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Tsumura H, Brandon D, Vacchiano C, Krishnamoorthy V, Bartz R, Pan W. Exploring phenotype-based ventilator parameter optimization to mitigate postoperative pulmonary complications: a retrospective observational cohort study. Surg Today 2024; 54:722-733. [PMID: 38095709 PMCID: PMC11176264 DOI: 10.1007/s00595-023-02785-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 11/01/2023] [Indexed: 06/15/2024]
Abstract
PURPOSE To identify tidal volume (VT) and positive end-expiratory pressure (PEEP) associated with the lowest incidence and severity of postoperative pulmonary complications (PPCs) for each phenotype based on preoperative characteristics. METHODS The subjects of this retrospective observational cohort study were 34,910 adults who underwent surgery, using general anesthesia with mechanical ventilation. Initially, the least absolute shrinkage and selection operator regression was employed to select relevant preoperative characteristics. Then, the classification and regression tree (CART) was built to identify phenotypes. Finally, we computed the area under the receiver operating characteristic curves from logistic regressions to identify VT and PEEP associated with the lowest incidence and severity of PPCs for each phenotype. RESULTS CARTs classified seven phenotypes for each outcome. A probability of the development of PPCs ranged from the lowest (3.51%) to the highest (68.57%), whereas the probability of the development of the highest level of PPC severity ranged from 3.3% to 91.0%. Across all phenotypes, the VT and PEEP associated with the most desirable outcomes were within a small range of VT 7-8 ml/kg predicted body weight with PEEP of between 6 and 8 cmH2O. CONCLUSIONS The ranges of optimal VT and PEEP were small, regardless of the phenotypes, which had a wide range of risk profiles.
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Affiliation(s)
- Hideyo Tsumura
- Duke University School of Nursing, 307 Trent Drive, Durham, NC, 27710, USA.
- Duke University Health System, 2301 Erwin Road, Durham, NC, 27710, USA.
| | - Debra Brandon
- Duke University School of Nursing, 307 Trent Drive, Durham, NC, 27710, USA
- Department of Pediatrics, Duke University School of Medicine, DUMC 3352, Durham, NC, 27710, USA
| | - Charles Vacchiano
- Duke University School of Nursing, 307 Trent Drive, Durham, NC, 27710, USA
| | - Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, DUMC 309427710, USA
- Department of Population Health Sciences Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
| | - Raquel Bartz
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Wei Pan
- Duke University School of Nursing, 307 Trent Drive, Durham, NC, 27710, USA
- Department of Population Health Sciences Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
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Jiang L, Deng Y, Xu F, Qiao S, Wang C. Individualized PEEP guided by EIT in patients undergoing general anesthesia: A systematic review and meta-analysis. J Clin Anesth 2024; 94:111397. [PMID: 38278058 DOI: 10.1016/j.jclinane.2024.111397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 12/27/2023] [Accepted: 01/13/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND The determination of optimal positive end-expiratory pressure (PEEP) values in patients undergoing general anesthesia remains controversial. Electrical impedance tomography (EIT) directed individualized PEEP has emerged as a novel approach to PEEP setting and has garnered increasing attention. This meta-analysis aims to systematically assess the effect of EIT-guided PEEP setting compared to traditional fixed PEEP values or other PEEP titration strategies in patients undergoing general anesthesia. METHODS A comprehensive search of electronic databases, including PubMed, Web of Science, EMBASE, and the Cochrane Library, was conducted from inception to January 2023, with no language restrictions. The search terms used were "EIT"and "PEEP" with their corresponding free words. Two researchers independently conducted literature screening, data extraction, and quality evaluation. The primary outcomes of interest were oxygenation index (OI), lung compliance, and number of postoperative pulmonary complications (PPCs). The secondary outcomes included mean arterial blood pressure (MAP) and number of vasoactive drug injections. RevMan 5.3 software was used to analyze the data and draw the forest plot, and Stata 14.2 software was used to conduct sensitivity analysis to assess the stability of the results. RESULTS 5 studies involving 272 participants were included in this meta-analysis. Our findings suggest that EIT-guided individualized PEEP setting is superior to traditional fixed PEEP values and other individualized PEEP titration methods in terms of intraoperative OI(OR = 95.73, 95%CI: (49.10, 142.37); P < 0.0001) and lung compliance(OR = 7.69, 95%CI: (5.55, 9.83); P < 0.00001), without affecting intraoperative hemodynamic parameters such as MAP(OR = 2.07, 95%CI: (-1.00, 5.13); P = 0.19) and the number of intravenous vasoactive drugs(OR = 1.22, 95%CI: (0.68, 2.21); P = 0.51) or increasing the incidence of postoperative PPCs(OR = 0.87, 95%CI: (0.41, 1.82); P = 0.71). CONCLUSIONS Our meta-analysis suggests potential benefits of EIT-guided individualized PEEP setting in improving intraoperative oxygenation and lung compliance in patients undergoing general anesthesia. However, further research is needed to establish conclusive evidence, and caution should be exercised in interpreting these findings as the current literature remains inconclusive regarding the impact on intraoperative hemodynamics and postoperative complications.
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Affiliation(s)
- Lingyan Jiang
- Faculty of Anesthesiology, Suzhou Hospital, Affiliated Hospital of Medical School, Nanjing University, Suzhou Science and Technology Town Hospital, Suzhou, China; Department of Anesthesiology and Pain Medicine, Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Yanjun Deng
- Faculty of Anesthesiology, Suzhou Hospital, Affiliated Hospital of Medical School, Nanjing University, Suzhou Science and Technology Town Hospital, Suzhou, China; Department of Intensive Care Unit, Suzhou Hospital, Affiliated Hospital of Medical School, Nanjing University, Suzhou Science and Technology Town Hospital, Suzhou, China
| | - Fuqi Xu
- Faculty of Anesthesiology, Suzhou Hospital, Affiliated Hospital of Medical School, Nanjing University, Suzhou Science and Technology Town Hospital, Suzhou, China
| | - Shigang Qiao
- Faculty of Anesthesiology, Suzhou Hospital, Affiliated Hospital of Medical School, Nanjing University, Suzhou Science and Technology Town Hospital, Suzhou, China; Institute of Clinical Medicine Research, Suzhou Hospital, Affiliated Hospital of Medical School, Nanjing University, Suzhou Science and Technology Town Hospital, Suzhou, Jiangsu Province, China
| | - Chen Wang
- Faculty of Anesthesiology, Suzhou Hospital, Affiliated Hospital of Medical School, Nanjing University, Suzhou Science and Technology Town Hospital, Suzhou, China; Institute of Clinical Medicine Research, Suzhou Hospital, Affiliated Hospital of Medical School, Nanjing University, Suzhou Science and Technology Town Hospital, Suzhou, Jiangsu Province, China.
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Anđelić N, Uvelin A, Stokić E, Popović R, Zdravković R, Preveden A, Zornić N. The Effect of Recruitment Maneuver on Static Lung Compliance in Patients Undergoing General Anesthesia for Laparoscopic Cholecystectomy: A Single-Centre Prospective Clinical Intervention Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:666. [PMID: 38674312 PMCID: PMC11052059 DOI: 10.3390/medicina60040666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/06/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024]
Abstract
Background and Objectives: The aim of this study was to examine whether the use of an alveolar recruitment maneuver (RM) leads to a significant increase in static lung compliance (Cstat) and an improvement in gas exchange in patients undergoing laparoscopic cholecystectomy. Material and Methods: A clinical prospective intervention study was conducted. Patients were divided into two groups according to their body mass index (BMI): normal-weight (group I) and pre-obese and obese grade I (group II). Lung mechanics were monitored (Cstat, dynamic compliance-Cdin, peak pressure-Ppeak, plateau pressure-Pplat, driving pressure-DP) alongside gas exchange, and hemodynamic changes (heart rate-HR, mean arterial pressure-MAP) at six time points: T1 (induction of anesthesia), T2 (formation of pneumoperitoneum), T3 (RM with a PEEP of 5 cm H2O), T4 (RM with a PEEP of 7 cm H2O), T5 (desufflation), and T6 (RM at the end). The RM was performed by increasing the peak pressure by +5 cm of H2O at an equal inspiration-to-expiration ratio (I/E = 1:1) and applying a PEEP of 5 and 7 cm of H2O. Results: Out of 96 patients, 33 belonged to group I and 63 to group II. An increase in Cstat values occurred after all three RMs. At each time point, the Cstat value was measured higher in group I than in group II. A higher increase in Cstat was observed in group II after the second and third RM. Cstat values were higher at the end of the surgical procedure compared to values after the induction of anesthesia. The RM led to a significant increase in PaO2 in both groups without changes in HR or MAP. Conclusions: During laparoscopic cholecystectomy, the application of RM leads to a significant increase in Cstat and an improvement in gas exchange. The prevention of atelectasis during anesthesia should be initiated immediately after the induction of anesthesia, using protective mechanical ventilation and RM.
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Affiliation(s)
- Nada Anđelić
- Clinic for Anesthesia, Intensive Care and Pain Medicine, Clinical Centre of Vojvodina, 21000 Novi Sad, Serbia; (N.A.); (R.P.)
