesia. During emergence, safety preoxygenation preparatory to extubation makes the lung susceptible to gas absorption and alveolar collapse, especially in dependent regions being kept open by PEEP. We hypothesized that withdrawing PEEP before starting emergence preoxygenation would limit postoperative atelectasis formation.
Methods
This was a randomized controlled evaluator-blinded trial in 30 healthy patients undergoing nonabdominal surgery under general anesthesia and mechanical ventilation with PEEP 7 or 9 cm H2O depending on body mass index. A computed tomography scan at the end of surgery assessed baseline atelectasis. The study subjects were thereafter allocated to either maintained PEEP (n = 16) or zero PEEP (n = 14) during emergence preoxygenation. The primary outcome was change in atelectasis area as evaluated by a second computed tomography scan 30 min after extubation. Oxygenation was assessed by arterial blood gases.
Results
Baseline atelectasis was small and increased modestly during awakening, with no statistically significant difference between groups. With PEEP applied during awakening, the increase in atelectasis area was median (range) 1.6 (−1.1 to 12.3) cm2 and without PEEP 2.3 (−1.6 to 7.8) cm2. The difference was 0.7 cm2 (95% CI, −0.8 to 2.9 cm2; P = 0.400). Postoperative atelectasis for all patients was median 5.2 cm2 (95% CI, 4.3 to 5.7 cm2), corresponding to median 2.5% of the total lung area (95% CI, 2.0 to 3.0%). Postoperative oxygenation was unchanged in both groups when compared to oxygenation in the preoperative awake state.
Conclusions
Withdrawing PEEP before emergence preoxygenation does not reduce atelectasis formation after nonabdominal surgery. Despite using 100% oxygen during awakening, postoperative atelectasis is small and does not affect oxygenation, possibly conditional on an open lung during anesthesia, as achieved by intraoperative PEEP.
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Zhang P, Wu L, Shi X, Zhou H, Liu M, Chen Y, Lv X. Positive End-Expiratory Pressure During Anesthesia for Prevention of Postoperative Pulmonary Complications: A Meta-analysis With Trial Sequential Analysis of Randomized Controlled Trials. Anesth Analg 2019; 130:879-889. [PMID: 31567322 DOI: 10.1213/ane.0000000000004421] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Whether intraoperative positive end-expiratory pressure (PEEP) can reduce the risk of postoperative pulmonary complications remains controversial. We performed a systematic review of currently available literature to investigate whether intraoperative PEEP decreases pulmonary complications in anesthetized patients undergoing surgery. METHODS We searched PubMed, Embase, and the Cochrane Library to identify randomized controlled trials (RCTs) that compared intraoperative PEEP versus zero PEEP (ZEEP) for postoperative pulmonary complications in adults. The prespecified primary outcome was postoperative pulmonary atelectasis. RESULTS Fourteen RCTs enrolling 1238 patients met the inclusion criteria. Meta-analysis using a random-effects model showed a decrease in postoperative atelectasis (relative risk [RR], 0.51; 95% confidence interval [CI], 0.35-0.76; trial sequential analyses [TSA]-adjusted CI, 0.10-2.55) and postoperative pneumonia (RR, 0.48; 95% CI, 0.27-0.84; TSA-adjusted CI, 0.05-4.86) in patients receiving PEEP ventilation. However, TSA showed that the cumulative Z-curve of 2 outcomes crossed the conventional boundary but did not cross the trial sequential monitoring boundary, indicating a possible false-positive result. We observed no effect of PEEP versus ZEEP ventilation on postoperative mortality (RR, 1.78; 95% CI, 0.55-5.70). CONCLUSIONS The evidence that intraoperative PEEP reduces postoperative pulmonary complications is suggestive but too unreliable to allow definitive conclusions to be drawn.
