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Electric impedance tomography and protective mechanical ventilation in elective robotic-assisted laparoscopy surgery with steep Trendelenburg position: a randomized controlled study. Sci Rep 2023; 13:2753. [PMID: 36797394 PMCID: PMC9935531 DOI: 10.1038/s41598-023-29860-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/11/2023] [Indexed: 02/18/2023] Open
Abstract
Electrical impedance tomography (EIT) reconstructs functional lung images and evaluates the variations of impedance during the breathing cycle. The aim of this study was to evaluate the effect of protective mechanical ventilation on ventilation distributions recorded by the EIT during elective robotic-assisted laparoscopy surgery with steep Trendelenburg position. This prospective, randomized single center study included patients with healthy lungs undergoing elective robot-assisted laparoscopic urological surgery in general anesthesia. Patients were randomly assigned to either protective lung ventilation or conventional ventilation. In the protective ventilation group, tidal volume (TV) was set at 6 ml/Kg predicted body weight (PBW), with PEEP 6 cmH2O, and recruitment maneuvers (RM) as needed. In the conventional ventilation group, TV was set at 9 ml/Kg PBW, with PEEP 2 cmH2O and RM only as needed. Ventilation distribution was assessed using an EIT device. This study included 40 patients in the functional image analysis. Significant differences were found in ventilation distribution in the region of interest (p < 0.05). Driving pressure was significantly lower in protective ventilation group (p < 0.05). Peak and plateau pressures were not different between the groups while statical significance was found in tidal volume and respiratory rate. EIT may be a valuable tool for monitoring lung function during general anesthesia. During elective robotic-assisted laparoscopy surgery with steep Trendelenburg position, protective mechanical ventilation may have a more homogenous distribution of intraoperative and postoperative ventilation. Larger sample size and long-term evaluation are needed in future studies to assess the benefit of EIT monitoring in operation room.Clinical trial registration ClinicalTrials.gov Identifier: NCT04194177 registered at 11th December 2019.
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Driving pressure-guided ventilation improves homogeneity in lung gas distribution for gynecological laparoscopy: a randomized controlled trial. Sci Rep 2022; 12:21687. [PMID: 36522433 PMCID: PMC9755264 DOI: 10.1038/s41598-022-26144-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022] Open
Abstract
To investigate whether driving pressure-guided ventilation could contribute to a more homogeneous distribution in the lung for gynecological laparoscopy. Chinese patients were randomized, after pneumoperitoneum, to receive either positive end expiratory pressure (PEEP) of 5 cm H2O (control group), or individualized PEEP producing the lowest driving pressure (titration group). Ventilation homogeneity is quantified as the global inhomogeneity (GI) index based on electrical impedance tomography, with a lower index implying more homogeneous ventilation. The perioperative arterial oxygenation index and respiratory system mechanics were also recorded. Blood samples were collected for lung injury biomarkers including interleukin-10, neutrophil elastase, and Clara Cell protein-16. A total of 48 patients were included for analysis. We observed a significant increase in the GI index immediately after tracheal extubation compared to preinduction in the control group (p = 0.040) but not in the titration group (p = 0.279). Furthermore, the GI index was obviously lower in the titration group than in the control group [0.390 (0.066) vs 0.460 (0.074), p = 0.0012]. The oxygenation index and respiratory compliance were significantly higher in the titration group than in the control group. No significant differences in biomarkers or hemodynamics were detected between the two groups. Driving pressure-guided PEEP led to more homogeneous ventilation, as well as improved gas exchange and respiratory compliance for patients undergoing gynecological laparoscopy.Trial Registration: ClinicalTrials.gov NCT04374162; first registration on 05/05/2020.
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Stenberg E, Dos Reis Falcão LF, O'Kane M, Liem R, Pournaras DJ, Salminen P, Urman RD, Wadhwa A, Gustafsson UO, Thorell A. Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update. World J Surg 2022; 46:729-751. [PMID: 34984504 PMCID: PMC8885505 DOI: 10.1007/s00268-021-06394-9] [Citation(s) in RCA: 124] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2021] [Indexed: 02/08/2023]
Abstract
Background This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing recommendations for each ERAS item within the ERAS® protocol. Methods A principal literature search was performed utilizing the Pubmed, EMBASE, Cochrane databases and ClinicalTrials.gov through December 2020, with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. After critical appraisal of these studies, the group of authors reached consensus regarding recommendations. Results The quality of evidence for many ERAS interventions remains relatively low in a bariatric setting and evidence-based practices may need to be extrapolated from other surgeries. Conclusion A comprehensive, updated evidence-based consensus was reached and is presented in this review by the ERAS® Society.
