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Koldova K, Rara A, Muller M, Tyll T, Roubik K. Cranial Electrode Belt Position Improves Diagnostic Possibilities of Electrical Impedance Tomography during Laparoscopic Surgery with Capnoperitoneum. SENSORS (BASEL, SWITZERLAND) 2023; 23:8644. [PMID: 37896737 PMCID: PMC10611224 DOI: 10.3390/s23208644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/16/2023] [Accepted: 10/20/2023] [Indexed: 10/29/2023]
Abstract
Laparoscopic surgery with capnoperitoneum brings many advantages to patients, but also emphasizes the negative impact of anesthesia and mechanical ventilation on the lungs. Even though many studies use electrical impedance tomography (EIT) for lung monitoring during these surgeries, it is not clear what the best position of the electrode belt on the patient's thorax is, considering the cranial shift of the diaphragm. We monitored 16 patients undergoing a laparoscopic surgery with capnoperitoneum using EIT with two independent electrode belts at different tomographic levels: in the standard position of the 4th-6th intercostal space, as recommended by the manufacturer, and in a more cranial position at the level of the axilla. Functional residual capacity (FRC) was measured, and a recruitment maneuver was performed at the end of the procedure by raising the positive end-expiratory pressure (PEEP) by 5 cmH2O. The results based on the spectral analysis of the EIT signal show that the ventilation-related impedance changes are not detectable by the belt in the standard position. In general, the cranial belt position might be more suitable for the lung monitoring during the capnoperitoneum since the ventilation signal remains dominant in the obtained impedance waveform. FRC was significantly decreased by the capnoperitoneum and remained lower also after desufflation.
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Affiliation(s)
- Kristyna Koldova
- Department of Biomedical Technology, Faculty of Biomedical Engineering, Czech Technical University in Prague, 272 01 Kladno, Czech Republic;
| | - Ales Rara
- Department of Anesthesiology, Resuscitation and Intensive Care Medicine First Faculty of Medicine, The Military University Hospital Prague, Charles University, 121 08 Prague, Czech Republic; (A.R.); (T.T.)
| | - Martin Muller
- Clinic of Anesthesiology, Critical Care 1st Faculty of Medicine, Thomayer University Hospital Prague, Charles University, 140 59 Prague, Czech Republic;
| | - Tomas Tyll
- Department of Anesthesiology, Resuscitation and Intensive Care Medicine First Faculty of Medicine, The Military University Hospital Prague, Charles University, 121 08 Prague, Czech Republic; (A.R.); (T.T.)
| | - Karel Roubik
- Department of Biomedical Technology, Faculty of Biomedical Engineering, Czech Technical University in Prague, 272 01 Kladno, Czech Republic;
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Yue C, He H, Su L, Wang J, Yuan S, Long Y, Zhao Z. A novel method for diaphragm-based electrode belt position of electrical impedance tomography by ultrasound. J Intensive Care 2023; 11:41. [PMID: 37749637 PMCID: PMC10518967 DOI: 10.1186/s40560-023-00691-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/14/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND This aim of study was to introduce a diaphragm-based EIT-belt placement method based on diaphragm position by ultrasound, and to evaluate the difference between diaphragm-based EIT-belt placement and conventional EIT-belt placement. METHOD The diaphragm position (L0) determined by ultrasound was taken as zero reference level. The direction of headward is defined as positive, and toward feet is negative. For EIT data collection, the electrode belt was placed at 7 different levels, respectively (denoted as L-2 cm, L0, L2cm, L4cm, L6cm, L8cm, L10cm) at supine position in healthy volunteers. The diaphragm-based EIT-belt level (Lxcm) was defined where highest tidal impedance variation (TV) was achieved. Subsequently, EIT measurements were conducted at diaphragm-based EIT-belt levels and traditional EIT-belt level in 50 critically ill patients under mechanical ventilation. RESULT The highest TV was achieved at L6cm and the smallest at L-2 cm., so the L6cm were taken as diaphragm-based EIT-belt level by ultrasound in 8 healthy volunteers. In 23 patients, the diaphragm-based EIT-belt plane agreed with the conventional planes (4th-6th ICS), which was defined as the Agreed group. Other patients were classified to the Disagreed group (above 4th ICS). The Disagreed group has a significantly higher BMI and lower global TV at the diaphragm-based EIT-belt plane compared to the Agreed group. CONCLUSIONS The diaphragm-based EIT-belt position by ultrasound was feasible and resulted in different belt positions compared to the conventional position in > 50% of the examined subjects, especially in patients with higher BMI. Further study is required to validate the impact on EIT images with this novel method on clinical management.
