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Sanchez AF, Ambrósio AM, Pinto ACBCF, Pereira MAA, Andrade FSRM, Rodrigues RR, de Carvalho Martins AR, Baroni CO, Ferrante B, Fantoni DT. Effects of a stepwise alveolar recruitment maneuver on lung volume distribution in dogs assessed by computed tomography. Front Vet Sci 2024; 10:1232635. [PMID: 38292132 PMCID: PMC10825017 DOI: 10.3389/fvets.2023.1232635] [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: 05/31/2023] [Accepted: 12/19/2023] [Indexed: 02/01/2024] Open
Abstract
Background Pulmonary atelectasis is a commonly occurs during anesthesia. In these cases, mechanical ventilation (MV) associated with alveolar recruitment maneuvers (ARMs) and positive end-expiratory pressure (PEEP) is indicated to reverse the condition, ensure adequate gas exchange and improve oxygenation. ARMs can trigger volutrauma, barotrauma, and atelectrauma. Therefore, computed tomography (CT) is the gold-standard method for monitoring lung aeration after ARM. Objective To evaluate lung volume distribution after stepwise ARMs using computed tomography (CT). Methods Twelve dogs weighing 24.0 ± 6.0 kg, aged 3 ± 1 years, of both sexes and different breeds, underwent orchiectomy or ovariohysterectomy. The animals were anesthetized and ventilated in volume-controlled mode. ARMs were then initiated by positive end-expiratory pressure (PEEP) titration (5, 10, 15, and 20 cmH2O). CT scans, cardiovascular parameters, and ventilatory mechanics were evaluated at all time points. Data were assessed for normality using the Shapiro-Wilk test and a two-way analysis of variance, followed by a post-hoc Bonferroni test to identify differences between time points. Statistical significance was attributed to a value of p of <0.05. Results CT demonstrated that the ARMs increased ventilation throughout the lung, including the dependent regions, with volumes that increased and decreased proportionally with PEEP titration. When they reached PEEP 10 and 5 cmH2O descending (d), they remained significantly higher than those in PEEP 0 cmH2O (baseline). Static compliance improved about 40% at PEEP 10d and PEEP 5d compared to baseline. There was an increase in heart rate (HR) from PEEP 15 increasing (i) (74.5%) to PEEP 10d (54.8%) compared to baseline. Mean arterial blood pressure (MABP) decreased approximately 9% from PEEP 15i to PEEP 15d compared to baseline. Conclusion Lung attenuation and regional and global volumes assessed by CT showed that maximum pulmonary aeration distribution followed by PEEP titration occurred at PEEP 20 cmH2O, maintaining the lungs normoaerated and without hyperaeration.
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Affiliation(s)
- Ana Flávia Sanchez
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Aline Magalhães Ambrósio
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Ana Carolina B. C. Fonseca Pinto
- Department of Veterinary Clinical Sciences, Diagnostic Imaging Purdue University College of Veterinary Medicine, West Lafayette, IN, United States
| | - Marco Aurélio Amador Pereira
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, São Paulo, Brazil
| | | | - Renata Ramos Rodrigues
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, São Paulo, Brazil
| | | | - Carina Outi Baroni
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Bruno Ferrante
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Denise Tabacchi Fantoni
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, São Paulo, Brazil
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Gómez Fernández L, Potter J, Hughes JML, Fernandez Perez C, Brama PAJ, Niimura Del Barrio MC. Effects of two alveolar recruitment manoeuvres (sustained inflation and stepwise) followed by positive end-expiratory pressure on cardiac output (measured with lithium dilution), invasive blood pressure and arterial oxygen tension in isoflurane-anaesthetised goats. Res Vet Sci 2022; 150:195-203. [PMID: 35842951 DOI: 10.1016/j.rvsc.2022.07.004] [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: 07/16/2021] [Revised: 04/03/2022] [Accepted: 07/07/2022] [Indexed: 11/22/2022]
Abstract
Alveolar recruitment manoeuvres (ARM) performed during general anaesthesia improve oxygenation; however cardiovascular depression may be observed. The aim of the study was to compare the effects of sustained inflation (SI) and stepwise ARMs on cardiac output (CO), mean arterial blood pressure and arterial oxygen tension (PaO2) in ten mechanically ventilated goats anaesthetised with isoflurane. In the SI ARM, peak inspiratory presure (PIP) was increased to 30 cmH2O and sustained for 20 s. In the stepwise ARM, the PIP was increased by 5 cmH2O each minute for three minutes from 10 to 25 cmH2O. Both ARMs were followed by positive end-expiratory pressure of 5 cmH2O. Paired lithium dilution CO measurements and arterial blood samples were obtained before and after each ARM. The order of the ARM was randomised and each goat was subjected to both techniques. Data was reported as median and interquartile range (IQR). Significance was set at 0.05. The median change in CO (measured by subtracting values after and before ARM) was -0.15 L min-1 (IQR -0.51; 0.03) and - 0.90 L min-1 (IQR -1.69; -0.58) for SI and stepwise ARM respectively (p = 0.04). The median change in PaO2 was 3 kPa (IQR -2.7; 7.6) and 0.4 kPa (IQR -3.4; 5.5) for SI and stepwise ARM respectively (p = 0.03). In conclusion, SI ARM causes less impact on CO and provides a better improvement in PaO2 compared to stepwise ARM in goats.