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Affiliation(s)
- Erik Stenberg
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | | | - Mary O'Kane
- Dietetic Department, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | - Ronald Liem
- Department of Surgery, Groene Hart Hospital, Gouda, Netherlands.,Dutch Obesity Clinic, The Hague, Netherlands
| | - Dimitri J Pournaras
- Department of Upper GI and Bariatric/Metabolic Surgery, North Bristol NHS Trust, Southmead Hospital, Southmead Road, Bristol, UK
| | - Paulina Salminen
- Department of Surgery, University of Turku, Turku, Finland.,Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anupama Wadhwa
- Department of Anesthesiology, Outcomes Research Institute, Cleveland Clinic, University of Texas Southwestern, Dallas, USA
| | - Ulf O Gustafsson
- Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Anders Thorell
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Ersta Hospital, Stockholm, Sweden
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Protective mechanical ventilation in the obese patient. Int Anesthesiol Clin 2021; 58:53-57. [PMID: 32404605 DOI: 10.1097/aia.0000000000000284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Xie C, Sun K, You Y, Ming Y, Yu X, Yu L, Huang J, Yan M. Feasibility and efficacy of lung ultrasound to investigate pulmonary complications in patients who developed postoperative Hypoxaemia-a prospective study. BMC Anesthesiol 2020; 20:220. [PMID: 32873237 PMCID: PMC7461251 DOI: 10.1186/s12871-020-01123-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 08/09/2020] [Indexed: 12/18/2022] Open
Abstract
Background Postoperative pulmonary complications (PPCs) and hypoxaemia are associated with morbidity and mortality. We aimed to evaluate the feasibility and efficacy of lung ultrasound (LUS) to diagnose PPCs in patients suffering from hypoxaemia after general anaesthesia and compare the results to those of thoracic computed tomography (CT). Methods Adult patients who received general anaesthesia and suffered from hypoxaemia in the postanaesthesia care unit (PACU) were analysed. Hypoxaemia was defined as an oxygen saturation measured by pulse oximetry (SPO2) less than 92% for more than 30 s under ambient air conditions. LUS was performed by two trained anaesthesiologists once hypoxaemia occurred. After LUS examination, each patient was transported to the radiology department for thoracic CT scan within 1 h before returning to the ward. Results From January 2019 to May 2019, 113 patients (61 men) undergoing abdominal surgery (45 patients, 39.8%), video-assisted thoracic surgery (31 patients, 27.4%), major orthopaedic surgery (17 patients, 15.0%), neurosurgery (10 patients, 8.8%) or other surgery (10 patients, 8.8%) were included. CT diagnosed 327 of 1356 lung zones as atelectasis, while LUS revealed atelectasis in 311 of the CT-confirmed zones. Pneumothorax was detected by CT scan in 75 quadrants, 72 of which were detected by LUS. Pleural effusion was diagnosed in 144 zones on CT scan, and LUS detected 131 of these zones. LUS was reliable in diagnosing atelectasis (sensitivity 98.0%, specificity 96.7% and diagnostic accuracy 97.2%), pneumothorax (sensitivity 90.0%, specificity 98.9% and diagnostic accuracy 96.7%) and pleural effusion (sensitivity 92.9%, specificity 96.0% and diagnostic accuracy 95.1%). Conclusions Lung ultrasound is feasible, efficient and accurate in diagnosing different aetiologies of postoperative hypoxia in healthy-weight patients in the PACU. Trial registration Current Controlled Trials NCT03802175, 2018/12/05, www.ClinicalTrials.gov
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Affiliation(s)
- Chen Xie
- Department of Anesthesiology and Pain Medicine, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou, 310016, People's Republic of China
| | - Kai Sun
- Department of Anesthesiology and Pain Medicine, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou, 310016, People's Republic of China
| | - Yueyang You
- Department of Anesthesiology and Pain Medicine, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou, 310016, People's Republic of China
| | - Yue Ming
- Department of Anesthesiology and Pain Medicine, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou, 310016, People's Republic of China
| | - Xiaoling Yu
- Department of Anesthesiology and Pain Medicine, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou, 310016, People's Republic of China
| | - Lina Yu
- Department of Anesthesiology and Pain Medicine, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou, 310016, People's Republic of China
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY, 40202, USA
| | - Min Yan
- Department of Anesthesiology and Pain Medicine, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou, 310016, People's Republic of China. .,Department of Anesthesiology and Pain Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, NO, China.