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Affiliation(s)
- Chaofu Yue
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital,Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Department of Intensive Care Unit, QuJing No.1 Hospital, QuJing, Yun Nan, China
| | - Huaiwu He
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital,Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
| | - Longxiang Su
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital,Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jun Wang
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital,Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Department of Intensive Care Unit, Shiyan People's Hospital of Bao'an District, Shenzhen, Guangdong, China
| | - Siyi Yuan
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital,Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital,Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
| | - Zhanqi Zhao
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital,Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
- Institute of Technical Medicine, Furtwangen University, VS-Schwenningen, Germany.
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Braun M, Ruscher L, Fuchs A, Kämpfer M, Huber M, Luedi MM, Riva T, Vogt A, Riedel T. Atelectasis in obese patients undergoing laparoscopic bariatric surgery are not increased upon discharge from Post Anesthesia Care Unit. Front Med (Lausanne) 2023; 10:1233609. [PMID: 37727763 PMCID: PMC10505733 DOI: 10.3389/fmed.2023.1233609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/31/2023] [Indexed: 09/21/2023] Open
Abstract
Background Obese patients frequently develop pulmonary atelectasis upon general anesthesia. The risk is increased during laparoscopic surgery. This prospective, observational single-center study evaluated atelectasis dynamics using Electric Impedance Tomography (EIT) in patients undergoing laparoscopic bariatric surgery. Methods We included adult patients with ASA physical status I-IV and a BMI of ≥40. Exclusion criteria were known severe pulmonary hypertension, home oxygen therapy, heart failure, and recent pulmonary infections. The primary outcome was the proportion of poorly ventilated lung regions (low tidal variation areas) and the global inhomogeneity (GI) index assessed by EIT before discharge from the Post Anesthesia Care Unit compared to these same measures prior to initiation of anesthesia. Results The median (IQR) proportion of low tidal variation areas at the different analysis points were T1 10.8% [3.6-15.1%] and T5 10.3% [2.6-18.9%], and the mean difference was -0.7% (95% CI: -5.8% -4.5%), i.e., lower than the predefined non-inferiority margin of 5% (p = 0.022). There were no changes at the four additional time points compared to T1 or postoperative pulmonary complications during the 14 days following the procedure. Conclusion We found that obese patients undergoing laparoscopic bariatric surgery do not leave the Post Anesthesia Care Unit with increased low tidal variation areas compared to the preoperative period.
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Affiliation(s)
- Matthias Braun
- Department of Anaesthesiology, Lindenhof Hospital, Bern, Switzerland
| | - Lea Ruscher
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Alexander Fuchs
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Martina Kämpfer
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Markus Huber
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Markus M. Luedi
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Andreas Vogt
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Thomas Riedel
- Division of Paediatric Intensive Care Medicine, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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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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Lagier D, Zeng C, Fernandez-Bustamante A, Melo MFV. Perioperative Pulmonary Atelectasis: Part II. Clinical Implications. Anesthesiology 2022; 136:206-236. [PMID: 34710217 PMCID: PMC9885487 DOI: 10.1097/aln.0000000000004009] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The development of pulmonary atelectasis is common in the surgical patient. Pulmonary atelectasis can cause various degrees of gas exchange and respiratory mechanics impairment during and after surgery. In its most serious presentations, lung collapse could contribute to postoperative respiratory insufficiency, pneumonia, and worse overall clinical outcomes. A specific risk assessment is critical to allow clinicians to optimally choose the anesthetic technique, prepare appropriate monitoring, adapt the perioperative plan, and ensure the patient's safety. Bedside diagnosis and management have benefited from recent imaging advancements such as lung ultrasound and electrical impedance tomography, and monitoring such as esophageal manometry. Therapeutic management includes a broad range of interventions aimed at promoting lung recruitment. During general anesthesia, these strategies have consistently demonstrated their effectiveness in improving intraoperative oxygenation and respiratory compliance. Yet these same intraoperative strategies may fail to affect additional postoperative pulmonary outcomes. Specific attention to the postoperative period may be key for such outcome impact of lung expansion. Interventions such as noninvasive positive pressure ventilatory support may be beneficial in specific patients at high risk for pulmonary atelectasis (e.g., obese) or those with clinical presentations consistent with lung collapse (e.g., postoperative hypoxemia after abdominal and cardiothoracic surgeries). Preoperative interventions may open new opportunities to minimize perioperative lung collapse and prevent pulmonary complications. Knowledge of pathophysiologic mechanisms of atelectasis and their consequences in the healthy and diseased lung should provide the basis for current practice and help to stratify and match the intensity of selected interventions to clinical conditions.