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Affiliation(s)
- L Gómez Fernández
- University College Dublin, UCD Veterinary Hospital, Belfield, Dublin 4 D04W6F6, Ireland; Department of Small Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, SK S7N 5B4, Canada.
| | - J Potter
- University College Dublin, UCD Veterinary Hospital, Belfield, Dublin 4 D04W6F6, Ireland
| | - J M L Hughes
- University College Dublin, UCD Veterinary Hospital, Belfield, Dublin 4 D04W6F6, Ireland
| | - C Fernandez Perez
- Servicio de Medicina Preventiva, Área Sanitaria de Santiago de Compostela y Barbanza, Instituto de Investigación Sanitaria de Santiago de Compostela, A Coruña, Spain
| | - P A J Brama
- University College Dublin, UCD Veterinary Hospital, Belfield, Dublin 4 D04W6F6, Ireland
| | - M C Niimura Del Barrio
- Lumbry Park Veterinary Specialists, Selborne Road, Alton, Hampshire GU34 3HL, United Kingdom
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Navarrete-Calvo R, Parra P, Rodríguez-Gómez IM, Morgaz J, Domínguez JM, Gómez-Villamandos RJ, Quirós-Carmona S, Pineda C, Granados MDM. Comparison of the efficacy of two alveolar recruitment manoeuvres in improving the lung mechanics and the degree of atelectasis in anaesthetized healthy sheep. Res Vet Sci 2022; 150:164-169. [PMID: 35841725 DOI: 10.1016/j.rvsc.2022.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/03/2022] [Accepted: 06/27/2022] [Indexed: 11/28/2022]
Abstract
The aim of the present study was to evaluate whether the application of two types of alveolar recruitment manoeuvres (ARMs) followed by a positive end-expiratory pressure (PEEP) improved lung mechanics and the degree of atelectasis caused by general anaesthesia. Twenty-one female Merino sheep were divided into three groups: sustained inflation ARM (ARMsust), stepwise ARM (AMRstep), and control (without ARM). Sheep received detomidine-morphine for premedication, propofol for induction, and isoflurane during general anaesthesia in a volume-controlled mode with 100% oxygen during the first 15 min of anaesthesia and 40% the rest of the study. The right jugular vein and metacarpal artery were catheterised for mixed venous and arterial blood sample collection, respectively. The quasistatic compliance (Cqst), oxygenation parameters, and shunt fraction (Qs/Qt) were monitored before ARM application (TpreARM), and at 10 (T10) and 60 min (T60) after ARM application. A pulmonary histopathological study was conducted on five animals from each group. A significant increase in Cqst was observed in both ARM groups at T10 compared to TpreARM (ARMsust: P = 0.001; ARMstep: P = 0.002), although only the ARMsust group showed significant differences compared to the control group. The ARMstep group presented a significant improvement in oxygenation parameters and Qs/Qt fraction (T10: 4.84 (3.26-16.48)%, P = 0.048; T60: 4.40 (4.31-14.16)%, P = 0.004) compared with TpreARM (21.48 (20.61-28.32)%). The ARMstep group had the highest percentage of alveolar area and the most homogeneous values. In conclusion, the application of a stepwise ARM followed by PEEP improved atelectasis caused by isoflurane anaesthesia in healthy sheep.