- Faculty of Medical Sciences, Kragujevac, University of Kragujevac, 34000 Kragujevac, Serbia;
| | - Arsen Uvelin
- Clinic for Anesthesia, Intensive Care and Pain Medicine, Clinical Centre of Vojvodina, 21000 Novi Sad, Serbia; (N.A.); (R.P.)
- Faculty of Medicine, Novi Sad, University of Novi Sad, 21000 Novi Sad, Serbia; (E.S.); (R.Z.); (A.P.)
| | - Edita Stokić
- Faculty of Medicine, Novi Sad, University of Novi Sad, 21000 Novi Sad, Serbia; (E.S.); (R.Z.); (A.P.)
- Clinic for Endocrinology, Diabetes and Metabolism, Clinical Centre of Vojvodina, 21000 Novi Sad, Serbia
| | - Radmila Popović
- Clinic for Anesthesia, Intensive Care and Pain Medicine, Clinical Centre of Vojvodina, 21000 Novi Sad, Serbia; (N.A.); (R.P.)
- Faculty of Medicine, Novi Sad, University of Novi Sad, 21000 Novi Sad, Serbia; (E.S.); (R.Z.); (A.P.)
| | - Ranko Zdravković
- Faculty of Medicine, Novi Sad, University of Novi Sad, 21000 Novi Sad, Serbia; (E.S.); (R.Z.); (A.P.)
- Institute of Cardiovascular Diseases of Vojvodina, 21204 Sremska Kamenica, Serbia
| | - Andrej Preveden
- Faculty of Medicine, Novi Sad, University of Novi Sad, 21000 Novi Sad, Serbia; (E.S.); (R.Z.); (A.P.)
- Institute of Cardiovascular Diseases of Vojvodina, 21204 Sremska Kamenica, Serbia
| | - Nenad Zornić
- Faculty of Medical Sciences, Kragujevac, University of Kragujevac, 34000 Kragujevac, Serbia;
- Department of Surgery, Clinical Centre of Kragujevac, 34000 Kragujevac, Serbia
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Simonte R, Cammarota G, De Robertis E. Intraoperative lung protection: strategies and their impact on outcomes. Curr Opin Anaesthesiol 2024; 37:184-191. [PMID: 38390864 DOI: 10.1097/aco.0000000000001341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW The present review summarizes the current knowledge and the barriers encountered when implementing tailoring lung-protective ventilation strategies to individual patients based on advanced monitoring systems. RECENT FINDINGS Lung-protective ventilation has become a pivotal component of perioperative care, aiming to enhance patient outcomes and reduce the incidence of postoperative pulmonary complications (PPCs). High-quality research has established the benefits of strategies such as low tidal volume ventilation and low driving pressures. Debate is still ongoing on the most suitable levels of positive end-expiratory pressure (PEEP) and the role of recruitment maneuvers. Adapting PEEP according to patient-specific factors offers potential benefits in maintaining ventilation distribution uniformity, especially in challenging scenarios like pneumoperitoneum and steep Trendelenburg positions. Advanced monitoring systems, which continuously assess patient responses and enable the fine-tuning of ventilation parameters, offer real-time data analytics to predict and prevent impending lung complications. However, their impact on postoperative outcomes, particularly PPCs, is an ongoing area of research. SUMMARY Refining protective lung ventilation is crucial to provide patients with the best possible care during surgery, reduce the incidence of PPCs, and improve their overall surgical journey.
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Affiliation(s)
- Rachele Simonte
- Department of Medicine and Surgery, Università degli Studi di Perugia, Perugia
| | - Gianmaria Cammarota
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Edoardo De Robertis
- Department of Medicine and Surgery, Università degli Studi di Perugia, Perugia
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Mato-Búa R, Prado-Rodríguez A, López-López D, Rama-Maceiras P, Molins-Gauna N, Álvarez-Refojo F. Intraoperative effects of an alveolar recruitment manoeuvre in patients undergoing laparoscopic colon surgery. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:151-159. [PMID: 38452926 DOI: 10.1016/j.redare.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
INTRODUCTION Pulmonary atelectasis is common in patients undergoing laparoscopic abdominal surgery under general anaesthesia, which increases the risk of perioperative respiratory complications. Alveolar recruitment manoeuvres (ARM) are used to open up the lung parenchyma with atelectasis, although the duration of their benefit has not been clearly established. The aim of this study was to determine the effectiveness of an ARM in laparoscopic colon surgery, the duration of response over time, and its haemodynamic impact. METHODS Twenty-five patients undergoing laparoscopic colon surgery were included. After anaesthetic induction and initiation of surgery with pneumoperitoneum, an ARM was performed, and then optimal PEEP determined. Respiratory mechanics and gas exchange variables, and haemodynamic parameters, were analysed before the manoeuvre and periodically over the following 90 min. RESULTS Three patients were excluded for surgical reasons. The alveolar arterial oxygen gradient went from 94.3 (62.3-117.8) mmHg before to 60.7 (29.6-91.0) mmHg after the manoeuvre (P < .05). This difference was maintained during the 90 min of the study. Dynamic compliance of the respiratory system went from 31.3 ml/cmH2O (26.1-39.2) before the manoeuvre to 46.1 ml/cmH2O (37.5-53.5) after the manoeuvre (P < .05). This difference was maintained for 60 min. No significant changes were identified in any of the haemodynamic variables studied. CONCLUSION In patients undergoing laparoscopic colon surgery, performing an intraoperative ARM improves the mechanics of the respiratory system and oxygenation, without associated haemodynamic compromise. The benefit of these manoeuvres lasts for at least one hour.
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Affiliation(s)
- R Mato-Búa
- Departamento de Anestesiología, Reanimación y Tratamiento del Dolor, Complexo Hospitalario Universitario de A Coruña, A Coruña, Galicia, Spain.
| | - A Prado-Rodríguez
- Departamento de Anestesiología, Reanimación y Tratamiento del Dolor, Complexo Hospitalario Universitario de A Coruña, A Coruña, Galicia, Spain
| | - D López-López
- Departamento de Anestesiología, Reanimación y Tratamiento del Dolor, Complexo Hospitalario Universitario de A Coruña, A Coruña, Galicia, Spain
| | - P Rama-Maceiras
- Departamento de Anestesiología, Reanimación y Tratamiento del Dolor, Complexo Hospitalario Universitario de A Coruña, A Coruña, Galicia, Spain
| | - N Molins-Gauna
- Departamento de Anestesiología, Reanimación y Tratamiento del Dolor, Complexo Hospitalario Universitario de A Coruña, A Coruña, Galicia, Spain
| | - F Álvarez-Refojo
- Departamento de Anestesiología, Reanimación y Tratamiento del Dolor, Complexo Hospitalario Universitario de A Coruña, A Coruña, Galicia, Spain
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Elefterion B, Cirenei C, Kipnis E, Cailliau E, Bruandet A, Tavernier B, Lamer A, Lebuffe G. Intraoperative Mechanical Power and Postoperative Pulmonary Complications in Noncardiothoracic Elective Surgery Patients: A 10-Year Retrospective Cohort Study. Anesthesiology 2024; 140:399-408. [PMID: 38011027 DOI: 10.1097/aln.0000000000004848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND Postoperative pulmonary complications is a major issue that affects outcomes of surgical patients. The hypothesis was that the intraoperative ventilation parameters are associated with occurrence of postoperative pulmonary complications. METHODS A single-center retrospective cohort study was conducted at the Lille University Hospital, France. The study included 33,701 adults undergoing noncardiac, nonthoracic elective surgery requiring general anesthesia with tracheal intubation between January 2010 and December 2019. Intraoperative ventilation parameters were compared between patients with and without one or more postoperative pulmonary complications (respiratory infection, respiratory failure, pleural effusion, atelectasis, pneumothorax, bronchospasm, and aspiration pneumonitis) within 7 days of surgery. RESULTS Among 33,701 patients, 2,033 (6.0%) had one or more postoperative pulmonary complications. The lower tidal volume to predicted body weight ratio (odds ratio per -1 ml·kgPBW-1, 1.08; 95% CI, 1.02 to 1.14; P < 0.001), higher mechanical power (odds ratio per 4 J·min-1, 1.37; 95% CI, 1.26 to 1.49; P < 0.001), dynamic respiratory system compliance less than 30 ml·cm H2O (1.30; 95% CI, 1.15 to 1.46; P < 0.001), oxygen saturation measured by pulse oximetry less than 96% (odds ratio, 2.42; 95% CI, 1.97 to 2.96; P < 0.001), and lower end-tidal carbon dioxide (odds ratio per -3 mmHg, 1.06; 95% CI, 1.00 to 1.13; P = 0.023) were independently associated with postoperative pulmonary complications. Patients with postoperative pulmonary complications were more likely to be admitted to the intensive care unit (odds ratio, 12.5; 95% CI, 6.6 to 10.1; P < 0.001), had longer hospital length of stay (subhazard ratio, 0.43; 95% CI, 0.40 to 0.45), and higher in-hospital (subhazard ratio, 6.0; 95% CI, 4.1 to 9.0; P < 0.001) and 1-yr mortality (subhazard ratio, 2.65; 95% CI, 2.33 to 3.02; P < 0.001). CONCLUSIONS In the study's population, decreased rather than increased tidal volume, decreased compliance, increased mechanical power, and decreased end-tidal carbon dioxide were independently associated with postoperative pulmonary complications. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Bertrand Elefterion
- Lille University Hospital, Surgical Critical Care, Department of Anesthesiology and Critical Care, Lille, France
| | - Cedric Cirenei
- Lille University Hospital, Surgical Critical Care, Department of Anesthesiology and Critical Care, Lille, France
| | - Eric Kipnis
- Lille University Hospital, Surgical Critical Care, Department of Anesthesiology and Critical Care, Lille, France
| | - Emeline Cailliau
- Lille University Hospital, Biostatistics Department, Lille, France