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Affiliation(s)
- Pengcheng Zhang
- From the Department of Anesthesiology, The First Hospital of Anhui Medical University, Hefei, China
| | - Lingmin Wu
- From the Department of Anesthesiology, The First Hospital of Anhui Medical University, Hefei, China
| | - Xuan Shi
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Huanping Zhou
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Meiyun Liu
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yuanli Chen
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xin Lv
- From the Department of Anesthesiology, The First Hospital of Anhui Medical University, Hefei, China.,Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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Wang ZG, Sun JR, Sha HW. Efficacy of ventilator for patients with atelectasis: A systematic review protocol of randomized controlled trials. Medicine (Baltimore) 2019; 98:e17259. [PMID: 31574839 PMCID: PMC6775436 DOI: 10.1097/md.0000000000017259] [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] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND This study aims to assess the efficacy and safety of ventilator for the treatment of atelectasis. METHODS We will search Cochrane Library, MEDLINE, EMBASE, CINAHL, EBSCO, Chinese database Chinese Biomedical Literature Database, China National Knowledge Infrastructure, and Wanfang data from inceptions to June 30, 2019 without language limitations. We will include randomized controlled trials (RCTs) of ventilator on evaluating the efficacy and safety of ventilator for atelectasis. We will use Cochrane risk of bias tool to assess the methodological quality for all included RCTs. RevMan 5.3 software will be used for statistical analysis. RESULTS The primary outcome is lung function. The secondary outcomes comprise of airway pressure, mean arterial pressure, arterial blood gas, heart rate, respiratory rate, oxygen saturation, and adverse events. CONCLUSION The findings of this study will provide most recent evidence of ventilator for the treatment of atelectasis. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019139329.
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Affiliation(s)
- Zhi-Guo Wang
- Department of Elderly Respiratory Medicine, Cardiovascular and Cerebrovascular Specialist Ward Affiliated to Yanan University
| | - Jian-Rong Sun
- Department of Elderly Respiratory Medicine, Dongguan Hospital of Yanan University Affiliated Hospital
| | - Hai-Wang Sha
- Surgical Intensive Care Center, Yanan University Affiliated Hospital, Yan’an, China
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Affiliation(s)
- Karen B Domino
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
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Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Anesthesia is increasingly common in elderly and overweight patients and prompted the current study to explore mechanisms of age- and weight-dependent worsening of arterial oxygen tension (Pao2).
Methods
This is a primary analysis of pooled data in patients with (1) American Society of Anesthesiologists (ASA) classification of 1; (2) normal forced vital capacity; (3) preoxygenation with an inspired oxygen fraction (Fio2) more than 0.8 and ventilated with Fio2 0.3 to 0.4; (4) measurements done during anesthesia before surgery. Eighty patients (21 women and 59 men, aged 19 to 69 yr, body mass index up to 30 kg/m2) were studied with multiple inert gas elimination technique to assess shunt and perfusion of poorly ventilated regions (low ventilation/perfusion ratio []) and computed tomography to assess atelectasis.
Results
Pao2/Fio2 was lower during anesthesia than awake (368; 291 to 470 [median; quartiles] vs. 441; 397 to 462 mm Hg; P = 0.003) and fell with increasing age and body mass index. Log shunt was best related to a quadratic function of age with largest shunt at 45 yr (r2 =0.17, P = 0.001). Log shunt was linearly related to body mass index (r2 = 0.15, P < 0.001). A multiple regression analysis including age, age2, and body mass index strengthened the association further (r2 = 0.27). Shunt was highly associated to atelectasis (r2 = 0.58, P < 0.001). Log low showed a linear relation to age (r2 = 0.14, P = 0.001).
Conclusions
Pao2/Fio2 ratio was impaired during anesthesia, and the impairment increased with age and body mass index. Shunt was related to atelectasis and was a more important cause of oxygenation impairment in middle-aged patients, whereas low, likely caused by airway closure, was more important in elderly patients. Shunt but not low increased with increasing body mass index. Thus, increasing age and body mass index impaired gas exchange by different mechanisms during anesthesia.
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Lee JH, Bae JI, Jang YE, Kim EH, Kim HS, Kim JT. Lung protective ventilation during pulmonary resection in children: a prospective, single-centre, randomised controlled trial. Br J Anaesth 2019; 122:692-701. [DOI: 10.1016/j.bja.2019.02.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 01/20/2019] [Accepted: 02/05/2019] [Indexed: 11/16/2022] Open
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