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Affiliation(s)
- Rocío Navarrete-Calvo
- Department of Animal Medicine and Surgery, University of Córdoba, Rabanales University Campus, National Road IV-A, km 396, Córdoba, Spain
| | - Pablo Parra
- Department of Animal Medicine and Surgery, University of Córdoba, Rabanales University Campus, National Road IV-A, km 396, Córdoba, Spain
| | - Irene Magdalena Rodríguez-Gómez
- Department of Anatomy and Comparative Pathology and Toxicology, University of Córdoba, Rabanales University Campus, National Road IV-A, km 396, Córdoba, Spain..
| | - Juan Morgaz
- Department of Animal Medicine and Surgery, University of Córdoba, Rabanales University Campus, National Road IV-A, km 396, Córdoba, Spain
| | - Juan Manuel Domínguez
- Department of Animal Medicine and Surgery, University of Córdoba, Rabanales University Campus, National Road IV-A, km 396, Córdoba, Spain
| | - Rafael Jesús Gómez-Villamandos
- Department of Animal Medicine and Surgery, University of Córdoba, Rabanales University Campus, National Road IV-A, km 396, Córdoba, Spain
| | - Setefilla Quirós-Carmona
- Department of Animal Medicine and Surgery, University of Córdoba, Rabanales University Campus, National Road IV-A, km 396, Córdoba, Spain
| | - Carmen Pineda
- Department of Animal Medicine and Surgery, University of Córdoba, Rabanales University Campus, National Road IV-A, km 396, Córdoba, Spain
| | - María Del Mar Granados
- Department of Animal Medicine and Surgery, University of Córdoba, Rabanales University Campus, National Road IV-A, km 396, Córdoba, Spain
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Machado ML, Soares JHN, Pypendop BH, Aguiar AJA, Braun C, Motta-Ribeiro GC, Jandre FC. Cardiovascular and Gas Exchange Effects of Individualized Positive End-Expiratory Pressures in Cats Anesthetized With Isoflurane. Front Vet Sci 2022; 9:865673. [PMID: 35601404 PMCID: PMC9114870 DOI: 10.3389/fvets.2022.865673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/18/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives To compare the effects of four levels of end-expiratory pressure [zero (ZEEP) and three levels of positive end-expiratory pressure (PEEP)] on the cardiovascular system and gas exchange of cats anesthetized with isoflurane and mechanically ventilated for 3 h with a tidal volume of 10 ml/kg. Study Design Prospective, randomized, controlled trial. Animals Six healthy male neutered purpose-bred cats. Methods Anesthesia was induced with isoflurane and maintained at 1.3 minimum alveolar concentration. PEEP of maximal respiratory compliance (PEEPmaxCrs) was identified in a decremental PEEP titration, and cats were randomly ventilated for 3 h with one of the following end-expiratory pressures: ZEEP, PEEPmaxCrs minus 2 cmH2O (PEEPmaxCrs−2), PEEPmaxCrs, and PEEPmaxCrs plus 2 cmH2O (PEEPmaxCrs+2). Cardiovascular and gas exchange variables were recorded at 5, 30, 60, 120, and 180 min (T5 to T180, respectively) of ventilation and compared between and within ventilation treatments with mixed-model ANOVA followed by Dunnet's and Tukey's tests (normal distribution) or Friedman test followed by the Dunn's test (non-normal distribution). Significance to reject the null hypothesis was considered p < 0.05. Results Mean arterial pressure (MAP—mmHg) was lower in PEEPmaxCrs+2 [63 (49–69); median (range)] when compared to ZEEP [71 (67–113)] at T5 and stroke index (ml/beat/kg) was lower in PEEPmaxCrs+2 (0.70 ± 0.20; mean ± SD) than in ZEEP (0.90 ± 0.20) at T60. Cardiac index, oxygen delivery index (DO2I), systemic vascular resistance index, and shunt fraction were not significantly different between treatments. The ratio between arterial partial pressure and inspired concentration of oxygen (PaO2/FIO2) was lower in ZEEP than in the PEEP treatments at various time points. At T180, DO2I was higher when compared to T5 in PEEPmaxCrs. Dopamine was required to maintain MAP higher than 60 mmHg in one cat during PEEPmaxCrs and in three cats during PEEPmaxCrs+2. Conclusion In cats anesthetized with isoflurane and mechanically ventilated for 3 h, all levels of PEEP mildly improved gas exchange with no significant difference in DO2I when compared to ZEEP. The PEEP levels higher than PEEPmaxCrs−2 caused more cardiovascular depression, and dopamine was an effective treatment. A temporal increase in DO2I was observed in the cats ventilated with PEEPmaxCrs. The effects of these levels of PEEP on respiratory mechanics, ventilation-induced lung injury, as well as in obese and critically ill cats deserve future investigation for a better understanding of the clinical use of PEEP in this species.