| | - Amélie Bruandet
- Lille University Hospital, Medical Information Department, Lille, France
| | - Benoit Tavernier
- Lille University Hospital, Surgical Critical Care, Department of Anesthesiology and Critical Care, Lille, France; and Lille University F-59000, ULR 2694-METRICS: Health Technology Assessment and Medical Practices Evaluation, Lille, France
| | - Antoine Lamer
- Lille University, Lille University Hospital, ULR 2694-METRICS: Health Technology Assessment and Medical Practices Evaluation, Lille, France
| | - Gilles Lebuffe
- Lille University Hospital, Surgical Critical Care, Department of Anesthesiology and Critical Care, Lille, France: Lille University F-59000, ULR 7365-Research Group on Injectable Forms and Associated Technologies, Lille, France
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Liu XM, Chang XL, Sun JY, Hao WW, An LX. Effects of individualized positive end-expiratory pressure on intraoperative oxygenation in thoracic surgical patients: study protocol for a prospective randomized controlled trial. Trials 2024; 25:19. [PMID: 38167071 PMCID: PMC10759667 DOI: 10.1186/s13063-023-07883-z] [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: 10/29/2023] [Accepted: 12/15/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Intraoperative hypoxemia and postoperative pulmonary complications (PPCs) often occur in patients with one-lung ventilation (OLV), due to both pulmonary shunt and atelectasis. It has been demonstrated that individualized positive end-expiratory pressure (iPEEP) can effectively improve intraoperative oxygenation, increase lung compliance, and reduce driving pressure, thereby decreasing the risk of developing PPCs. However, its effect during OLV is still unknown. Therefore, we aim to investigate whether iPEEP ventilation during OLV is superior to 5 cmH2O PEEP in terms of intraoperative oxygenation and the occurrence of PPCs. METHODS This study is a prospective, randomized controlled, single-blind, single-center trial. A total of 112 patients undergoing thoracoscopic pneumonectomy surgery and OLV will be enrolled in the study. They will be randomized into two groups: the static lung compliance guided iPEEP titration group (Cst-iPEEP Group) and the constant 5 cmH2O PEEP group (PEEP 5 Group). The primary outcome will be the oxygenation index at 30 min after OLV and titration. Secondary outcomes are oxygenation index at other operative time points, PPCs, postoperative adverse events, ventilator parameters, vital signs, pH value, inflammatory factors, and economic indicators. DISCUSSION This trial explores the effect of iPEEP on intraoperative oxygenation during OLV and PPCs. It provides some clinical references for optimizing the lung protective ventilation strategy of OLV, improving patient prognosis, and accelerating postoperative rehabilitation. TRIAL REGISTRATION www.Chictr.org.cn ChiCTR2300073411 . Registered on 10 July 2023.
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Affiliation(s)
- Xu-Ming Liu
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yongan Road, Xicheng District, Beijing, 100050, China
| | - Xin-Lu Chang
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yongan Road, Xicheng District, Beijing, 100050, China
| | - Jing-Yi Sun
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yongan Road, Xicheng District, Beijing, 100050, China
| | - Wen-Wen Hao
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yongan Road, Xicheng District, Beijing, 100050, China
| | - Li-Xin An
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yongan Road, Xicheng District, Beijing, 100050, China.
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Li R, Liu L, Wei K, Zheng X, Zeng J, Chen Q. Effect of noninvasive respiratory support after extubation on postoperative pulmonary complications in obese patients: A systematic review and network meta-analysis. J Clin Anesth 2023; 91:111280. [PMID: 37801822 DOI: 10.1016/j.jclinane.2023.111280] [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: 03/12/2023] [Revised: 09/16/2023] [Accepted: 09/27/2023] [Indexed: 10/08/2023]
Abstract
STUDY OBJECTIVE Obesity is associated with an increased risk of sleep-disordered breathing (SDB) and postoperative pulmonary complications (PPCs). Postoperative noninvasive respiratory support (NRS) has been recommended to obese patients despite the controversy about its benefit. The network meta-analysis (NMA) was used in this study to compare the effect of different methods of NRS on preventing PPCs in obese patients. DESIGN This study is a network meta-analysis. SETTING Post-anesthesia care unit and inpatient ward. PATIENTS 20 randomized controlled trials involving 1184 obese patients were included in the final analysis. INTERVENTIONS One of the four NRS techniques, which include continuous positive airway pressure (CPAP), bi-level positive airway pressure (BiPAP), high-flow nasal cannula (HFNC), or conventional oxygen therapy (COT), was performed after general anesthesia. MEASUREMENTS The primary outcome was the incidence of PPCs, e.g., atelectasis, pneumonia, hypoxemia, and respiratory failure. The secondary outcomes included the incidence of oxygen treatment failure and anastomotic leakage, oxygenation index, and length of hospital stay (LOS). RevMan 5.3 and STATA 16.0 were used to analyze the results and any potential bias. MAIN RESULTS Compared with COT, BiPAP and HFNC were both effective in reducing the occurrence of postoperative atelectasis. There were no significant differences in the occurrence of other PPCs including pneumonia, hypoxemia and respiratory failure between the four NRS techniques. CPAP and HFNC were superior to other techniques in improving oxygenation and shortening LOS respectively. No differences were found in oxygen treatment failure and anastomotic leakage between the patients with different NRS. HFNC ranked the first in five of the eight outcomes (hypoxemia, respiratory failure, treatment failure, anastomotic leakage, LOS) in this review by the surface under the cumulative ranking curve (SUCRA). CONCLUSION Among the four postoperative NRS techniques, HFNC seems to be the optimal choice for obese patients which shows certain advantages in reducing the risk of PPCs and shortening LOS.
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Affiliation(s)
- Ruike Li
- The First Affiliated Hospital of Chongqing Medical University, Department of Anesthesiology, Youyi Road, Chongqing 400016, China
| | - Ling Liu
- The First Affiliated Hospital of Chongqing Medical University, Department of Anesthesiology, Youyi Road, Chongqing 400016, China
| | - Ke Wei
- The First Affiliated Hospital of Chongqing Medical University, Department of Anesthesiology, Youyi Road, Chongqing 400016, China.
| | - Xiaozhuo Zheng
- The First Affiliated Hospital of Chongqing Medical University, Department of Respiratory and Critical Care Medicine, Youyi Road, Chongqing 400016, China
| | - Jie Zeng
- Stomatological Hospital of Chongqing Medical University, Department of Anesthesiology, Songshibei Road, Chongqing 400016, China
| | - Qi Chen
- Chongqing University Cancer Hospital, Department of Anesthesiology, Hanyu Road, Chongqing 400016, China
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Kim YJ, Kim BR, Kim HW, Jung JY, Cho HY, Seo JH, Kim WH, Kim HS, Hwangbo S, Yoon HK. Effect of driving pressure-guided positive end-expiratory pressure on postoperative pulmonary complications in patients undergoing laparoscopic or robotic surgery: a randomised controlled trial. Br J Anaesth 2023; 131:955-965. [PMID: 37679285 DOI: 10.1016/j.bja.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 07/27/2023] [Accepted: 08/01/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Individualised positive end-expiratory pressure (PEEP) improves respiratory mechanics. However, whether PEEP reduces postoperative pulmonary complications (PPCs) remains unclear. We investigated whether driving pressure-guided PEEP reduces PPCs after laparoscopic/robotic abdominal surgery. METHODS This single-centre, randomised controlled trial enrolled patients at risk for PPCs undergoing laparoscopic or robotic lower abdominal surgery. The individualised group received driving pressure-guided PEEP, whereas the comparator group received 5 cm H2O fixed PEEP during surgery. Both groups received a tidal volume of 8 ml kg-1 ideal body weight. The primary outcome analysed per protocol was a composite of pulmonary complications (defined by pre-specified clinical and radiological criteria) within 7 postoperative days after surgery. RESULTS Some 384 patients (median age: 67 yr [inter-quartile range: 61-73]; 66 [18%] female) were randomised. Mean (standard deviation) PEEP in patients randomised to individualised PEEP (n=178) was 13.6 cm H2O (2.1). Individualised PEEP resulted in lower mean driving pressures (14.7 cm H2O [2.6]), compared with 185 patients randomised to standard PEEP (18.4 cm H2O [3.2]; mean difference: -3.7 cm H2O [95% confidence interval (CI): -4.3 to -3.1 cm H2O]; P<0.001). There was no difference in the incidence of pulmonary complications between individualised (25/178 [14.0%]) vs standard PEEP (36/185 [19.5%]; risk ratio [95% CI], 0.72 [0.45-1.15]; P=0.215). Pulmonary complications as a result of desaturation were less frequent in patients randomised to individualised PEEP (8/178 [4.5%], compared with standard PEEP (30/185 [16.2%], risk ratio [95% CI], 0.28 [0.13-0.59]; P=0.001). CONCLUSIONS Driving pressure-guided PEEP did not decrease the incidence of pulmonary complications within 7 days of laparoscopic or robotic lower abdominal surgery, although uncertainty remains given the lower than anticipated event rate for the primary outcome. CLINICAL TRIAL REGISTRATION KCT0004888 (http://cris.nih.go.kr, registration date: April 6, 2020).