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Affiliation(s)
- David Lagier
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Congli Zeng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Marcos F. Vidal Melo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Effects of individualized PEEP obtained by two different titration methods on postoperative atelectasis in obese patients: study protocol for a randomized controlled trial. Trials 2021; 22:704. [PMID: 34654446 PMCID: PMC8517565 DOI: 10.1186/s13063-021-05671-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 09/30/2021] [Indexed: 11/25/2022] Open
Abstract
Background The incidence of postoperative pulmonary complications (PPCs) is higher in obese patients undergoing general anesthesia and mechanical ventilation due to the reduction of oxygen reserve, functional residual capacity, and lung compliance. Individualized positive end-expiratory pressure (iPEEP) along with other lung-protective strategies is effective in alleviating postoperative atelectasis. Here, we compared the best static lung compliance (Cstat) titration of iPEEP with electrical impedance tomography (EIT) titration to observe their effects on postoperative atelectasis in obese patients undergoing laparoscopic surgery. Methods A total number of 140 obese patients with BMI ≥ 32.5kg/m2 undergoing elective laparoscopic gastric volume reduction and at moderate to high risk of developing PPCs will be enrolled and randomized into the optimal static lung compliance-directed iPEEP group and EIT titration iPEEP group. The primary endpoint will be pulmonary atelectasis measured and calculated by EIT immediately after extubation and 2 h after surgery. Secondary endpoints will be intraoperative oxygenation index, organ dysfunction, incidence of PPCs, hospital expenses, and length of hospital stay. Discussion Many iPEEP titration methods effective for normal weight patients may not be appropriate for obese patients. Although EIT-guided iPEEP titration is effective in obese patients, its high price and complexity limit its application in many clinical facilities. This trial will test the efficacy of iPEEP via the optimal static lung compliance-guided titration procedure by comparing it with EIT-guided PEEP titration. The results of this trial will provide a feasible and convenient method for anesthesiologists to set individualized PEEP for obese patients during laparoscopic surgery. Trial registration ClinicalTrials.govChiCTR2000039144. Registered on October 19, 2020 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05671-1.