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Affiliation(s)
- Marcela L. Machado
- William Pritchard Veterinary Medical Teaching Hospital, University of California, Davis, Davis, CA, United States
| | - Joao H. N. Soares
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
- *Correspondence: Joao H. N. Soares
| | - Bruno H. Pypendop
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Antonio J. A. Aguiar
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
- Departamento de Cirurgia e Anestesiologia Veterinária, Faculdade de Medicina Veterinária e Zootecnia, UNESP—Univ. Estadual Paulista, Botucatu, Brazil
| | - Christina Braun
- Anaesthesiology and Perioperative Intensive Care, University of Veterinary Medicine Vienna, Vienna, Austria
| | - Gabriel C. Motta-Ribeiro
- Laboratory of Pulmonary and Cardiovascular Engineering, Biomedical Engineering Program/COPPE, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Frederico C. Jandre
- Laboratory of Pulmonary and Cardiovascular Engineering, Biomedical Engineering Program/COPPE, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Biomedical Instrumentation Laboratory, Biomedical Engineering Program/COPPE, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Martin-Flores M, Araos JD, Daniels ZS, Newman A, Nugen SA, Campoy L. The effects of intraoperative positive end-expiratory pressure and fraction of inspired oxygen on postoperative oxygenation in dogs undergoing stifle surgery. Vet Anaesth Analg 2022; 49:275-281. [DOI: 10.1016/j.vaa.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 02/03/2022] [Accepted: 02/04/2022] [Indexed: 11/27/2022]
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García-Sanz V, Aguado D, Gómez de Segura IA, Canfrán S. Individualized positive end-expiratory pressure following alveolar recruitment manoeuvres in lung-healthy anaesthetized dogs: a randomized clinical trial on early postoperative arterial oxygenation. Vet Anaesth Analg 2021; 48:841-853. [PMID: 34391669 DOI: 10.1016/j.vaa.2021.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 01/26/2021] [Accepted: 03/27/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To assess and compare the effect of intraoperative stepwise alveolar recruitment manoeuvres (ARMs), followed by individualized positive end-expiratory pressure (PEEP), defined as PEEP at maximal respiratory system compliance + 2 cmH2O (PEEPmaxCrs+2), with that of spontaneous ventilation (SV) and controlled mechanical ventilation (CMV) without ARM or PEEP on early postoperative arterial oxygenation in anaesthetized healthy dogs. STUDY DESIGN Prospective, randomized, nonblinded clinical study. ANIMALS A total of 32 healthy client-owned dogs undergoing surgery in dorsal recumbency. METHODS Dogs were ventilated intraoperatively (inspired oxygen fraction: 0.5) with one of the following strategies: SV, CMV alone, and CMV with PEEPmaxCrs+2 following a single ARM (ARM1) or two ARMs (ARM2, the second ARM at the end of surgery). Arterial blood gas analyses were performed before starting the ventilatory strategy, at the end of surgery, and at 5, 10, 15, 30 and 60 minutes after extubation while breathing room air. Data were analysed using Kruskal-Wallis and Friedman tests (p < 0.050). RESULTS At any time point after extubation, PaO2 was not significantly different between groups. At 5 minutes after extubation, PaO2 was 95.1 (78.1-104.0), 93.8 (88.3-104.0), 96.9 (86.6-115.0) and 89.1 (87.6-102.0) mmHg in the SV, CMV, ARM1 and ARM2 groups, respectively. PaO2 decreased at 30 minutes after extubation in the CMV, ARM1 and ARM2 groups (p < 0.050), but it did not decrease after 30 minutes in the SV group. Moderate hypoxaemia (PaO2, 60-80 mmHg) was observed in one dog in the ARM1 group and two dogs each in the SV and ARM2 groups. CONCLUSIONS AND CLINICAL RELEVANCE Intraoperative ARMs, followed by PEEPmaxCrs+2, did not improve early postoperative arterial oxygenation compared with SV or CMV alone in healthy anaesthetized dogs. Therefore, this ventilatory strategy might not be clinically advantageous for improving postoperative arterial oxygenation in healthy dogs undergoing surgery when positioned in dorsal recumbency.
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Affiliation(s)
- Virginia García-Sanz
- Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Madrid, Spain
| | - Delia Aguado
- Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Madrid, Spain.
