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Wang Z, Cheng Q, Huang S, Sun J, Xu J, Xie J, Cao H, Guo F. Effect of perioperative sigh ventilation on postoperative hypoxemia and pulmonary complications after on-pump cardiac surgery (E-SIGHT): study protocol for a randomized controlled trial. Trials 2024; 25:585. [PMID: 39232795 PMCID: PMC11373100 DOI: 10.1186/s13063-024-08416-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 08/21/2024] [Indexed: 09/06/2024] Open
Abstract
BACKGROUND Postoperative hypoxemia and pulmonary complications remain a frequent event after on-pump cardiac surgery and mostly characterized by pulmonary atelectasis. Surfactant dysfunction or hyposecretion happens prior to atelectasis formation, and sigh represents the strongest stimulus for surfactant secretion. The role of sigh breaths added to conventional lung protective ventilation in reducing postoperative hypoxemia and pulmonary complications among cardiac surgery is unknown. METHODS The perioperative sigh ventilation in cardiac surgery (E-SIGHT) trial is a single-center, two-arm, randomized controlled trial. In total, 192 patients scheduled for elective cardiac surgery with cardiopulmonary bypass (CPB) and aortic cross-clamp will be randomized into one of the two treatment arms. In the experimental group, besides conventional lung protective ventilation, sigh volumes producing plateau pressures of 35 cmH2O (or 40 cmH2O for patients with body mass index > 35 kg/m2) delivered once every 6 min from intubation to extubation. In the control group, conventional lung protective ventilation without preplanned recruitment maneuvers is used. Lung protective ventilation (LPV) consists of low tidal volumes (6-8 mL/kg of predicted body weight) and positive end-expiratory pressure (PEEP) setting according to low PEEP/FiO2 table for acute respiratory distress syndrome (ARDS). The primary endpoint is time-weighted average SpO2/FiO2 ratio during the initial post-extubation hour. Main secondary endpoint is the severity of postoperative pulmonary complications (PPCs) computed by postoperative day 7. DISCUSSION The E-SIGHT trial will be the first randomized controlled trial to evaluate the impact of perioperative sigh ventilation on the postoperative outcomes after on-pump cardiac surgery. The trial will introduce and assess a novel perioperative ventilation approach to mitigate the risk of postoperative hypoxemia and PPCs in patients undergoing cardiac surgery. Also provide the basis for a future larger trial aiming at verifying the impact of sigh ventilation on postoperative pulmonary complications. TRIAL REGISTRATION ClinicalTrials.gov NCT06248320. Registered on January 30, 2024. Last updated February 26, 2024.
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Affiliation(s)
- Zhichang Wang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Qiyu Cheng
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Shenglun Huang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Jie Sun
- Department of Anesthesiology, Surgery and Pain Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Jingyuan Xu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Hailong Cao
- Department of Cardiothoracic Surgery, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China.
| | - Fengmei Guo
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China.
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Nagrebetsky A, Zhu M, Deng H, Gaissert HA, Gama de Abreu M, Frendl G, Schaefer MS, Vidal Melo MF. Impaired oxygenation after lung resection: Incidence and perioperative risk factors. J Clin Anesth 2024; 96:111485. [PMID: 38718685 DOI: 10.1016/j.jclinane.2024.111485] [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: 09/26/2023] [Revised: 04/14/2024] [Accepted: 04/19/2024] [Indexed: 06/16/2024]
Abstract
STUDY OBJECTIVE To estimate the incidence of postoperative oxygenation impairment after lung resection in the era of lung-protective management, and to identify perioperative factors associated with that impairment. DESIGN Registry-based retrospective cohort study. SETTING Two large academic hospitals in the United States. PATIENTS 3081 ASA I-IV patients undergoing lung resection. MEASUREMENTS 79 pre- and intraoperative variables, selected for inclusion based on a causal inference framework. The primary outcome of impaired oxygenation, an early marker of lung injury, was defined as at least one of the following within seven postoperative days: (1) SpO2 < 92%; (2) imputed PaO2/FiO2 < 300 mmHg [(1) or (2) occurring at least twice within 24 h]; (3) intensive oxygen therapy (mechanical ventilation or > 50% oxygen or high-flow oxygen). MAIN RESULTS Oxygenation was impaired within seven postoperative days in 70.8% of patients (26.6% with PaO2/FiO2 < 200 mmHg or intensive oxygen therapy). In multivariable analysis, each additional cmH2O of intraoperative median driving pressure was associated with a 7% higher risk of impaired oxygenation (OR 1.07; 95%CI 1.04 to 1.10). Higher median intraoperative FiO2 (OR 1.23; 95%CI 1.14 to 1.31 per 0.1) and PEEP (OR 1.12; 95%CI 1.04 to 1.21 per 1 cm H2O) were also associated with increased risk. History of COPD (OR 2.55; 95%CI 1.95 to 3.35) and intraoperative albuterol administration (OR 2.07; 95%CI 1.17 to 3.67) also showed reliable effects. CONCLUSIONS Impaired postoperative oxygenation is common after lung resection and is associated with potentially modifiable pre- and intraoperative respiratory factors.