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Affiliation(s)
- Yoon Jung Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Bo Rim Kim
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Hee Won Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ji-Yoon Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hye-Yeon Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeoung-Hwa Seo
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Suhyun Hwangbo
- Department of Genomic Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyun-Kyu Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
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10
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Girrbach F, Petroff D, Mols S, Brechtelsbauer K, Wrigge H, Simon P. Extubation with Reduced Inspiratory Oxygen Concentration or Postoperative Continuous Positive Pressure to Improve Oxygenation after Laparoscopic Bariatric Surgery: A Randomized Controlled Trial. Anesthesiology 2023; 139:546-548. [PMID: 37698435 DOI: 10.1097/aln.0000000000004654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
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11
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Li X, Liu H, Wang J, Ni ZL, Liu ZX, Jiao JL, Han Y, Cao JL. Individualized Positive End-expiratory Pressure on Postoperative Atelectasis in Patients with Obesity: A Randomized Controlled Clinical Trial. Anesthesiology 2023; 139:262-273. [PMID: 37440205 DOI: 10.1097/aln.0000000000004603] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
BACKGROUND Individualized positive end-expiratory pressure (PEEP) guided by dynamic compliance improves oxygenation and reduces postoperative atelectasis in nonobese patients. The authors hypothesized that dynamic compliance-guided PEEP could also reduce postoperative atelectasis in patients undergoing bariatric surgery. METHODS Patients scheduled to undergo laparoscopic bariatric surgery were eligible. Dynamic compliance-guided PEEP titration was conducted in all patients using a downward approach. A recruitment maneuver (PEEP from 10 to 25 cm H2O at 5-cm H2O step every 30 s, with 15-cm H2O driving pressure) was conducted both before and after the titration. Patients were then randomized (1:1) to undergo surgery under dynamic compliance-guided PEEP (PEEP with highest dynamic compliance plus 2 cm H2O) or PEEP of 8 cm H2O. The primary outcome was postoperative atelectasis, as assessed with computed tomography at 60 to 90 min after extubation, and expressed as percentage to total lung tissue volume. Secondary outcomes included Pao2/inspiratory oxygen fraction (Fio2) and postoperative pulmonary complications. RESULTS Forty patients (mean ± SD; 28 ± 7 yr of age; 25 females; average body mass index, 41.0 ± 4.7 kg/m2) were enrolled. Median PEEP with highest dynamic compliance during titration was 15 cm H2O (interquartile range, 13 to 17; range, 8 to 19) in the entire sample of 40 patients. The primary outcome of postoperative atelectasis (available in 19 patients in each group) was 13.1 ± 5.3% and 9.5 ± 4.3% in the PEEP of 8 cm H2O and dynamic compliance-guided PEEP groups, respectively (intergroup difference, 3.7%; 95% CI, 0.5 to 6.8%; P = 0.025). Pao2/Fio2 at 1 h after pneumoperitoneum was higher in the dynamic compliance-guided PEEP group (397 vs. 337 mmHg; group difference, 60; 95% CI, 9 to 111; P = 0.017) but did not differ between the two groups 30 min after extubation (359 vs. 375 mmHg; group difference, -17; 95% CI, -53 to 21; P = 0.183). The incidence of postoperative pulmonary complications was 4 of 20 in both groups. CONCLUSIONS Postoperative atelectasis was lower in patients undergoing laparoscopic bariatric surgery under dynamic compliance-guided PEEP versus PEEP of 8 cm H2O. Postoperative Pao2/Fio2 did not differ between the two groups. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Xiang Li
- Department of Anesthesiology, Eye & Ear, Nose, and Throat Hospital of Fudan University, Shanghai, China; Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China; Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - He Liu
- Department of Anesthesiology, Huzhou Central Hospital, Huzhou, China
| | - Jun Wang
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China; Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zhi-Lin Ni
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China; Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zhong-Xiao Liu
- Department of Radiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Jia-Li Jiao
- Institute of Translational Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuan Han
- Department of Anesthesiology, Eye & Ear, Nose, and Throat Hospital of Fudan University, Shanghai, China; Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
| | - Jun-Li Cao
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China.; NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, China
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12
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Boesing C, Schaefer L, Hammel M, Otto M, Blank S, Pelosi P, Rocco PRM, Luecke T, Krebs J. Individualized Positive End-expiratory Pressure Titration Strategies in Superobese Patients Undergoing Laparoscopic Surgery: Prospective and Nonrandomized Crossover Study. Anesthesiology 2023; 139:249-261. [PMID: 37224406 DOI: 10.1097/aln.0000000000004631] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND Superobesity and laparoscopic surgery promote negative end-expiratory transpulmonary pressure that causes atelectasis formation and impaired respiratory mechanics. The authors hypothesized that end-expiratory transpulmonary pressure differs between fixed and individualized positive end-expiratory pressure (PEEP) strategies and mediates their effects on respiratory mechanics, end-expiratory lung volume, gas exchange, and hemodynamic parameters in superobese patients. METHODS In this prospective, nonrandomized crossover study including 40 superobese patients (body mass index 57.3 ± 6.4 kg/m2) undergoing laparoscopic bariatric surgery, PEEP was set according to (1) a fixed level of 8 cm H2O (PEEPEmpirical), (2) the highest respiratory system compliance (PEEPCompliance), or (3) an end-expiratory transpulmonary pressure targeting 0 cm H2O (PEEPTranspul) at different surgical positioning. The primary endpoint was end-expiratory transpulmonary pressure at different surgical positioning; secondary endpoints were respiratory mechanics, end-expiratory lung volume, gas exchange, and hemodynamic parameters. RESULTS Individualized PEEPCompliance compared to fixed PEEPEmpirical resulted in higher PEEP (supine, 17.2 ± 2.4 vs. 8.0 ± 0.0 cm H2O; supine with pneumoperitoneum, 21.5 ± 2.5 vs. 8.0 ± 0.0 cm H2O; and beach chair with pneumoperitoneum; 15.8 ± 2.5 vs. 8.0 ± 0.0 cm H2O; P < 0.001 each) and less negative end-expiratory transpulmonary pressure (supine, -2.9 ± 2.0 vs. -10.6 ± 2.6 cm H2O; supine with pneumoperitoneum, -2.9 ± 2.0 vs. -14.1 ± 3.7 cm H2O; and beach chair with pneumoperitoneum, -2.8 ± 2.2 vs. -9.2 ± 3.7 cm H2O; P < 0.001 each). Titrated PEEP, end-expiratory transpulmonary pressure, and lung volume were lower with PEEPCompliance compared to PEEPTranspul (P < 0.001 each). Respiratory system and transpulmonary driving pressure and mechanical power normalized to respiratory system compliance were reduced using PEEPCompliance compared to PEEPTranspul. CONCLUSIONS In superobese patients undergoing laparoscopic surgery, individualized PEEPCompliance may provide a feasible compromise regarding end-expiratory transpulmonary pressures compared to PEEPEmpirical and PEEPTranspul, because PEEPCompliance with slightly negative end-expiratory transpulmonary pressures improved respiratory mechanics, lung volumes, and oxygenation while preserving cardiac output. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Christoph Boesing
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany; Theodor-Kutzer-Ufer 1-3, Mannheim, Germany
| | - Laura Schaefer
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany; Theodor-Kutzer-Ufer 1-3, Mannheim, Germany
| | - Marvin Hammel
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany; Theodor-Kutzer-Ufer 1-3, Mannheim, Germany
| | - Mirko Otto
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany; Theodor-Kutzer-Ufer 1-3, Mannheim, Germany
| | - Susanne Blank
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy; Anesthesiology and Critical Care - San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Ilha do Fundao, Rio de Janeiro, Brazil
| | - Thomas Luecke
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany; Theodor-Kutzer-Ufer 1-3, Mannheim, Germany
| | - Joerg Krebs
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany; Theodor-Kutzer-Ufer 1-3, Mannheim, Germany
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13
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Wrigge H, Petroff D, Fernandez-Bustamante A. Pressure for High Positive End-expiratory Pressure in Obese Surgical Patients Is Growing. Anesthesiology 2023; 139:239-243. [PMID: 37552098 PMCID: PMC10662970 DOI: 10.1097/aln.0000000000004665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Affiliation(s)
- Hermann Wrigge
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, Germany
- Medical Faculty, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - David Petroff
- Clinical Trial Centre, University of Leipzig, Leipzig, Germany
| | - Ana Fernandez-Bustamante
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, United States of America
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14
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Syrafe M, Köhne W, Börgers A, Löwen H, Krege S, Groeben H. Perioperative lung function following flow controlled ventilation for robot-assisted prostatectomies in steep trendelenburg position: an observational study. Intensive Care Med Exp 2023; 11:49. [PMID: 37563521 PMCID: PMC10415243 DOI: 10.1186/s40635-023-00537-z] [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: 02/27/2023] [Accepted: 07/05/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Steep Trendelenburg position combined with capnoperitoneum can lead to pulmonary complications and prolonged affection of postoperative lung function. Changes in pulmonary function occur independent of different modes of ventilation and levels of positive end-expiratory pressure (PEEP). The effect of flow-controlled ventilation (FCV) has not been evaluated yet. We perioperatively measured spirometric lung function parameters in patients undergoing robot-assisted prostatectomy under FCV. Our primary hypothesis was that there is no significant difference in the ratio of the maximal mid expiratory and inspiratory flow (MEF50/MIF50) after surgery. METHODS In 20 patients, spirometric measurements were obtained preoperatively, 40, 120, and 240 min and 1 and 5 days postoperatively. We measured MEF50/MIF50, vital capacity (VC), forced expiratory volume in 1 s (FEV1), and intraoperative ventilation parameters. RESULTS MEF50/MIF50 ratio increased from 0.92 (CI 0.73-1.11) to 1.38 (CI 1.01-1.75, p < 0.0001) and returned to baseline within 24 h, while VC and FEV1 decreased postoperatively with a second nadir at 24 h and only normalized by the fifth day (p < 0.0001). Compared to patients with PCV, postoperative lung function changes similarly. CONCLUSION Flow-controlled ventilation led to changes in lung function similar to those observed with pressure-controlled ventilation. While the ratio of MEF50/MIF50 normalized within 24 h, VC and FEV1 recovered within 5 days after surgery.