| | - Ignacio A Gómez de Segura
- Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Madrid, Spain
| | - Susana Canfrán
- Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Madrid, Spain
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Longhini F, Pasin L, Montagnini C, Konrad P, Bruni A, Garofalo E, Murabito P, Pelaia C, Rondi V, Dellapiazza F, Cammarota G, Vaschetto R, Schultz MJ, Navalesi P. Intraoperative protective ventilation in patients undergoing major neurosurgical interventions: a randomized clinical trial. BMC Anesthesiol 2021; 21:184. [PMID: 34187530 PMCID: PMC8241565 DOI: 10.1186/s12871-021-01404-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 06/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Post-operative pulmonary complications (PPC) can develop in up to 13% of patients undergoing neurosurgical procedures and may adversely affect clinical outcome. The use of intraoperative lung protective ventilation (LPV) strategies, usually including the use of a low Vt, low PEEP and low plateau pressure, seem to reduce the risk of PPC and are strongly recommended in almost all surgical procedures. Nonetheless, feasibility of LPV strategies in neurosurgical patients are still debated because the use of low Vt during LPV might result in hypercapnia with detrimental effects on cerebrovascular physiology. Aim of our study was to determine whether LPV strategies would be feasible compared with a control group in adult patients undergoing cranial or spinal surgery. METHODS This single-centre, pilot randomized clinical trial was conducted at the University Hospital "Maggiore della Carità" (Novara, Italy). Adult patients undergoing major cerebral or spinal neurosurgical interventions with risk index for pulmonary post-operative complications > 2 and not expected to need post-operative intensive care unit (ICU) admission were considered eligible. Patients were randomly assigned to either LPV (Vt = 6 ml/kg of ideal body weight (IBW), respiratory rate initially set at 16 breaths/min, PEEP at 5 cmH2O and application of a recruitment manoeuvre (RM) immediately after intubation and at every disconnection from the ventilator) or control treatment (Vt = 10 ml/kg of IBW, respiratory rate initially set at 6-8 breaths/min, no PEEP and no RM). Primary outcomes of the study were intraoperative adverse events, the level of cerebral tension at dura opening and the intraoperative control of PaCO2. Secondary outcomes were the rate of pulmonary and extrapulmonary complications, the number of unplanned ICU admissions, ICU and hospital lengths of stay and mortality. RESULTS A total of 60 patients, 30 for each group, were randomized. During brain surgery, the number of episodes of intraoperative hypercapnia and grade of cerebral tension were similar between patients randomized to receive control or LPV strategies. No difference in the rate of intraoperative adverse events was found between groups. The rate of postoperative pulmonary and extrapulmonary complications and major clinical outcomes were similar between groups. CONCLUSIONS LPV strategies in patients undergoing major neurosurgical intervention are feasible. Larger clinical trials are needed to assess their role in postoperative clinical outcome improvements. TRIAL REGISTRATION registered on the Australian New Zealand Clinical Trial Registry ( www.anzctr.org.au ), registration number ACTRN12615000707561.
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Affiliation(s)
- Federico Longhini
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Laura Pasin
- Anesthesia and Intensive Care, University Hospital of Padua, Via Giustiniani 2, Padova, Italy.
| | - Claudia Montagnini
- Anesthesia and Intensive Care, "Maggiore Della Carità" Hospital, Novara, Italy
| | - Petra Konrad
- Anesthesia and Intensive Care, "Maggiore Della Carità" Hospital, Novara, Italy
| | - Andrea Bruni
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Eugenio Garofalo
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Paolo Murabito
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Corrado Pelaia
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Valentina Rondi
- Anesthesia and Intensive Care, "Maggiore Della Carità" Hospital, Novara, Italy
| | | | - Gianmaria Cammarota
- Anesthesia and Intensive Care, "Maggiore Della Carità" Hospital, Novara, Italy
| | - Rosanna Vaschetto
- Anesthesia and Intensive Care, "Maggiore Della Carità" Hospital, Novara, Italy
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Amsterdam, The Netherlands
| | - Paolo Navalesi
- Anesthesia and Intensive Care, University Hospital of Padua, Via Giustiniani 2, Padova, Italy.,Anesthesiology and Intensive Care Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
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Definition and clinical evaluation of a recruiting airway pressure based on the specific lung elastance in anesthetized dogs. Vet Anaesth Analg 2021; 48:484-492. [PMID: 33926822 DOI: 10.1016/j.vaa.2021.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the specific lung elastance (SEL) in anesthetized dogs and to evaluate the efficacy of a SEL-based recruiting airway pressure (RPaw) at improving global and regional lung aeration. STUDY DESIGN Retrospective and prospective clinical study. ANIMALS A total of 28 adult dogs were included in the retrospective study and six adult dogs in the prospective study. METHODS Retrospective study: SEL and SEL-based RPaw were determined using previously published data. In mechanically ventilated dogs undergoing thoracic computed tomography (CT), SEL was calculated as ΔPL/(VT/EELV), where ΔPL is the driving transpulmonary pressure, VT is the tidal volume and EELV is the end-expiratory lung volume. The ratio of lung to respiratory system elastance (EL/Ers) was determined. SEL and EL/Ers were used to calculate the SEL-based RPaw. Prospective study: dogs underwent thoracic CT at end-expiration and at end-inspiration using the SEL-based RPaw, and global and regional aeration was determined. For analysis of regional aeration, lungs were divided into cranial, intermediate and caudal regions. Regional compliance was also calculated. A p value <0.05 was considered significant. RESULTS The SEL and EL/Ers were 12.7 ± 3.1 cmH2O and 0.54 ± 0.07, respectively. The SEL-based RPaw was 29.1 ± 7.6 cmH2O. In the prospective study, the RPaw was 28.2 ± 1.3 cmH2O. During RPaw, hyperinflation increased (p = 0.0003) whereas poorly aerated (p < 0.0001) and nonaerated (p = 0.01) tissue decreased. Normally aerated tissue did not change (p = 0.265). Regional compliance was higher in the intermediate (p = 0.0003) and caudal (p = 0.034) regions compared with the cranial region. Aeration did not differ between regions (p > 0.05). CONCLUSIONS AND CLINICAL RELEVANCE An SEL-based RPaw reduces poorly and nonaerated lung tissue in anesthetized dogs. In nonsurgical anesthetized dogs, an RPaw near 30 cmH2O is effective at improving lung aeration.