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Affiliation(s)
- Alexander Nagrebetsky
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Min Zhu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hao Deng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Henning A Gaissert
- Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcelo Gama de Abreu
- Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gyorgy Frendl
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Marcos F Vidal Melo
- Division of Adult Cardiothoracic Anesthesiology, Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, USA
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Szamos K, Balla B, Pálóczi B, Enyedi A, Sessler DI, Fülesdi B, Végh T. One-lung ventilation with fixed and variable tidal volumes on oxygenation and pulmonary outcomes: A randomized trial. J Clin Anesth 2024; 95:111465. [PMID: 38581926 DOI: 10.1016/j.jclinane.2024.111465] [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] [Revised: 03/22/2024] [Accepted: 04/01/2024] [Indexed: 04/08/2024]
Abstract
OBJECTIVE Test the hypothesis that one-lung ventilation with variable tidal volume improves intraoperative oxygenation and reduces postoperative pulmonary complications after lung resection. BACKGROUND Constant tidal volume and respiratory rate ventilation can lead to atelectasis. Animal and human ARDS studies indicate that oxygenation improves with variable tidal volumes. Since one-lung ventilation shares characteristics with ARDS, we tested the hypothesis that one-lung ventilation with variable tidal volume improves intraoperative oxygenation and reduces postoperative pulmonary complications after lung resection. DESIGN Randomized trial. SETTING Operating rooms and a post-anesthesia care unit. PATIENTS Adults having elective open or video-assisted thoracoscopic lung resection surgery with general anesthesia were randomly assigned to intraoperative ventilation with fixed (n = 70) or with variable (n = 70) tidal volumes. INTERVENTIONS Patients assigned to fixed ventilation had a tidal volume of 6 ml/kgPBW, whereas those assigned to variable ventilation had tidal volumes ranging from 6 ml/kg PBW ± 33% which varied randomly at 5-min intervals. MEASUREMENTS The primary outcome was intraoperative oxygenation; secondary outcomes were postoperative pulmonary complications, mortality within 90 days of surgery, heart rate, and SpO2/FiO2 ratio. RESULTS Data from 128 patients were analyzed with 65 assigned to fixed-tidal volume ventilation and 63 to variable-tidal volume ventilation. The time-weighted average PaO2 during one-lung ventilation was 176 (86) mmHg in patients ventilated with fixed-tidal volume and 147 (72) mmHg in the patients ventilated with variable-tidal volume, a difference that was statistically significant (p < 0.01) but less than our pre-defined clinically meaningful threshold of 50 mmHg. At least one composite complication occurred in 11 (17%) of patients ventilated with variable-tidal volume and in 17 (26%) of patients assigned to fixed-tidal volume ventilation, with a relative risk of 0.67 (95% CI 0.34-1.31, p = 0.24). Atelectasis in the ventilated lung was less common with variable-tidal volumes (4.7%) than fixed-tidal volumes (20%) in the initial three postoperative days, with a relative risk of 0.24 (95% CI 0.01-0.8, p = 0.02), but there were no significant late postoperative differences. No other secondary outcomes were both statistically significant and clinically meaningful. CONCLUSION One-lung ventilation with variable tidal volume does not meaningfully improve intraoperative oxygenation, and does not reduce postoperative pulmonary complications.