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Elshazly M, Khair T, Bassem M, Mansour M. The use of intraoperative bedside lung ultrasound in optimizing positive end expiratory pressure in obese patients undergoing laparoscopic bariatric surgeries. Surg Obes Relat Dis 2020; 17:372-378. [PMID: 33092957 DOI: 10.1016/j.soard.2020.09.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/31/2020] [Accepted: 09/10/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Anesthetic management of patients with obesity undergoing laparoscopic abdominal surgeries requires careful plan for intraoperative mechanical ventilation aiming to avoid lung atelectasis and/or overdistention. There are conflicting data on the optimum positive end expiratory pressure (PEEP) during these surgeries. We hypothesized that lung ultrasound could be used for PEEP titration during laparoscopic surgery. OBJECTIVE The purpose of this study is to evaluate the effectiveness of intraoperative individualized lung ultrasound-guided PEEP in obese patients undergoing laparoscopic bariatric surgery on intraoperative partial arterial oxygen tension (PaO2) and early postoperative pulmonary complications. METHODS A randomized controlled trial included 40 adult patients with body mass index (BMI) > 35 kg/m2 undergoing laparoscopic bariatric surgery. Patients were randomized into: control group (n = 20) who received PEEP 4 cm.H2 O and ultrasound-guided group (n = 20) who received individualized lung ultrasound stepwise PEEP. All patients received volume-controlled ventilation with a tidal volume of 6 mL/kg of ideal weight and a fraction of inspired oxygen of .5. The primary outcome was the difference in partial arterial oxygen tension (PaO2) between the control group and the ultrasound-guided group. The secondary outcomes included the incidence of early postoperative pulmonary atelectasis, respiratory failure, bronchospasm, hypoxia or pneumothorax. SETTINGS General surgery operating theatre at Cairo University hospitals. RESULTS Ultrasound-guided group showed higher PO2 after PEEP optimization and postoperatively compared with control group (P = .005, and P = .01 respectively). Also, ultrasound-guided group showed no postoperative complications compared with control group that had 5 cases who developed postoperative pulmonary complications in the form of hypoxia and basal collapse in the first 24 hour postoperatively chest x ray (0% versus 25%, P = .047). CONCLUSION In patients with obesity undergoing laparoscopic bariatric surgery, the use of lung ultrasound individualized stepwise PEEP approach improved oxygenation, compliance and reduced the incidence of postoperative pulmonary atelectasis and hypoxia without causing hemodynamic instability.
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Affiliation(s)
- Mohamed Elshazly
- Department of Anesthesia, Surgical ICU, and Pain Management, Cairo University, Cairo, Egypt.
| | - Tamer Khair
- Department of Anesthesia, Surgical ICU, and Pain Management, Cairo University, Cairo, Egypt
| | - Marina Bassem
- Department of Anesthesia, Surgical ICU, and Pain Management, Cairo University, Cairo, Egypt
| | - Mohamed Mansour
- Department of Anesthesia, Surgical ICU, and Pain Management, Cairo University, Cairo, Egypt
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Mechanick JI, Apovian C, Brethauer S, Timothy Garvey W, Joffe AM, Kim J, Kushner RF, Lindquist R, Pessah-Pollack R, Seger J, Urman RD, Adams S, Cleek JB, Correa R, Figaro MK, Flanders K, Grams J, Hurley DL, Kothari S, Seger MV, Still CD. Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Obesity (Silver Spring) 2020; 28:O1-O58. [PMID: 32202076 DOI: 10.1002/oby.22719] [Citation(s) in RCA: 145] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 10/09/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists. METHODS Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. RESULTS New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). CONCLUSIONS Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.
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Affiliation(s)
- Jeffrey I Mechanick
- Guideline Task Force Chair (AACE); Professor of Medicine, Medical Director, Marie-Josée and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart; Director, Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York; Past President, AACE and ACE
| | - Caroline Apovian
- Guideline Task Force Co-Chair (TOS); Professor of Medicine and Director, Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Stacy Brethauer
- Guideline Task Force Co-Chair (ASMBS); Professor of Surgery, Vice Chair of Surgery, Quality and Patient Safety; Medical Director, Supply Chain Management, Ohio State University, Columbus, Ohio