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Soares JHN, Braun C, Machado ML, Oliveira RL, Henao-Guerrero N, Countermash-Ott S, Allen IC, Grant DC, Giannella-Neto A. Cardiovascular function, pulmonary gas exchange and tissue oxygenation in isoflurane-anesthetized, mechanically ventilated Beagle dogs with four levels of positive end-expiratory pressure. Vet Anaesth Analg 2021; 48:324-333. [PMID: 33741264 DOI: 10.1016/j.vaa.2021.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/07/2021] [Accepted: 01/24/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To compare pulmonary gas exchange, tissue oxygenation and cardiovascular effects of four levels of end-expiratory pressure: no positive end-expiratory pressure (ZEEP), positive end-expiratory pressure (PEEP) of maximal respiratory system compliance (PEEPmaxCrs), PEEPmaxCrs + 2 cmH2O (PEEPmaxCrs+2), PEEPmaxCrs + 4 cmH2O (PEEPmaxCrs+4), in isoflurane-anesthetized dogs. STUDY DESIGN Prospective randomized crossover study. ANIMALS A total of seven healthy male Beagle dogs, aged 1 year and weighing 10.2 ± 0.7 kg (mean ± standard deviation). METHODS The dogs were administered acepromazine and anesthesia was induced with propofol and maintained with isoflurane. Ventilation was controlled for 4 hours with ZEEP, PEEPmaxCrs, PEEPmaxCrs+2 or PEEPmaxCrs+4. Cardiovascular, pulmonary gas exchange and tissue oxygenation data were evaluated at 5, 60, 120, 180 and 240 minutes of ventilation and compared using a mixed-model anova followed by Bonferroni test. p < 0.05 was considered significant. RESULTS Cardiac index (CI) and mean arterial pressure (MAP) were lower in all PEEP treatments at 5 minutes when compared with ZEEP. CI persisted lower throughout the 4 hours only in PEEPmaxCrs+4 with the lowest CI at 5 minutes (2.15 ± 0.70 versus 3.45 ± 0.94 L minute-1 m-2). At 180 and 240 minutes, MAP was lower in PEEPmaxCrs+4 than in PEEPmaxCrs, with the lowest value at 180 minutes (58 ± 7 versus 67 ± 7 mmHg). Oxygen delivery index (DO2I) was lower in PEEPmaxCrs+4 than in ZEEP at 5, 60, 120 and 180 minutes. Venous admixture was not different among treatments. CONCLUSION AND CLINICAL RELEVANCE The use of PEEP caused a transient decrease in MAP and CI in lung-healthy dogs anesthetized with isoflurane, which improved after 60 minutes of ventilation in all levels of PEEP except PEEPmaxCrs+4. A clinically significant improvement in arterial oxygenation and DO2I was not observed with PEEPmaxCrs and PEEPmaxCrs+2 in comparison with ZEEP, whereas PEEPmaxCrs+4 decreased DO2I.