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Affiliation(s)
- Katalin Szamos
- University of Debrecen, Department of Anesthesiology and Intensive Care, Debrecen, Hungary
| | - Boglárka Balla
- University of Debrecen, Department of Anesthesiology and Intensive Care, Debrecen, Hungary
| | - Balázs Pálóczi
- University of Debrecen, Department of Anesthesiology and Intensive Care, Debrecen, Hungary
| | - Attila Enyedi
- University of Debrecen, Institute of Surgery, Department of Thoracic Surgery, Debrecen, Hungary
| | - Daniel I Sessler
- Outcomes Research Consortium, Cleveland, OH, USA; Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Béla Fülesdi
- University of Debrecen, Department of Anesthesiology and Intensive Care, Debrecen, Hungary; Outcomes Research Consortium, Cleveland, OH, USA
| | - Tamás Végh
- University of Debrecen, Department of Anesthesiology and Intensive Care, Debrecen, Hungary; Outcomes Research Consortium, Cleveland, OH, USA.
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Wang X, Guo K, Sun J, Yang Y, Wu Y, Tang X, Xu Y, Chen Q, Zeng S, Wang L, Liu S. Semirecumbent Positioning During Anesthesia Recovery and Postoperative Hypoxemia: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2416797. [PMID: 38941098 PMCID: PMC11214118 DOI: 10.1001/jamanetworkopen.2024.16797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 04/09/2024] [Indexed: 06/29/2024] Open
Abstract
Importance The efficacy of a semirecumbent position (SRP) in reducing postoperative hypoxemia during anesthesia emergence is unclear despite its widespread use. Objective To determine the differences in postoperative hypoxemia between patients in an SRP and a supine position. Design, Setting, and Participants This randomized clinical trial was performed at a tertiary hospital in China between March 20, 2021, and May 10, 2022. Patients scheduled to undergo laparoscopic upper abdominal surgery under general anesthesia were enrolled. Study recruitment and follow-up are complete. Interventions Patients were randomized to 1 of the following positions at the end of the operation until leaving the postanesthesia care unit: supine (group S), 15° SRP (group F), or 30° SRP (group T). Main Outcomes and Measures The primary outcome was the incidence of postoperative hypoxemia in the postanesthesia care unit. Severe hypoxemia was also evaluated. Results Out of 700 patients (364 men [52.0%]; mean [SD] age, 47.8 [11.3] years), 233 were randomized to group S (126 men [54.1%]; mean [SD] age, 48.2 [10.9] years), 233 to group F (122 men [52.4%]; mean [SD] age, 48.1 [10.9] years), and 234 to group T (118 women [50.4%]; mean [SD] age, 47.2 [12.1] years). Postoperative hypoxemia differed significantly among the 3 groups (group S, 109 of 233 [46.8%]; group F, 105 of 233 [45.1%]; group T, 76 of 234 [32.5%]; P = .002). This difference was statistically significant for groups T vs S (risk ratio [RR], 0.69 [95% CI, 0.55-0.87]; P = .002) and groups T vs F (RR, 0.72 [95% CI, 0.57-0.91]; P = .007), but not for groups F vs S (RR, 0.96 [95% CI, 0.79-1.17]; P = .78). Severe hypoxemia also differed among the 3 groups (group S, 61 of 233 [26.2%]; group F, 53 of 233 [22.7%]; group T, 36 of 234 [15.4%]; P = .01). This difference was statistically significant for groups T vs S (RR, 0.59 [95% CI, 0.41-0.85]; P = .005). Conclusions and Relevance In this randomized clinical trial of SRP during anesthesia recovery in patients undergoing laparoscopic upper abdominal surgery, postoperative hypoxemia was significantly reduced in group T compared with group F or group S. Trial Registration Chinese Clinical Trial Registry Identifier: ChiCTR2100045087.