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Affiliation(s)
- Mustafa Syrafe
- Department of Anaesthesia, Critical Care Medicine and Pain Therapy, Kliniken Essen-Mitte, Henricistr. 92, 45136, Essen, Germany
| | - Wiebke Köhne
- Department of Anaesthesia, Critical Care Medicine and Pain Therapy, Kliniken Essen-Mitte, Henricistr. 92, 45136, Essen, Germany
| | - Andre Börgers
- Department of Anaesthesia, Critical Care Medicine and Pain Therapy, Kliniken Essen-Mitte, Henricistr. 92, 45136, Essen, Germany
| | - Heinrich Löwen
- Department of Urology, Pediatric Urology, and Urologic Oncology, Kliniken Essen-Mitte, Essen, Germany
| | - Susanne Krege
- Department of Urology, Pediatric Urology, and Urologic Oncology, Kliniken Essen-Mitte, Essen, Germany
| | - Harald Groeben
- Department of Anaesthesia, Critical Care Medicine and Pain Therapy, Kliniken Essen-Mitte, Henricistr. 92, 45136, Essen, Germany.
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15
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Zhang YW, Li Y, Huang WB, Wang J, Qian XE, Yang Y, Huang CS. Utilization of deep neuromuscular blockade combined with reduced abdominal pressure in laparoscopic radical gastrectomy for gastric cancer: An academic perspective. World J Gastrointest Surg 2023; 15:1405-1415. [PMID: 37555115 PMCID: PMC10405126 DOI: 10.4240/wjgs.v15.i7.1405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/20/2023] [Accepted: 06/02/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Few studies have examined the specific efficacy of deep neuromuscular blockade (NMB) combined with pneumoperitoneal pressure reduction in laparoscopic radical gastrectomy (LRG) in the elderly. AIM To investigate the application effect of deep neuromuscular blockade (NMB) combined with reduced pneumoperitoneum pressure in LRG for gastric cancer (GC) in elderly patients and its influence on inflammation. METHODS Totally 103 elderly patients with GC treated in our hospital between January 2020 and January 2022 were retrospectively analyzed. Among them, 45 patients treated with surgery based on deep NMB and conventional pneumoperitoneum pressure were assigned to the control group, while the rest of the 58 patients who underwent surgery based on deep NMB and reduced pneumoperitoneum pressure were assigned to the observation group. The two groups were compared in the changes of the Leiden-surgical rating scale score, serum tumor necrosis fact-α (TNF-α) and interleukin 6 (IL-6) before and after therapy. The visual analogue scale (VAS) was adopted for evaluating the shoulder pain of patients at 8 h, 24 h and 48 h after the operation. The driving pressure of the two groups at different time points was also compared. Additionally, the operation time, pneumoperitoneum time, infusion volume, blood loss, extubation time after surgery, residence time in the resuscitation room, TOF% = 90% time and post-anesthetic recovery room (PACU) stay time were all recorded, and adverse PACU-associated respiratory events were also recorded. The postoperative hospitalization time and postoperative expenses of the two groups were counted and compared. RESULTS No significant difference was found between the two groups at the time of skin incision, 60 minutes since the operation and abdominal closure after surgery (P > 0.05). The observation group exhibited significantly lower VAS scores than the control group at 24 and 48h after surgery (P < 0.05). Additionally, the observation group had significantly lower driving pressure than the control group at 5 min and 60 min after the establishment of pneumoperitoneum (P < 0.05). Additionally, the two groups were similar in terms of the operation time, pneumoperitoneum time, infusion volume, blood loss, extubation time after surgery, residence time in the resuscitation room and TOF% = 90% time (P > 0.05), and the observation group showed significantly lower TNF-α and IL-6 Levels than the control group at 24 h after therapy (P < 0.05). Moreover, the incidence of adverse events was not significantly different between the two groups (P > 0.05), and the observation group experienced significantly less hospitalization time and postoperative expenses than the control group (P < 0.05). CONCLUSION Deep NMB combined with reduced pneumoperitoneum pressure can decrease the VAS score of shoulder pain and inflammatory reaction, without hindering the surgical vision and increasing adverse PACU-associated respiratory events, and can thus shorten the hospitalization time and treatment cost for patient.
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Affiliation(s)
- Yi-Wei Zhang
- Department of Anesthesiology, Ningbo First Hospital, Ningbo 315016, Zhejiang Province, China
| | - Yong Li
- Department of Anesthesiology, Ningbo First Hospital, Ningbo 315016, Zhejiang Province, China
| | - Wan-Bo Huang
- Department of Anesthesiology, Ningbo First Hospital, Ningbo 315016, Zhejiang Province, China
| | - Jue Wang
- Department of Anesthesiology, Ningbo First Hospital, Ningbo 315016, Zhejiang Province, China
| | - Xing-Er Qian
- Department of Anesthesiology, Ningbo First Hospital, Ningbo 315016, Zhejiang Province, China
| | - Yu Yang
- Department of Anesthesiology, Ningbo First Hospital, Ningbo 315016, Zhejiang Province, China
| | - Chang-Shun Huang
- Department of Anesthesiology, Ningbo First Hospital, Ningbo 315016, Zhejiang Province, China
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16
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Grieco DL, Russo A, Anzellotti GM, Romanò B, Bongiovanni F, Dell'Anna AM, Mauti L, Cascarano L, Gallotta V, Rosà T, Varone F, Menga LS, Polidori L, D'Indinosante M, Cappuccio S, Galletta C, Tortorella L, Costantini B, Gueli Alletti S, Sollazzi L, Scambia G, Antonelli M. Lung-protective ventilation during Trendelenburg pneumoperitoneum surgery: A randomized clinical trial. J Clin Anesth 2023; 85:111037. [PMID: 36495775 DOI: 10.1016/j.jclinane.2022.111037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/31/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
Study objective To assess the effects of a protective ventilation strategy during Trendelenburg pneumoperitoneum surgery on postoperative oxygenation. DESIGNS Parallel-group, randomized trial. SETTING Operating room of a university hospital, Italy. PATIENTS Morbidly obese patients undergoing Trendelenburg pneumoperitoneum gynaecological surgery. INTERVENTIONS Participants were randomized to standard (SV: tidal volume = 10 ml/kg of predicted body weight, PEEP = 5 cmH2O) or protective (PV: tidal volume = 6 ml/kg of predicted body weight, PEEP = 10 cmH2O, recruitment maneuvers) ventilation during anesthesia. MEASUREMENTS Primary outcome was PaO2/FiO2 one hour after extubation. Secondary outcomes included day-1 PaO2/FiO2, day-2 respiratory function and intraoperative respiratory/lung mechanics, assessed through esophageal manometry, end-expiratory lung volume (EELV) measurement and pressure-volume curves. MAIN RESULTS Sixty patients were analyzed (31 in SV group, 29 in PV group). Median [IqR] tidal volume was 350 ml [300-360] in PV group and 525 [500-575] in SV group. Median PaO2/FiO2 one hour after extubation was 280 mmHg [246-364] in PV group vs. 298 [250-343] in SV group (p = 0.64). Day-1 PaO2/FiO2, day-2 forced vital capacity, FEV-1 and Tiffenau Index were not different between groups (all p > 0.10). Intraoperatively, 59% of patients showed complete airway closure during pneumoperitoneum, without difference between groups: median airway opening pressure was 17 cmH2O. In PV group, airway and transpulmonary driving pressure were lower (12 ± 5 cmH2O vs. 17 ± 7, p < 0.001; 9 ± 4 vs. 13 ± 7, p < 0.001), PaCO2 and respiratory rate were higher (48 ± 8 mmHg vs. 42 ± 12, p < 0.001; 23 ± 5 breaths/min vs. 16 ± 4, p < 0.001). Intraoperative EELV was similar between PV and SV group (1193 ± 258 ml vs. 1207 ± 368, p = 0.80); ratio of tidal volume to EELV was lower in PV group (0.45 ± 0.12 vs. 0.32 ± 0.09, p < 0.001). CONCLUSIONS In obese patients undergoing Trendelenburg pneumoperitoneum surgery, PV did not improve postoperative oxygenation nor day-2 respiratory function. PV was associated with intraoperative respiratory mechanics indicating less injurious ventilation. The high prevalence of complete airway closure may have affected study results. TRIAL REGISTRATION Prospectively registered on http://clinicaltrials.govNCT03157479 on May 17th, 2017.