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Affiliation(s)
- Joao H N Soares
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA.
| | - Christina Braun
- Anesthesiology and Perioperative Intensive Care, University of Veterinary Medicine Vienna, Vienna, Austria
| | - Marcela L Machado
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - Renato L Oliveira
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - Natalia Henao-Guerrero
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - Sherryl Countermash-Ott
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - Irving C Allen
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - David C Grant
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - Antonio Giannella-Neto
- Laboratory of Pulmonary Engineering, Biomedical Engineering Program/COPPE, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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10
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Effect of recumbency and body condition score on open-lung positive end-expiratory pressure and respiratory system compliance following a stepwise lung recruitment manoeuvre in healthy dogs during general anaesthesia. Res Vet Sci 2020; 132:177-185. [PMID: 32593862 DOI: 10.1016/j.rvsc.2020.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 06/15/2020] [Accepted: 06/15/2020] [Indexed: 12/16/2022]
Abstract
The aim was to assess the effects of recumbency and body condition score (BCS) on open-lung positive end-expiratory pressure (OL-PEEP) and quasistatic respiratory system compliance (Crs) following stepwise lung recruitment manoeuvre (RM) in healthy dogs under general anaesthesia. Thirty-four dogs were anaesthetised and mechanically ventilated (tidal volume of 10 mL/kg) without PEEP for 1 min (baseline). A stepwise RM was then performed and the individual OL-PEEP was subsequently applied. The Crs was registered at baseline and every 10-min for 50 min after RM. Dogs were classified into either dorsal or lateral recumbency groups, and as normal (score 4-5/9) or high (≥6/9) BCS groups. The OL-PEEP was higher in lateral than in dorsal recumbency (P = .002), but differences were not observed between normal and high BCS (P = .865). The Crs was increased from baseline at all time points after RM in all groups. The Crs did not differ between dorsally and laterally recumbent dogs at any time point. However, the baseline Crs was significantly lower in dogs with a high BCS than in those with a normal BCS (P < .001); therefore, the absolute change from baseline was considered when comparing Crs after the RM and it was similar in both BCS groups. In conclusion, in anaesthetised healthy dogs the OL-PEEP following RM was lower when dogs were positioned in dorsal than in lateral recumbency. The Crs after RM remained unchanged regardless of the dogs' recumbency. A stepwise RM followed by OL-PEEP could compensate for the potential negative impact of moderately increased BCS on Crs.
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11
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García-Sanz V, Aguado D, Gómez de Segura IA, Canfrán S. Comparative effects of open-lung positive end-expiratory pressure (PEEP) and fixed PEEP on respiratory system compliance in the isoflurane anaesthetised healthy dog. Res Vet Sci 2019; 127:91-98. [PMID: 31683197 DOI: 10.1016/j.rvsc.2019.10.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 12/18/2022]
Abstract
This study was performed to assess the effects of open-lung positive end-expiratory pressure (OL-PEEP) following stepwise recruitment manoeuvre (RM) and those of a fixed PEEP of 5 cm H2O without previous RM on respiratory system compliance (Crs) and selected cardiovascular variables in healthy dogs under general anaesthesia. Forty-five healthy client-owned dogs undergoing surgery were anaesthetised and mechanically ventilated (tidal volume, VT = 10-12 mL/kg; PEEP = 0 cm H2O) for 1 min (baseline) and randomly allocated into zero positive end-expiratory pressure (ZEEP), PEEP (5 cm H2O) and OL-PEEP treatment groups. In the OL-PEEP group, a stepwise RM was performed and the individual OL-PEEP was subsequently applied. The Crs, heart rate (HR) and non-invasive mean arterial pressure (NIMAP) were registered at baseline and then every 10 min during 60 min. In the ZEEP group, Crs decreased from baseline. In the PEEP group, Crs was not different from either baseline or ZEEP group values. In the OL-PEEP group, Crs was higher than both baseline and ZEEP group values at all time points as well as of those in the PEEP group during at least 20 min after RM. There were no differences for HR and NIMAP between groups. A clinically relevant hypotension following RM was observed in 40% of dogs. Therefore, an individually set OL-PEEP following stepwise RM improved Crs in anaesthetised healthy dogs, although transient but clinically relevant hypotension was observed during RM in some dogs. Fixed PEEP of 5 cm H2O without previous RM did not improve Crs, although it prevented it from decreasing.
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Affiliation(s)
- Virginia García-Sanz
- Anaesthesiology Service, Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Avda. Puerta de Hierro s/n, 28040 Madrid, Spain.
| | - Delia Aguado
- Anaesthesiology Service, Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Avda. Puerta de Hierro s/n, 28040 Madrid, Spain.
| | - Ignacio A Gómez de Segura
- Anaesthesiology Service, Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Avda. Puerta de Hierro s/n, 28040 Madrid, Spain.
| | - Susana Canfrán
- Anaesthesiology Service, Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Avda. Puerta de Hierro s/n, 28040 Madrid, Spain.