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Affiliation(s)
- Xinghe Wang
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
- Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
- NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, China
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, China
| | - Kedi Guo
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
- Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
- NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, China
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Jia Sun
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, China
| | - Yuping Yang
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
- Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
- NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, China
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yan Wu
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
- Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
- NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, China
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xihui Tang
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
- Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
- NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, China
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yuqing Xu
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
- Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
- NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, China
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Qingsong Chen
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
- Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
- NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, China
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Si Zeng
- Department of Anesthesiology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Liwei Wang
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, China
| | - Su Liu
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
- Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
- NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, China
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
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Placenti A, Fratebianchi F. Mean airway pressure as a parameter of lung-protective and heart-protective ventilation. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:466-478. [PMID: 38615712 DOI: 10.1016/j.redare.2024.04.005] [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: 05/25/2022] [Accepted: 01/30/2024] [Indexed: 04/16/2024]
Abstract
Mean airway pressure (MAP) is the mean pressure generated in the airway during a single breath (inspiration + expiration), and is displayed on most anaesthesia and intensive care ventilators. This parameter, however, is not usually monitored during mechanical ventilation because it is poorly understood and usually only used in research. One of the main determinants of MAP is PEEP. This is because in respiratory cycles with an I:E ratio of 1:2, expiration is twice as long as inspiration. Although MAP can be used as a surrogate for mean alveolar pressure, these parameters differ considerably in some situations. Recently, MAP has been shown to be a useful prognostic factor for respiratory morbidity and mortality in mechanically ventilated patients of various ages. Low MAP has been associated with a lower incidence of 90-day mortality, shorter ICU stay, and shorter mechanical ventilation time. MAP also affects haemodynamics: there is evidence of a causal relationship between high MAP and low perfusion index, both of which are associated with poor prognosis in mechanically ventilated patients. Elevated MAP values have also been associated with high central venous pressure and lactate, which are indicative of ventilator-associated right ventricular failure and tissue hypoperfusion, respectively. MAP, therefore, is an important parameter to measure in clinical practice. The aim of this review has been to identify the determinants of MAP, the pros and cons of using MAP instead of traditional protective ventilation parameters, and the evidence that supports the use of MAP in clinical practice.
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Affiliation(s)
- A Placenti
- División de Anestesia, Analgesia y Reanimación, Hospital de Clínicas "José de San Martín", Universidad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina.
| | - F Fratebianchi
- División de Anestesia, Analgesia y Reanimación, Hospital de Clínicas "José de San Martín", Universidad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
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Ryu JH, Jeon YT, Sim KM, Lee S, Oh AY, Koo CH. Role of oxygen reserve index monitoring in patients undergoing robot-assisted radical prostatectomy: a retrospective study. World J Urol 2024; 42:232. [PMID: 38613597 PMCID: PMC11015992 DOI: 10.1007/s00345-024-04938-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 03/20/2024] [Indexed: 04/15/2024] Open
Abstract
PURPOSE Robot-assisted radical prostatectomy (RARP) is a common surgical procedure for the treatment of prostate cancer. Although beneficial, it can lead to intraoperative hypoxia due to high-pressure pneumoperitoneum and Trendelenburg position. This study explored the use of oxygen reserve index (ORi) to monitor and predict hypoxia during RARP. METHODS A retrospective analysis was conducted on 329 patients who underwent RARP at the Seoul National University Bundang Hospital between July 2021 and March 2023. Various pre- and intraoperative variables were collected, including ORi values. The relationship between ORi values and hypoxia occurrence was assessed using receiver operating characteristic curves and logistic regression analysis. RESULTS Intraoperative hypoxia occurred in 18.8% of the patients. The receiver operating characteristic curve showed a satisfactory area under the curve of 0.762, with the ideal ORi cut-off value for predicting hypoxia set at 0.16. Sensitivity and specificity were 64.5% and 75.7%, respectively. An ORi value of < 0.16 and a higher body mass index were identified as independent risk factors of hypoxia during RARP. CONCLUSIONS ORi monitoring provides a non-invasive approach to predict intraoperative hypoxia during RARP, enabling early management. Additionally, the significant relationship between a higher body mass index and hypoxia underscores the importance of individualized patient assessment.
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Affiliation(s)
- Jung-Hee Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, 13620, Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, 03080, Korea
| | - Young-Tae Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, 13620, Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, 03080, Korea
| | - Kyu Man Sim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, 13620, Korea
| | - Soowon Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, 13620, Korea
| | - Ah-Young Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, 13620, Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, 03080, Korea
| | - Chang-Hoon Koo
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, 13620, Korea.
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, 03080, Korea.