| | - W Timothy Garvey
- Guideline Task Force Co-Chair (AACE); Butterworth Professor, Department of Nutrition Sciences, GRECC Investigator and Staff Physician, Birmingham VAMC; Director, UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- Guideline Task Force Co-Chair (ASA); Professor of Anesthesiology, Service Chief, Otolaryngology, Oral, Maxillofacial, and Urologic Surgeries, Associate Medical Director, Respiratory Care, University of Washington, Harborview Medical Center, Seattle, Washington
| | - Julie Kim
- Guideline Task Force Co-Chair (ASMBS); Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Robert F Kushner
- Guideline Task Force Co-Chair (TOS); Professor of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Richard Lindquist
- Guideline Task Force Co-Chair (OMA); Director, Medical Weight Management, Swedish Medical Center; Director, Medical Weight Management, Providence Health Services; Obesity Medicine Consultant, Seattle, Washington
| | - Rachel Pessah-Pollack
- Guideline Task Force Co-Chair (AACE); Clinical Associate Professor of Medicine, Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
| | - Jennifer Seger
- Guideline Task Force Co-Chair (OMA); Adjunct Assistant Professor, Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
| | - Richard D Urman
- Guideline Task Force Co-Chair (ASA); Associate Professor of Anesthesia, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stephanie Adams
- Writer (AACE); AACE Director of Clinical Practice Guidelines Development, Jacksonville, Florida
| | - John B Cleek
- Writer (TOS); Associate Professor, Department of Nutrition Sciences, University of Alabama, Birmingham, Alabama
| | - Riccardo Correa
- Technical Analysis (AACE); Assistant Professor of Medicine and Endocrinology, Diabetes and Metabolism Fellowship Director, University of Arizona College of Medicine, Phoenix, Arizona
| | - M Kathleen Figaro
- Technical Analysis (AACE); Board-certified Endocrinologist, Heartland Endocrine Group, Davenport, Iowa
| | - Karen Flanders
- Writer (ASMBS); Massachusetts General Hospital Weight Center, Boston, Massachusetts
| | - Jayleen Grams
- Writer (AACE); Associate Professor, Department of Surgery, University of Alabama at Birmingham; Staff Surgeon, Birmingham VA Medical Center, Birmingham, Alabama
| | - Daniel L Hurley
- Writer (AACE); Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Shanu Kothari
- Writer (ASMBS); Fellowship Director of MIS/Bariatric Surgery, Gundersen Health System, La Crosse, Wisconsin
| | - Michael V Seger
- Writer (OMA); Bariatric Medical Institute of Texas, San Antonio, Texas, Clinical Assistant Professor, University of Texas Health Science Center, Houston, Texas
| | - Christopher D Still
- Writer (TOS); Medical Director, Center for Nutrition and Weight Management Director, Geisinger Obesity Institute; Medical Director, Employee Wellness, Geisinger Health System, Danville, Pennsylvania
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Carron M, Safaee Fakhr B, Ieppariello G, Foletto M. Perioperative care of the obese patient. Br J Surg 2020; 107:e39-e55. [DOI: 10.1002/bjs.11447] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/07/2019] [Indexed: 12/17/2022]
Abstract
Abstract
Background
Obesity has become an increasing problem worldwide during the past few decades. Hence, surgeons and anaesthetists will care for an increasing number of obese patients in the foreseeable future, and should be prepared to provide optimal management for these individuals. This review provides an update of recent evidence regarding perioperative strategies for obese patients.
Methods
A search for papers on the perioperative care of obese patients (English language only) was performed in July 2019 using the PubMed, Scopus, Web of Science and Cochrane Library electronic databases. The review focused on the results of RCTs, although observational studies, meta-analyses, reviews, guidelines and other reports discussing the perioperative care of obese patients were also considered. When data from obese patients were not available, relevant data from non-obese populations were used.
Results and conclusion
Obese patients require comprehensive preoperative evaluation. Experienced medical teams, appropriate equipment and monitoring, careful anaesthetic management, and an adequate perioperative ventilation strategy may improve postoperative outcomes. Additional perioperative precautions are necessary in patients with severe morbid obesity, metabolic syndrome, untreated or severe obstructive sleep apnoea syndrome, or obesity hypoventilation syndrome; patients receiving home ventilatory support or postoperative opioid therapy; and obese patients undergoing open operations, long procedures or revisional surgery.