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Affiliation(s)
- Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Andrea Russo
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gian Marco Anzellotti
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Bruno Romanò
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Filippo Bongiovanni
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio M Dell'Anna
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Mauti
- Department of Internal medicine, Catholic University of The Sacred Heart, Rome, Italy; Respiratory Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Laura Cascarano
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Valerio Gallotta
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Tommaso Rosà
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Varone
- Department of Internal medicine, Catholic University of The Sacred Heart, Rome, Italy; Respiratory Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luca S Menga
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lorenzo Polidori
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco D'Indinosante
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Serena Cappuccio
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Claudia Galletta
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lucia Tortorella
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Barbara Costantini
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Salvatore Gueli Alletti
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Liliana Sollazzi
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Scambia
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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17
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Choi JY, Al-Saedy MA, Carlson B. Positive end-expiratory pressure and postoperative complications in patients with obesity: a review and meta-analysis. Obesity (Silver Spring) 2023; 31:955-964. [PMID: 36855005 DOI: 10.1002/oby.23675] [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: 05/18/2022] [Revised: 10/25/2022] [Accepted: 11/15/2022] [Indexed: 03/02/2023]
Abstract
OBJECTIVE In patients with obesity, use of positive end-expiratory pressure (PEEP) > 5 cm H2 O (centimeters of water) has been shown to prevent intraoperative atelectasis. This study compares the rate of postoperative pulmonary complications (PPCs) associated with PEEP > 5 cm H2 O and PEEP ≤ 5 cm H2 O in patients with obesity who underwent surgery under general anesthesia with mechanical ventilation. METHODS This study searched Medline, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) using the terms "PEEP," "anesthesia," and "ventilation." Cochrane ReviewManager (RevMan) version 5 was used for data analysis. The primary outcome was a composite of PPCs, including atelectasis, pneumonia, pneumothorax, and acute respiratory failure. RESULTS The initial search identified 903 titles and abstracts, and 4 randomized controlled trials were included for analysis. We included a total of 2116 participants from four randomized controlled trials that compared PEEP ≤ 5 cm H2 O with PEEP > 5 cm H2 O in adult patients with obesity. There was no statistically significant difference in PPCs between the PEEP ≤ 5 cm H2 O and PEEP > 5 cm H2 O groups (risk ratio = 2.21, 95% CI: 0.41-11.83; p = 0.35). However, a significant heterogeneity was found within included studies (I2 = 53%). CONCLUSIONS It is unclear whether PEEP > 5 cm H2 O improves the postoperative clinical outcome in patients with obesity, which is in contrast to previously established evidence that it reduces atelectasis in patients with obesity.
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Affiliation(s)
- Jae Y Choi
- Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington, USA
| | - Miriam A Al-Saedy
- Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington, USA
| | - Brian Carlson
- Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington, USA
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Hennessey E, Bittner E, White P, Kovar A, Meuchel L. Intraoperative Ventilator Management of the Critically Ill Patient. Anesthesiol Clin 2023; 41:121-140. [PMID: 36871995 PMCID: PMC9985493 DOI: 10.1016/j.anclin.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Strategies for the intraoperative ventilator management of the critically ill patient focus on parameters used for lung protective ventilation with acute respiratory distress syndrome, preventing or limiting the deleterious effects of mechanical ventilation, and optimizing anesthetic and surgical conditions to limit postoperative pulmonary complications for patients at risk. Patient conditions such as obesity, sepsis, the need for laparoscopic surgery, or one-lung ventilation may benefit from intraoperative lung protective ventilation strategies. Anesthesiologists can use risk evaluation and prediction tools, monitor advanced physiologic targets, and incorporate new innovative monitoring techniques to develop an individualized approach for patients.
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Affiliation(s)
- Erin Hennessey
- Stanford University - School of Medicine Department of Anesthesiology, Perioperative and Pain Medicine, 300 Pasteur Drive, Room H3580, Stanford, CA 94305, USA.
| | - Edward Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Peggy White
- University of Florida College of Medicine, Department of Anesthesiology, 1500 SW Archer Road, PO Box 100254, Gainesville, FL 32610, USA
| | - Alan Kovar
- Oregon Health and Science University, 3161 SW Pavilion Loop, Portland, OR 97239, USA
| | - Lucas Meuchel
- Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
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19
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Martinsson A, Houltz E, Wallinder A, Magnusson J, Lindgren S, Stenqvist O, Thorén A. Inspiratory and end-expiratory effects of lung recruitment in the prone position on dorsal lung aeration - new physiological insights in a secondary analysis of a randomised controlled study in post-cardiac surgery patients. BJA OPEN 2022; 4:100105. [PMID: 37588783 PMCID: PMC10430825 DOI: 10.1016/j.bjao.2022.100105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/20/2022] [Indexed: 08/18/2023]
Abstract
Background Cardiac surgery produces dorso-basal atelectasis and ventilation/perfusion mismatch, associated with infection and prolonged intensive care. A postoperative lung volume recruitment manoeuvre to decrease the degree of atelectasis is routine. In patients with severe respiratory failure, prone positioning and recruitment manoeuvres may increase survival, oxygenation, or both. We compared the effects of lung recruitment in prone vs supine positions on dorsal inspiratory and end-expiratory lung aeration. Methods In a prospective RCT, 30 post-cardiac surgery patients were randomly allocated to recruitment manoeuvres in the prone (n=15) or supine position (n=15). The primary endpoints were late dorsal inspiratory volume (arbitrary units [a.u.]) and left/right dorsal end-expiratory lung volume change (a.u.), prone vs supine after extubation, measured using electrical impedance tomography. Secondary outcomes included left/right dorsal inspiratory volumes (a.u.) and left/right dorsal end-expiratory lung volume change (a.u.) after prone recruitment and extubation. Results The last part of dorsal end-inspiratory volume after extubation was higher after prone (49.1 a.u.; 95% confidence interval [CI], 37.4-60.6) vs supine recruitment (24.2 a.u.; 95% CI, 18.4-29.6; P=0.024). Improvement in left dorsal end-expiratory lung volume after extubation was higher after prone (382 a.u.; 95% CI, 261-502) vs supine recruitment (-71 a.u., 95% CI, -140 to -2; n=15; P<0.001). After prone recruitment, left vs right predominant end-expiratory dorsal lung volume change disappeared after extubation. However, both left and right end-expiratory volumes were higher in the prone group, after extubation. Conclusions Recruitment in the prone position improves dorsal inspiratory and end-expiratory lung volumes after cardiac surgery. Clinical trial registration NCT03009331.