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Anusic N, Sessler DI. Innovative designs for trials informing the care of cardiac surgical patients: Part II. Curr Opin Anaesthesiol 2024; 37:49-54. [PMID: 38085856 DOI: 10.1097/aco.0000000000001334] [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: 12/20/2023]
Abstract
PURPOSE OF REVIEW This review examines advances in clinical trial methodologies relevant to cardiac anesthesia. It focuses on innovative approaches, including factorial randomization, composite outcomes, and cluster randomized trials, which enhance the efficiency, practical relevance, and generalizability of trial outcomes. RECENT FINDINGS Factorial randomization is becoming popular because the approach allows investigators to simultaneously evaluate two or more interventions. Furthermore, factorial designs can evaluate interactions among treatments which is highly relevant information that cannot be obtained from separate trials. Composite outcomes are also increasingly utilized, combining multiple individual outcomes into a single measure, which increases statistical power and can better represent relevant physiology. Designing valid composites requires careful consideration of component outcome severity and incidence. Cluster randomized trials, including stepped wedge and multiple crossover designs, address the challenges of group-level effects and shared environments. SUMMARY The evolution of clinical trial designs is marked by a shift towards methodologies that enhance efficiency and provide more nuanced insights into treatment effects. These include factorial designs for simultaneous intervention assessment, composite outcomes for comprehensive physiological representation, and cluster trials for group-level effect analysis. Such advancements are shaping the future of clinical research, making it more relevant, efficient, and broadly applicable.
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Affiliation(s)
- Nikola Anusic
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
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Tartler TM, Ahrens E, Munoz-Acuna R, Azizi BA, Chen G, Suleiman A, Wachtendorf LJ, Costa ELV, Talmor DS, Amato MBP, Baedorf-Kassis EN, Schaefer MS. High Mechanical Power and Driving Pressures are Associated With Postoperative Respiratory Failure Independent From Patients' Respiratory System Mechanics. Crit Care Med 2024; 52:68-79. [PMID: 37695139 DOI: 10.1097/ccm.0000000000006038] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
OBJECTIVES High mechanical power and driving pressure (ΔP) have been associated with postoperative respiratory failure (PRF) and may be important parameters guiding mechanical ventilation. However, it remains unclear whether high mechanical power and ΔP merely reflect patients with poor respiratory system mechanics at risk of PRF. We investigated the effect of mechanical power and ΔP on PRF in cohorts after exact matching by patients' baseline respiratory system compliance. DESIGN Hospital registry study. SETTING Academic hospital in New England. PATIENTS Adult patients undergoing general anesthesia between 2008 and 2020. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS The primary exposure was high (≥ 6.7 J/min, cohort median) versus low mechanical power and the key-secondary exposure was high (≥ 15.0 cm H 2 O) versus low ΔP. The primary endpoint was PRF (reintubation or unplanned noninvasive ventilation within seven days). Among 97,555 included patients, 4,030 (4.1%) developed PRF. In adjusted analyses, high intraoperative mechanical power and ΔP were associated with higher odds of PRF (adjusted odds ratio [aOR] 1.37 [95% CI, 1.25-1.50]; p < 0.001 and aOR 1.45 [95% CI, 1.31-1.60]; p < 0.001, respectively). There was large variability in applied ventilatory parameters, dependent on the anesthesia provider. This facilitated matching of 63,612 (mechanical power cohort) and 53,260 (ΔP cohort) patients, yielding identical baseline standardized respiratory system compliance (standardized difference [SDiff] = 0.00) with distinctly different mechanical power (9.4 [2.4] vs 4.9 [1.3] J/min; SDiff = -2.33) and ΔP (19.3 [4.1] vs 11.9 [2.1] cm H 2 O; SDiff = -2.27). After matching, high mechanical power and ΔP remained associated with higher risk of PRF (aOR 1.30 [95% CI, 1.17-1.45]; p < 0.001 and aOR 1.28 [95% CI, 1.12-1.46]; p < 0.001, respectively). CONCLUSIONS High mechanical power and ΔP are associated with PRF independent of patient's baseline respiratory system compliance. Our findings support utilization of these parameters for titrating mechanical ventilation in the operating room and ICU.