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Affiliation(s)
- M Carron
- Department of Medicine – DIMED, Section of Anaesthesiology and Intensive Care, University of Padua, Padua, Italy
| | - B Safaee Fakhr
- Department of Medicine – DIMED, Section of Anaesthesiology and Intensive Care, University of Padua, Padua, Italy
| | - G Ieppariello
- Department of Medicine – DIMED, Section of Anaesthesiology and Intensive Care, University of Padua, Padua, Italy
| | - M Foletto
- Department of Surgical, Oncological and Gastroenterological Sciences, Section of Surgery, University of Padua, Padua, Italy
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Öztürk MC, Demiroluk Ö, Abitagaoglu S, Ari DE. The Effect of sevoflurane, desflurane and propofol on respiratory mechanics and integrated pulmonary index scores in laparoscopic sleeve gastrectomy. A randomized trial. Saudi Med J 2019; 40:1235-1241. [PMID: 31828275 PMCID: PMC6969621 DOI: 10.15537/smj.2019.12.24693] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objectives: To compare the effects of sevoflurane, desflurane, and propofol on respiratory mechanics, and integrated pulmonary index (IPI) scores in patients undergoing laparoscopic sleeve gastrectomy. Methods: A total of 60 patients with a body mass index of ≥40 kg/m2, who underwent laparoscopic sleeve gastrectomy between September 2015 and September 2016 at Fatih Sultan Mehmet Health Application and Research Center, Istanbul, Turkey were included in this randomized prospective study. After induction, anesthesia was maintained by sevoflurane in group S, desflurane in group D, and propofol in group P. Peak inspiratory pressure (PIP), plateau pressure (Pplateau), compliance (Cdyn), respiratory resistance (Rrs), and IPI values were recorded. Mann-Whitney U, Kruskal-Wallis, Dunn’s, Friedman, and Fisher-Freeman-Halton tests were performed for statistical analysis. A p value of <0.05 was considered statistically significant. Results: A significant increase was found in PIP in group S (T1: 25; T2: 27 cmH2O), and group D (T1: 25; T2: 29,5 cmH2O) during pneumoperitoneum. Dynamic compliance decreased in all groups during pneumoperitoneum. In group S, the decrease in Cdyn was also statistically significant after pneumoperitoneum (T1: 43.65; T5: 41.25 ml/cmH2O). Comparison between groups the values of PIP, Pplateau, Cdyn, Rrs, and IPI were similar. Conclusion: In morbidly obese patients, sevoflurane, desflurane, and propofol are similar in terms of the intraoperative respiratory mechanics, and perioperative respiratory parameters provided with IPI.
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Affiliation(s)
- Mehmet C Öztürk
- Intensive Care Unit, Dokuz Eylül University, Izmir, Turkey. E-mail.
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Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations. Br J Anaesth 2019; 123:898-913. [DOI: 10.1016/j.bja.2019.08.017] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/22/2019] [Accepted: 08/04/2019] [Indexed: 12/16/2022] Open
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Mechanick JI, Apovian C, Brethauer S, Garvey WT, Joffe AM, Kim J, Kushner RF, Lindquist R, Pessah-Pollack R, Seger J, Urman RD, Adams S, Cleek JB, Correa R, Figaro MK, Flanders K, Grams J, Hurley DL, Kothari S, Seger MV, Still CD. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Surg Obes Relat Dis 2019; 16:175-247. [PMID: 31917200 DOI: 10.1016/j.soard.2019.10.025] [Citation(s) in RCA: 240] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists. METHODS Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. RESULTS New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). CONCLUSIONS Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.
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Affiliation(s)
- Jeffrey I Mechanick
- Marie-Josée and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart, New York, New York; Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Caroline Apovian
- Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | | | - W Timothy Garvey
- Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama; UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- University of Washington, Harborview Medical Center, Seattle, Washington
| | - Julie Kim
- Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Robert F Kushner
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Rachel Pessah-Pollack
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
| | - Jennifer Seger
- Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
| | | | - Stephanie Adams
- American Association of Clinical Endocrinologists, Jacksonville, Florida
| | - John B Cleek
- Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama
| | | | | | - Karen Flanders
- Massachusetts General Hospital Weight Center, Boston, Massachusetts
| | - Jayleen Grams
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama; Birmingham VA Medical Center, Birmingham, Alabama
| | - Daniel L Hurley
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | | | - Michael V Seger
- Bariatric Medical Institute of Texas, San Antonio, Texas, University of Texas Health Science Center, Houston, Texas
| | - Christopher D Still
- Center for Nutrition and Weight Management Director, Geisinger Obesity Institute, Danville, Pennsylvania; Employee Wellness, Geisinger Health System, Danville, Pennsylvania
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Response to: 'Positive end-expiratory pressure in obese patients during general anaesthesia. The role of intra-abdominal pressure'. Br J Anaesth 2018; 120:410-411. [PMID: 29406194 DOI: 10.1016/j.bja.2017.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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