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Affiliation(s)
- Andreas Martinsson
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Erik Houltz
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Andreas Wallinder
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jesper Magnusson
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Pulmonary Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sophie Lindgren
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Ola Stenqvist
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Anders Thorén
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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Ellenberger C, Pelosi P, de Abreu MG, Wrigge H, Diaper J, Hagerman A, Adam Y, Schultz MJ, Licker M. Distribution of ventilation and oxygenation in surgical obese patients ventilated with high versus low positive end-expiratory pressure: A substudy of a randomised controlled trial. Eur J Anaesthesiol 2022; 39:875-884. [PMID: 36093886 PMCID: PMC9553219 DOI: 10.1097/eja.0000000000001741] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND Intra-operative ventilation using low/physiological tidal volume and positive end-expiratory pressure (PEEP) with periodic alveolar recruitment manoeuvres (ARMs) is recommended in obese surgery patients. OBJECTIVES To investigate the effects of PEEP levels and ARMs on ventilation distribution, oxygenation, haemodynamic parameters and cerebral oximetry. DESIGN A substudy of a randomised controlled trial. SETTING Tertiary medical centre in Geneva, Switzerland, between 2015 and 2018. PATIENTS One hundred and sixty-two patients with a BMI at least 35 kg per square metre undergoing elective open or laparoscopic surgery lasting at least 120 min. INTERVENTION Patients were randomised to PEEP of 4 cmH 2 O ( n = 79) or PEEP of 12 cmH 2 O with hourly ARMs ( n = 83). MAIN OUTCOME MEASURES The primary endpoint was the fraction of ventilation in the dependent lung as measured by electrical impedance tomography. Secondary endpoints were the oxygen saturation index (SaO 2 /FIO 2 ratio), respiratory and haemodynamic parameters, and cerebral tissue oximetry. RESULTS Compared with low PEEP, high PEEP was associated with smaller intra-operative decreases in dependent lung ventilation [-11.2%; 95% confidence interval (CI) -8.7 to -13.7 vs. -13.9%; 95% CI -11.7 to -16.5; P = 0.029], oxygen saturation index (-49.6%; 95% CI -48.0 to -51.3 vs. -51.3%; 95% CI -49.6 to -53.1; P < 0.001) and a lower driving pressure (-6.3 cmH 2 O; 95% CI -5.7 to -7.0). Haemodynamic parameters did not differ between the groups, except at the end of ARMs when arterial pressure and cardiac index decreased on average by -13.7 mmHg (95% CI -12.5 to -14.9) and by -0.54 l min -1 m -2 (95% CI -0.49 to -0.59) along with increased cerebral tissue oximetry (3.0 and 3.2% on left and right front brain, respectively). CONCLUSION In obese patients undergoing abdominal surgery, intra-operative PEEP of 12 cmH 2 O with periodic ARMs, compared with intra-operative PEEP of 4 cmH 2 O without ARMs, slightly redistributed ventilation to dependent lung zones with minor improvements in peripheral and cerebral oxygenation. TRIAL REGISTRATION NCT02148692, https://clinicaltrials.gov/ct2.
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Affiliation(s)
- Christoph Ellenberger
- From the Department of Anaesthesia, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, rue Gabriel-Perret-Gentil (CE, JD, AH, YA, ML), Faculty of Medicine, University of Geneva, Geneva, Switzerland (CE, ML), Department of Surgical Sciences and Integrated Diagnostics, University of Genoa (PP), Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy (PP), Pulmonary Engineering Group, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany (MGdA), Department of Outcomes Research (MGdA), Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA (MGdA), Department of Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital (HW), Medical Faculty, Martin-Luther-University Halle-Wittenberg, Halle, Germany (HW), Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands (MJS)
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Wang J, Zeng J, Zhang C, Zheng W, Huang X, Zhao N, Duan G, Yu C. Optimized ventilation strategy for surgery on patients with obesity from the perspective of lung protection: A network meta-analysis. Front Immunol 2022; 13:1032783. [PMID: 36330511 PMCID: PMC9623268 DOI: 10.3389/fimmu.2022.1032783] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/03/2022] [Indexed: 11/28/2022] Open
Abstract
Objectives New ventilation modes have been proposed to support the perioperative treatment of patients with obesity, but there is a lack of consensus regarding the optimal strategy. Therefore, a network meta-analysis update of 13 ventilation strategies was conducted to determine the optimal mode of mechanical ventilation as a protective ventilation strategy decreases pulmonary atelectasis caused by inflammation. Methods The following databases were searched: MEDLINE; Cochrane Library; Embase; CINAHL; Google Scholar; and Web of Science for randomized controlled trials of mechanical ventilation in patients with obesity published up to May 1, 2022. Results Volume-controlled ventilation with individualized positive end-expiratory pressure and a recruitment maneuver (VCV+PEEPind+RM) was found to be the most effective strategy for improving ratio of the arterial O2 partial pressure to the inspiratory O2 concentration (PaO2/FiO2), and superior to pressure-controlled ventilation (PCV), volume-controlled ventilation (VCV), volume-controlled ventilation with recruitment maneuver (VCV+RM), volume-controlled ventilation with low positive end-expiratory pressure (VCV+lowPEEP), volume-controlled ventilation with lower positive expiratory end pressure (PEEP) and recruitment maneuver (VCV+lowPEEP+RM), and the mean difference [MD], the 95% confidence intervals [CIs] and [quality of evidence] were: 162.19 [32.94, 291.45] [very low]; 180.74 [59.22, 302.27] [low]; 171.07 [40.60, 301.54] [very low]; 135.14 [36.10, 234.18] [low]; and 139.21 [27.08, 251.34] [very low]. Surface under the cumulative ranking curve (SUCRA) value showed VCV+PEEPind+RM was the best strategy for improving PaO2/FiO2 (SUCRA: 0.963). VCV with high positive PEEP and recruitment maneuver (VCV+highPEEP+RM) was more effective in decreasing postoperative pulmonary atelectasis than the VCV+lowPEEP+RM strategy. It was found that volume-controlled ventilation with high positive expiratory end pressure (VCV+highPEEP), risk ratio [RR] [95% CIs] and [quality of evidence], 0.56 [0.38, 0.81] [moderate], 0.56 [0.34, 0.92] [moderate]. SUCRA value ranked VCV+highPEEP+RM the best strategy for improving postoperative pulmonary atelectasis intervention (SUCRA: 0.933). It should be noted that the quality of evidence was in all cases very low or only moderate. Conclusions This research suggests that VCV+PEEPind+RM is the optimal ventilation strategy for patients with obesity and is more effective in increasing PaO2/FiO2, improving lung compliance, and among the five ventilation strategies for postoperative atelectasis, VCV+highPEEP+RM had the greatest potential to reduce atelectasis caused by inflammation. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021288941.
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Affiliation(s)
- Jing Wang
- Department of Anesthesiology, The Stomatology Hospital Affiliated Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing, China
- Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
| | - Jie Zeng
- Department of Anesthesiology, The Stomatology Hospital Affiliated Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing, China
- Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
| | - Chao Zhang
- Department of Anesthesiology, The Stomatology Hospital Affiliated Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing, China
- Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
| | - Wenwen Zheng
- Department of Anesthesiology, The Stomatology Hospital Affiliated Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing, China
- Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
| | - Xilu Huang
- Department of Anesthesiology, The Stomatology Hospital Affiliated Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing, China
- Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
| | - Nan Zhao
- Department of Anesthesiology, The Stomatology Hospital Affiliated Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing, China
- Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
| | - Guangyou Duan
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Cong Yu
- Department of Anesthesiology, The Stomatology Hospital Affiliated Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing, China
- Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
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22
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Zorrilla-Vaca A, Grant MC, Urman RD, Frendl G. Individualised positive end-expiratory pressure in abdominal surgery: a systematic review and meta-analysis. Br J Anaesth 2022; 129:815-825. [PMID: 36031417 DOI: 10.1016/j.bja.2022.07.009] [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: 10/28/2021] [Revised: 06/29/2022] [Accepted: 07/09/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Individualised PEEP may optimise pulmonary compliance, thereby potentially mitigating lung injury. This meta-analysis aimed to determine the impact of individualised PEEP vs fixed PEEP during abdominal surgery on postoperative pulmonary outcomes. METHODS Medical databases (PubMed, Embase, Web of Science, ScienceDirect, Google Scholar, and the China National Knowledge Infrastructure) were searched for RCTs comparing fixed vs individualised PEEP. The composite primary outcome of pulmonary complications comprised hypoxaemia, atelectasis, pneumonia, and acute respiratory distress syndrome. Secondary outcomes included oxygenation (PaO2/FiO2) and systemic inflammatory markers (interleukin-6 [IL-6] and club cell protein-16 [CC16]). We calculated risk ratios (RRs) and mean differences (MDs) with 95% confidence interval (CI) using DerSimonian and Laird random effects models. Cochrane risk-of-bias tool was applied. RESULTS Ten RCTs (n=1117 patients) met the criteria for inclusion, with six reporting the primary endpoint. Individualised PEEP reduced the incidence of overall pulmonary complications (141/412 [34.2%]) compared with 183/415 (44.1%) receiving fixed PEEP (RR 0.69 [95% CI: 0.51-0.93]; P=0.016; I2=43%). Risk-of-bias analysis did not alter these findings. Individualised PEEP reduced postoperative hypoxaemia (74/392 [18.9%]) compared with 110/395 (27.8%) participants receiving fixed PEEP (RR 0.68 [0.52-0.88]; P=0.003; I2=0%) but not postoperative atelectasis (RR 0.93 [0.81-1.07]; P=0.297; I2=0%). Individualised PEEP resulted in higher PaO2/FiO2 (MD 20.8 mm Hg [4.6-36.9]; P=0.012; I2=80%) and reduced systemic inflammation (lower plasma IL-6 [MD -6.8 pg ml-1; -11.9 to -1.7]; P=0.009; I2=6%; and CC16 levels [MD -6.2 ng ml-1; -8.8 to -3.5]; P<0.001; I2=0%) at the end of surgery. CONCLUSIONS Individualised PEEP may reduce pulmonary complications, improve oxygenation, and reduce systemic inflammation after abdominal surgery. CLINICAL TRIAL REGISTRATION CRD42021277973.
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Affiliation(s)
- Andres Zorrilla-Vaca
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Universidad Del Valle, Hospital Universitario Del Valle, Cali, Colombia.