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Affiliation(s)
- Tim M Tartler
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Department of Anesthesia, Critical Care and Pain Medicine, Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Elena Ahrens
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Department of Anesthesia, Critical Care and Pain Medicine, Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ricardo Munoz-Acuna
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Department of Anesthesia, Critical Care and Pain Medicine, Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Basit A Azizi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Department of Anesthesia, Critical Care and Pain Medicine, Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Guanqing Chen
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Aiman Suleiman
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Luca J Wachtendorf
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Department of Anesthesia, Critical Care and Pain Medicine, Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Eduardo L V Costa
- Divisão de Pneumologia, Cardiopulmonary Department, Heart Institute (INCOR), São Paulo, SP, Brazil
| | - Daniel S Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marcelo B P Amato
- Divisão de Pneumologia, Cardiopulmonary Department, Heart Institute (INCOR), São Paulo, SP, Brazil
| | - Elias N Baedorf-Kassis
- Department of Anesthesia, Critical Care and Pain Medicine, Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Department of Anesthesia, Critical Care and Pain Medicine, Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
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9
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Rehman TA, John K, Maslow A. Protective Lung Ventilation: What Do We Know?-"In An Investigation, Details Matter"-Jack Reacher TV Series. J Cardiothorac Vasc Anesth 2023; 37:2572-2576. [PMID: 37423839 PMCID: PMC10264327 DOI: 10.1053/j.jvca.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/11/2023] [Indexed: 07/11/2023]
Affiliation(s)
- T A Rehman
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Boston, MA
| | - K John
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - A Maslow
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI.
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Yeom R, Gorgone M, Malinovic M, Panzica P, Maslow A, Augoustides JG, Marchant BE, Fernando RJ, Nampi RG, Pospishil L, Neuburger PJ. Surgical Aortic Valve Replacement in a Patient with Very Severe Chronic Obstructive Pulmonary Disease. J Cardiothorac Vasc Anesth 2023; 37:2335-2349. [PMID: 37657996 DOI: 10.1053/j.jvca.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 08/06/2023] [Indexed: 09/03/2023]
Affiliation(s)
- Richard Yeom
- Department of Anesthesiology, Westchester Medical Center, Valhalla, NY
| | - Michelle Gorgone
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - Matea Malinovic
- Department of Anesthesiology, Westchester Medical Center, Valhalla, NY
| | - Peter Panzica
- Department of Anesthesiology, Westchester Medical Center, Valhalla, NY
| | - Andrew Maslow
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - John G Augoustides
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Bryan E Marchant
- Department of Anesthesiology, Cardiothoracic and Critical Care Sections, Wake Forest University School of Medicine, Winston Salem, NC
| | - Rohesh J Fernando
- Department of Anesthesiology, Cardiothoracic Section, Wake Forest University School of Medicine, Medical Center Boulevard, Winston Salem, NC.
| | - Robert G Nampi
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY
| | - Liliya Pospishil
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY
| | - Peter J Neuburger
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY
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Almonacid-Cardenas F, Saab R, Nemirovsky ES, Rivas E, Araujo-Duran J, Mao G, Esa WAS, Ruetzler K, Argalious M, Turan A. The effect of intraoperative positive end expiratory pressure and tidal volume on postoperative acute kidney injury after orthopedic surgery. Acta Anaesthesiol Scand 2023; 67:1348-1355. [PMID: 37650561 DOI: 10.1111/aas.14314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/06/2023] [Accepted: 07/13/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND To test whether higher intraoperative PEEP levels and/or higher TV levels are associated with higher incidence of postoperative AKI within the first postoperative week, in adult patients having orthopedic surgeries under general anesthesia. METHODS We conducted a sub analysis of a non-randomized alternating intervention cross over study performed in patients undergoing orthopedic surgery under general anesthesia at Cleveland Clinic, Cleveland, OH. We included four different combinations of PEEP (5 or 8 cm H2 O) and TV (6 or 10 mL/kg of PBW) that alternated each week in the six orthopedic operating rooms. Our primary outcome was postoperative AKI defined by the KDIGO criteria with baseline creatinine as the closest preoperative value to the time of surgery obtained within 30 days and postoperative value as the highest creatinine value within 7 days after surgery. Secondary outcome was the maximum postoperative in-hospital creatinine level within seven postoperative days. MAIN RESULTS A total of 1933 patients were included in the analysis. The incidence of AKI was 6.8% in the study population and similar in high TV versus low TV group and high PEEP versus low PEEP group. Neither TV nor PEEP significantly impacted AKI incidence. The estimated odds ratio of AKI comparing TV = 6 mL/kg to TV = 10 mL/kg was 0.96 (97.5% CI: 0.63, 1.46; p = .811); while the estimated odds ratio of AKI comparing PEEP = 5cm H2 O to PEEP = 8cm H2 O was 0.92 (97.5% CI: 0.60, 1.39; p = .623). No interaction was found between TV and PEEP on AKI. Additionally, neither TV nor PEEP had a significant effect on the seven postoperative day creatinine levels. CONCLUSION Higher levels of PEEP or TV during mechanical ventilation in adult patients undergoing orthopedic surgeries under general anesthesia do not increase the odds of developing postoperative AKI within the narrow limits studied.