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Kirov MY, Kuzkov VV. Protective ventilation from ICU to operating room: state of art and new horizons. Korean J Anesthesiol 2020; 73:179-193. [PMID: 32008277 PMCID: PMC7280889 DOI: 10.4097/kja.19499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 01/26/2020] [Accepted: 01/27/2020] [Indexed: 12/16/2022] Open
Abstract
The prevention of ventilator-associated lung injury (VALI) and postoperative pulmonary complications (PPC) is of paramount importance for improving outcomes both in the operating room and in the intensive care unit (ICU). Protective respiratory support includes a wide spectrum of interventions to decrease pulmonary stress-strain injuries. The motto 'low tidal volume for all' should become routine, both during major surgery and in the ICU, while application of a high positive end-expiratory pressure (PEEP) strategy and of alveolar recruitment maneuvers requires a personalized approach and requires further investigation. Patient self-inflicted lung injury is an important type of VALI, which should be diagnosed and mitigated at the early stage, during restoration of spontaneous breathing. This narrative review highlights the strategies used for protective positive pressure ventilation. The emerging concepts of damaging energy and power, as well as pathways to personalization of the respiratory settings, are discussed in detail. In the future, individualized approaches to protective ventilation may involve multiple respiratory settings extending beyond low tidal volume and PEEP, implemented in parallel with quantifying the risk of VALI and PPC.
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Affiliation(s)
- Mikhail Y. Kirov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russian Federation
| | - Vsevolod V. Kuzkov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russian Federation
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Rackley CR, MacIntyre NR. Low Tidal Volumes for Everyone? Chest 2019; 156:783-791. [DOI: 10.1016/j.chest.2019.06.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/13/2019] [Accepted: 06/06/2019] [Indexed: 01/03/2023] Open
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Scaramuzzo G, Broche L, Pellegrini M, Porra L, Derosa S, Tannoia AP, Marzullo A, Borges JB, Bayat S, Bravin A, Larsson A, Perchiazzi G. Regional Behavior of Airspaces During Positive Pressure Reduction Assessed by Synchrotron Radiation Computed Tomography. Front Physiol 2019; 10:719. [PMID: 31231245 PMCID: PMC6567926 DOI: 10.3389/fphys.2019.00719] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 05/23/2019] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The mechanisms of lung inflation and deflation are only partially known. Ventilatory strategies to support lung function rely upon the idea that lung alveoli are isotropic balloons that progressively inflate or deflate and that lung pressure/volume curves derive only by the interplay of critical opening pressures, critical closing pressures, lung history, and position of alveoli inside the lung. This notion has been recently challenged by subpleural microscopy, magnetic resonance, and computed tomography (CT). Phase-contrast synchrotron radiation CT (PC-SRCT) can yield in vivo images at resolutions higher than conventional CT. OBJECTIVES We aimed to assess the numerosity (ASden) and the extension of the surface of airspaces (ASext) in healthy conditions at different volumes, during stepwise lung deflation, in concentric regions of the lung. METHODS The study was conducted in seven anesthetized New Zealand rabbits. They underwent PC-SRCT scans (resolution of 47.7 μm) of the lung at five decreasing positive end expiratory pressure (PEEP) levels of 12, 9, 6, 3, and 0 cmH2O during end-expiratory holds. Three concentric regions of interest (ROIs) of the lung were studied: subpleural, mantellar, and core. The images were enhanced by phase contrast algorithms. ASden and ASext were computed by using the Image Processing Toolbox for MatLab. Statistical tests were used to assess any significant difference determined by PEEP or ROI on ASden and ASext. RESULTS When reducing PEEP, in each ROI the ASden significantly decreased. Conversely, ASext variation was not significant except for the core ROI. In the latter, the angular coefficient of the regression line was significantly low. CONCLUSION The main mechanism behind the decrease in lung volume at PEEP reduction is derecruitment. In our study involving lung regions laying on isogravitational planes and thus equally influenced by gravitational forces, airspace numerosity and extension of surface depend on the local mechanical properties of the lung.
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Affiliation(s)
- Gaetano Scaramuzzo
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Ludovic Broche
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- The European Synchrotron Radiation Facility, Grenoble, France
- INSERM UA7, Synchrotron Radiation for Biomedicine (STROBE) Laboratory, Grenoble Alpes University, Amiens, France
| | - Mariangela Pellegrini
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Department of Anesthesia and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
| | - Liisa Porra
- Department of Physics, Faculty of Mathematics and Natural Sciences, University of Helsinki, Helsinki, Finland
- Helsinki University Central Hospital, Helsinki, Finland
| | - Savino Derosa
- Department of Emergency and Organ Transplant, University of Bari Aldo Moro, Bari, Italy
| | | | - Andrea Marzullo
- Department of Emergency and Organ Transplant, University of Bari Aldo Moro, Bari, Italy
| | - Joao Batista Borges
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Centre for Human and Applied Physiological Sciences, Faculty of Sciences and Medicine, King’s College London, London, United Kingdom
| | - Sam Bayat
- INSERM UA7, Synchrotron Radiation for Biomedicine (STROBE) Laboratory, Grenoble Alpes University, Amiens, France
| | - Alberto Bravin
- The European Synchrotron Radiation Facility, Grenoble, France
| | - Anders Larsson
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Gaetano Perchiazzi
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Department of Anesthesia and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
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