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gyorgy Frendl
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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23
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Non-invasive over-distension measurements: data driven vs model-based. J Clin Monit Comput 2022; 37:389-398. [PMID: 35920951 DOI: 10.1007/s10877-022-00900-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 07/22/2022] [Indexed: 10/16/2022]
Abstract
Clinical measurements offer bedside monitoring aiming to minimise unintended over-distension, but have limitations and cannot be predicted for changes in mechanical ventilation (MV) settings and are only available in certain MV modes. This study introduces a non-invasive, real-time over-distension measurement, which is robust, predictable, and more intuitive than current methods. The proposed over-distension measurement, denoted as OD, is compared with the clinically proven stress index (SI). Correlation is analysed via R2 and Spearman rs. The OD safe range corresponding to the unit-less SI safe range (0.95-1.05) is calibrated by sensitivity and specificity test. Validation is fulfilled with 19 acute respiratory distress syndrome (ARDS) patients data (196 cases), including assessment across ARDS severity. Overall correlation between OD and SI yielded R2 = 0.76 and Spearman rs = 0.89. Correlation is higher considering only moderate and severe ARDS patients. Calibration of OD to SI yields a safe range defined: 0 ≤ OD ≤ 0.8 cmH2O. The proposed OD offers an efficient, general, real-time measurement of patient-specific lung mechanics, which is more intuitive and robust than SI. OD eliminates the limitations of SI in MV mode and its less intuitive lung status value. Finally, OD can be accurately predicted for new ventilator settings via its foundation in a validated predictive personalized lung mechanics model. Therefore, OD offers potential clinical value over current clinical methods.
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Methods for Determination of Individual PEEP for Intraoperative Mechanical Ventilation Using a Decremental PEEP Trial. J Clin Med 2022; 11:jcm11133707. [PMID: 35806990 PMCID: PMC9267263 DOI: 10.3390/jcm11133707] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/22/2022] [Accepted: 06/24/2022] [Indexed: 02/04/2023] Open
Abstract
(1) Background: Individual PEEP settings (PEEPIND) may improve intraoperative oxygenation and optimize lung mechanics. However, there is uncertainty concerning the optimal procedure to determine PEEPIND. In this secondary analysis of a randomized controlled clinical trial, we compared different methods for PEEPIND determination. (2) Methods: Offline analysis of decremental PEEP trials was performed and PEEPIND was retrospectively determined according to five different methods (EIT-based: RVDI method, Global Inhomogeneity Index [GI], distribution of tidal ventilation [EIT VT]; global dynamic and quasi-static compliance). (3) Results: In the 45 obese and non-obese patients included, PEEPIND using the RVDI method (PEEPRVD) was 16.3 ± 4.5 cm H2O. Determination of PEEPIND using the GI and EIT VT resulted in a mean difference of −2.4 cm H2O (95%CI: −1.2;−3.6 cm H2O, p = 0.01) and −2.3 cm H2O (95% CI: −0.9;3.7 cm H2O, p = 0.01) to PEEPRVD, respectively. PEEPIND selection according to quasi-static compliance showed the highest agreement with PEEPRVD (p = 0.67), with deviations > 4 cm H2O in 3/42 patients. PEEPRVD and PEEPIND according to dynamic compliance also showed a high level of agreement, with deviations > 4 cm H2O in 5/42 patients (p = 0.57). (4) Conclusions: High agreement of PEEPIND determined by the RVDI method and compliance-based methods suggests that, for routine clinical practice, PEEP selection based on best quasi-static or dynamic compliance is favorable.
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25
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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: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The development of pulmonary atelectasis is common in the surgical patient. Pulmonary atelectasis can cause various degrees of gas exchange and respiratory mechanics impairment during and after surgery. In its most serious presentations, lung collapse could contribute to postoperative respiratory insufficiency, pneumonia, and worse overall clinical outcomes. A specific risk assessment is critical to allow clinicians to optimally choose the anesthetic technique, prepare appropriate monitoring, adapt the perioperative plan, and ensure the patient's safety. Bedside diagnosis and management have benefited from recent imaging advancements such as lung ultrasound and electrical impedance tomography, and monitoring such as esophageal manometry. Therapeutic management includes a broad range of interventions aimed at promoting lung recruitment. During general anesthesia, these strategies have consistently demonstrated their effectiveness in improving intraoperative oxygenation and respiratory compliance. Yet these same intraoperative strategies may fail to affect additional postoperative pulmonary outcomes. Specific attention to the postoperative period may be key for such outcome impact of lung expansion. Interventions such as noninvasive positive pressure ventilatory support may be beneficial in specific patients at high risk for pulmonary atelectasis (e.g., obese) or those with clinical presentations consistent with lung collapse (e.g., postoperative hypoxemia after abdominal and cardiothoracic surgeries). Preoperative interventions may open new opportunities to minimize perioperative lung collapse and prevent pulmonary complications. Knowledge of pathophysiologic mechanisms of atelectasis and their consequences in the healthy and diseased lung should provide the basis for current practice and help to stratify and match the intensity of selected interventions to clinical conditions.
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Affiliation(s)
- David Lagier
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Congli Zeng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Marcos F. Vidal Melo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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26
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Obesity and Positive End-expiratory Pressure: Reply. Anesthesiology 2021; 135:1160-1162. [PMID: 34610085 DOI: 10.1097/aln.0000000000004004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nascimento MS, Alcala GC, Guzman AIA, Corrêa LC, Baggio DM, Rossi FS, Fascina LP, Amato MBP, do Prado C. Electrical impedance tomography in pediatric patients with COVID-19, the first reports. BMC Pulm Med 2021; 21:357. [PMID: 34749685 PMCID: PMC8573758 DOI: 10.1186/s12890-021-01716-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 10/25/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Electrical impedance tomography (EIT) is a noninvasive, radiation-free, bedside tool to monitor ventilation distribution in real time. Objective To evaluate, in pediatric COVID-19 patients, the ventilation distribution using EIT and compare it to thoracic computed tomography (TCT) or chest radiograph results obtained in these patients. Methods This was a prospective, observational clinical study including pediatric patients admitted to the intensive care unit of a private hospital. The patients monitored with EIT tested positive for COVID-19 and were submitted to the previously mentioned radiation exams. EIT monitoring lasted 15 min and no sedation was used. Results Six patients were included in this study. The main differences observed in the EIT were in the right-left distribution and were compatible with the morphological changes found in the TCT or radiograph images due to COVID-19 infection. Conclusion We conclude that EIT is ready to investigate the ventilatory profile present at different lung diseases, including COVID-19, and might postpone or mitigate the need of repeated ionizing radiation exams in the pediatric population, although larger pediatric cohorts comparing to standard radiological imaging are needed.
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Affiliation(s)
- Milena S Nascimento
- Department of Pediatrics, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 627-701, São Paulo, SP, 05651-901, Brazil.
| | | | | | | | - Diana M Baggio
- Department of Pediatrics, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 627-701, São Paulo, SP, 05651-901, Brazil
| | - Felipe S Rossi
- Department of Pediatrics, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 627-701, São Paulo, SP, 05651-901, Brazil
| | - Linus P Fascina
- Department of Pediatrics, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 627-701, São Paulo, SP, 05651-901, Brazil
| | - Marcelo B P Amato
- Divisão de Pneumologia, Cardiopulmonary Department, Heart Institute (INCOR), São Paulo, SP, Brazil
| | - Cristiane do Prado
- Department of Pediatrics, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 627-701, São Paulo, SP, 05651-901, Brazil
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Intraoperative Positive End-expiratory Pressure for Obese Patients: A Step Forward, a Long Road Still Ahead. Anesthesiology 2021; 134:838-840. [PMID: 33909874 DOI: 10.1097/aln.0000000000003806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wrigge H, Streibert F. [Intraoperative Ventilation in Adults]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:318-328. [PMID: 34038971 DOI: 10.1055/a-1189-8057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Avoiding postoperative pulmonary complications (PPC) is an important goal for anesthesiologists during general anesthesia, and ventilation strategies may play a role. It seems reasonable to apply knowledge from lessons we learned from ventilation of intensive care unit patients aiming at avoiding ventilator associated lung injury. Ventilation associated lung injuries occur frequently and are associated with substantial morbidity and mortality. Strategies of lung protective ventilation, like lower tidal volumes and the use of positive end-expiatory pressure (PEEP), can usually be transferred safely to perioperative ventilation, although some issues such as hemodynamic side effects must be considered. For some reasons, however, current evidence is conflicting and there is no consensus on ventilatory perioperative management to avoid PPCs so far. This paper briefly summarizes physiological backgrounds in a functional context, current evidence, and provides some recommendations at "expert" opinion level for perioperative ventilation procedures.Especially in patients at risk and/or during surgery with higher surgical trauma and inflammation, we recommend limiting tidal volume to 6 - 8 ml/kg predicted body weight and the use of PEEP, which should be individualized e.g. by minimizing driving pressure. Recruitment maneuvers may be considered and should be carried out by using the ventilator.Obese patients are an increasing entity and can be challenging during anesthesia and ventilation. From a physiological point of view, these patients require much higher ventilation pressures as currently used, although recent evidence is not in favor of using moderately higher PEEP, which is matter of discussion.
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