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Affiliation(s)
| | - Remie Saab
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eitan Scher Nemirovsky
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eva Rivas
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Anesthesia, Hospital Clinic of Barcelona, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - Jorge Araujo-Duran
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Guangmei Mao
- Department of Quantitative Health Services, Cleveland Clinic, Cleveland, Ohio, USA
| | - Wael Ali Sakr Esa
- Department of General Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of General Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Maged Argalious
- Department of General Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alparslan Turan
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of General Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
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12
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Schmidt M, Rössler J, Brooker J, Lara-Erazo V, Ekrami E, Pu X, Turan A, Sessler DI, Ruetzler K. Postoperative oxygenation assessed by SpO 2/FiO 2 ratio and respiratory complications after reversal of neuromuscular block with Sugammadex or neostigmine: A retrospective cohort study. J Clin Anesth 2023; 88:111138. [PMID: 37148836 DOI: 10.1016/j.jclinane.2023.111138] [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: 01/24/2023] [Revised: 03/31/2023] [Accepted: 04/26/2023] [Indexed: 05/08/2023]
Abstract
STUDY OBJECTIVE Residual neuromuscular block may lead to postoperative muscle weakness, inadequate oxygenation, and other pulmonary complications. Sugammadex may provide more rapid and effective restoration of neuromuscular function than neostigmine. We therefore tested the primary hypothesis that noncardiac surgical patients given sugammadex oxygenate better during initial recovery than those given neostigmine. Secondarily, we tested the hypothesis that patients given sugammadex have fewer pulmonary complications during hospitalization. DESIGN Retrospective cohort analysis. SETTING Postoperative recovery area of a tertiary care hospital. PATIENTS Adults who had non-cardiothoracic surgery and were given either neostigmine or sugammadex. INTERVENTIONS None. MEASUREMENTS The primary outcome was the lowest SpO2/FiO2 ratio in the post-anesthesia care unit. The secondary outcome was a composite of pulmonary complications. MAIN RESULTS Among 71,457 cases, 10,708 (15%) were given sugammadex and 60,749 (85%) received neostigmine. After propensity weighting, the mean minimum SpO2/FiO2 ratio was 301 ± 77 (SD) in patients given sugammadex and 303 ± 71 in those given neostigmine, yielding an estimated difference in means of -3.5 (95% confidence interval: -5.3, -1.7; P = 0.0002). 4.4% of patients given sugammadex and 3.6% of patients given neostigmine had postoperative pulmonary complications (P = 0.0005, number-needed-to-be-exposed =136; 95% CI: 83, 330), with the main contributing components being new bronchospasm or exacerbation of obstructive pulmonary disease. CONCLUSIONS Postoperative minimum SpO2/FiO2 ratio during PACU admission was similar after reversal of neuromuscular block by sugammadex and neostigmine. Reversal with sugammadex was associated with more pulmonary complications, but most were minor and of little consequence.
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Affiliation(s)
- Marc Schmidt
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Jack Brooker
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Valentina Lara-Erazo
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Elyad Ekrami
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Xuan Pu
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of Quantitative Health Sciences, Cleveland Clinic, OH, United States of America
| | - Alparslan Turan
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America.
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13
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Einfluss von Tidalvolumen und PEEP auf postoperative Hypoxie und Lungenfunktion. Anasthesiol Intensivmed Notfallmed Schmerzther 2023. [DOI: 10.1055/a-2002-4246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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