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12
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García-Fernández J, Romero A, Blanco A, Gonzalez P, Abad-Gurumeta A, Bergese SD. Recruitment manoeuvres in anaesthesia: How many more excuses are there not to use them? ACTA ACUST UNITED AC 2018; 65:209-217. [PMID: 29395110 DOI: 10.1016/j.redar.2017.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 12/05/2017] [Indexed: 11/29/2022]
Abstract
Pulmonary recruitment manoeuvres (RM) are intended to reopen collapsed lung areas. RMs are present in nature as a physiological mechanism to get a newborn to open their lungs for the first time at birth, and we also use them, in our usual anaesthesiological clinical practice, after induction or during general anaesthesia when a patient is desaturated. However, there is much confusion in clinical practice regarding their safety, the best way to perform them, when to do them, in which patients they are indicated, and in those where they are totally contraindicated. There are important differences between RM in the patient with adult respiratory distress syndrome, and in a healthy patient during general anaesthesia. Our intention is to review, from a clinical and practical point of view, the use of RM, specifically in anaesthesia.
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Affiliation(s)
- J García-Fernández
- Servicio de Anestesiología, Cuidados Críticos y Dolor. Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España; Departamento de Cirugía, Facultad de Medicina, Universidad Autónoma , Madrid, España.
| | - A Romero
- Servicio de Anestesiología, Cuidados Críticos y Dolor. Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | - A Blanco
- Servicio de Anestesiología, Cuidados Críticos y Dolor. Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | - P Gonzalez
- Department of Anesthesia and Perioperative Medicine, Akademiska University Hospital, Uppsala, Suecia
| | - A Abad-Gurumeta
- Servicio de Anestesiología, Cuidados Críticos y Dolor, Hospital Universitario Infanta Leonor, , Madrid, España; La Revista Española de Anestesiología y Reanimación; Departamento de Farmacología, Facultad de Medicina. Universidad Complutense , Madrid, España
| | - S D Bergese
- Neurosurgical Anesthesia, Departments of Anesthesiology and Neurological Surgery, The Ohio State University, Columbus, Ohio, Estados Unidos
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Thiele RH, Raghunathan K, Brudney CS, Lobo DN, Martin D, Senagore A, Cannesson M, Gan TJ, Mythen MMG, Shaw AD, Miller TE. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on perioperative fluid management within an enhanced recovery pathway for colorectal surgery. Perioper Med (Lond) 2016; 5:24. [PMID: 27660701 PMCID: PMC5027098 DOI: 10.1186/s13741-016-0049-9] [Citation(s) in RCA: 123] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 08/24/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Enhanced recovery may be viewed as a comprehensive approach to improving meaningful outcomes in patients undergoing major surgery. Evidence to support enhanced recovery pathways (ERPs) is strong in patients undergoing colorectal surgery. There is some controversy about the adoption of specific elements in enhanced recovery "bundles" because the relative importance of different components of ERPs is hard to discern (a consequence of multiple simultaneous changes in clinical practice when ERPs are initiated). There is evidence that specific approaches to fluid management are better than alternatives in patients undergoing colorectal surgery; however, several specific questions remain. METHODS In the "Perioperative Quality Initiative (POQI) Fluids" workgroup, we developed a framework broadly applicable to the perioperative management of intravenous fluid therapy in patients undergoing elective colorectal surgery within an ERP. DISCUSSION We discussed aspects of ERPs that impact fluid management and made recommendations or suggestions on topics such as bowel preparation; preoperative oral hydration; intraoperative fluid therapy with and without devices for goal-directed fluid therapy; and type of fluid.
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Affiliation(s)
- Robert H Thiele
- Departments of Anesthesiology and Biomedical Engineering, Divisions of Cardiac, Thoracic, and Critical Care Anesthesiology, UVA Enhanced Recovery after Surgery (ERAS) Program, University of Virginia School of Medicine, Charlottesville, VA USA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710 USA
| | - C S Brudney
- Duke University and Durham VA Medical Center, Durham, NC USA
| | - Dileep N Lobo
- Gastrointestinal Surgery, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH UK
| | - Daniel Martin
- Division of Surgery and Interventional Science, University College London, Royal Free Hospital, London, NW3 2QG UK ; Anaesthetic Department, Royal Free Perioperative Research Group, Royal Free Hospital, London, NW3 2QG UK
| | - Anthony Senagore
- Department of Surgery, University of Texas-Medical Branch at Galveston, Galveston, TX 77555 USA
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA USA
| | - Tong Joo Gan
- Department of Anesthesiology, Stony Brook University School of Medicine, Stony Brook, NY USA
| | - Michael Monty G Mythen
- University College London Hospitals, National Institute of Health Research Biomedical Research Centre, London, UK
| | - Andrew D Shaw
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN USA
| | - Timothy E Miller
- Division of General, Vascular and Transplant Anesthesia, American Society for Enhanced Recovery, Duke University Medical Center, Durham, NC 27710 USA
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