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Arora L, Sharma S, Carillo JF. Obesity and anesthesia. Curr Opin Anaesthesiol 2024; 37:299-307. [PMID: 38573180 DOI: 10.1097/aco.0000000000001377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
PURPOSE OF REVIEW Surgical procedures on obese patients are dramatically increasing worldwide over the past few years. In this review, we discuss the physiopathology of predominantly respiratory system in obese patients, the importance of preoperative evaluation, preoxygenation and intraoperative positive end expiratory pressure (PEEP) titration to prevent pulmonary complications and the optimization of airway management and oxygenation to reduce or prevent postoperative respiratory complications. RECENT FINDINGS Many patients are coming to preoperative clinic with medication history of glucagon-like-peptide 1 agonists ( GLP-1) agonists and it has raised many questions regarding Nil Per Os (NPO)/perioperative fasting guidelines due to delayed gastric emptying caused by these medications. American Society of Anesthesiologists (ASA) has come up with guiding document to help with such situations. Ambulatory surgery centers are doing more obesity cases in a safe manner which were deemed unsafe at one point . Quantitative train of four (TOF) monitoring, better neuromuscular reversal agents and gastric ultrasounds seemed to have made a significant impact in the care of obese patients in the perioperative period. SUMMARY Obese patients are at higher risk of perioperative complications, mainly associated with those related to the respiratory function. An appropriate preoperative evaluation, intraoperative management, and postoperative support and monitoring is essential to improve outcome and increase the safety of the surgical procedure.
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Affiliation(s)
- Lovkesh Arora
- Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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2
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Iwata H, Yoshida T, Hoshino T, Aiyama Y, Maezawa T, Hashimoto H, Koyama Y, Yamada T, Fujino Y. Electrical Impedance Tomography-based Ventilation Patterns in Patients after Major Surgery. Am J Respir Crit Care Med 2024; 209:1328-1337. [PMID: 38346178 DOI: 10.1164/rccm.202309-1658oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 02/12/2024] [Indexed: 06/01/2024] Open
Abstract
Rationale: General anesthesia and mechanical ventilation have negative impacts on the respiratory system, causing heterogeneous distribution of lung aeration, but little is known about the ventilation patterns of postoperative patients and their association with clinical outcomes. Objectives: To clarify the phenotypes of ventilation patterns along a gravitational direction after surgery by using electrical impedance tomography (EIT) and to evaluate their association with postoperative pulmonary complications (PPCs) and other relevant clinical outcomes. Methods: Adult postoperative patients at high risk for PPCs, receiving mechanical ventilation on ICU admission (N = 128), were prospectively enrolled between November 18, 2021 and July 18, 2022. PPCs were prospectively scored until hospital discharge, and their association with phenotypes of ventilation patterns was studied. The secondary outcomes were the times to wean from mechanical ventilation and oxygen use and the length of ICU stay. Measurements and Main Results: Three phenotypes of ventilation patterns were revealed by EIT: phenotype 1 (32% [n = 41], a predominance of ventral ventilation), phenotype 2 (41% [n = 52], homogeneous ventilation), and phenotype 3 (27% [n = 35], a predominance of dorsal ventilation). The median PPC score was higher in phenotype 1 and phenotype 3 than in phenotype 2. The median time to wean from mechanical ventilation was longer in phenotype 1 versus phenotype 2. The median duration of ICU stay was longer in phenotype 1 versus phenotype 2. The median time to wean from oxygen use was longer in phenotype 1 and phenotype 3 than in phenotype 2. Conclusions: Inhomogeneous ventilation patterns revealed by EIT on ICU admission were associated with PPCs, delayed weaning from mechanical ventilation and oxygen use, and a longer ICU stay.
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Affiliation(s)
- Hirofumi Iwata
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan; and
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan; and
| | - Taiki Hoshino
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan; and
| | - Yuki Aiyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan; and
| | - Takashi Maezawa
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan; and
| | - Haruka Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan; and
| | - Yukiko Koyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan; and
| | - Tomomi Yamada
- The Department of Medical Innovation Data Coordinating Center, Osaka University Hospital, Suita, Japan
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan; and
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3
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Abbott M, Pereira SM, Sanders N, Girard M, Sankar A, Sklar MC. Weaning from mechanical ventilation in the operating room: a systematic review. Br J Anaesth 2024:S0007-0912(24)00263-0. [PMID: 38816331 DOI: 10.1016/j.bja.2024.03.043] [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: 11/09/2023] [Revised: 02/27/2024] [Accepted: 03/22/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Postoperative pulmonary complications (PPCs) are associated with postoperative mortality and prolonged hospital stay. Although intraoperative mechanical ventilation (MV) is a risk factor for PPCs, strategies addressing weaning from MV are understudied. In this systematic review, we evaluated weaning strategies and their effects on postoperative pulmonary outcomes. METHODS Our protocol was registered on PROSPERO (CRD42022379145). Eligible studies included randomised controlled trials and observational studies of adults weaned from MV in the operating room. Primary outcomes included atelectasis and oxygenation; secondary outcomes included lung volume changes and PPCs. Risk of bias was assessed using the Cochrane Risk of Bias (RoB2) tool, and quality of evidence with the GRADE framework. RESULTS Screening identified 14 randomised controlled trials including 1719 patients; seven studies were limited to the weaning phase and seven included interventions not restricted to the weaning phase. Strategies combining pressure support ventilation (PSV) with positive end-expiratory pressure (PEEP) and low fraction of inspired oxygen (FiO2) improved atelectasis, oxygenation, and lung volumes. Low FiO2 improved atelectasis and oxygenation but might not improve lung volumes. A fixed-PEEP strategy led to no improvement in oxygenation or atelectasis; however, individualised PEEP with low FiO2 improved oxygenation and might be associated with reduced PPCs. Half of included studies are of moderate or high risk of bias; the overall quality of evidence is low. CONCLUSIONS There is limited research evaluating weaning from intraoperative MV. Based on low-quality evidence, PSV, individualised PEEP, and low FiO2 may be associated with reduced postoperative pulmonary outcomes. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42022379145).
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Affiliation(s)
- Megan Abbott
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada
| | - Sergio M Pereira
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Noah Sanders
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada
| | - Martin Girard
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada; Division of Critical Care, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada; Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal Research Center, Montreal, QC, Canada
| | - Ashwin Sankar
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Michael C Sklar
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
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Liang TW, Shen CH, Wu YS, Chang YT. Erector spinae plane block reduces opioid consumption and improves incentive spirometry volume after cardiac surgery: A retrospective cohort study. J Chin Med Assoc 2024; 87:550-557. [PMID: 38501787 DOI: 10.1097/jcma.0000000000001086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Effective postoperative pain management is vital in cardiac surgery to prevent opioid dependency and respiratory complications. Previous studies on the erector spinae plane (ESP) block have focused on single-shot applications or immediate postoperative outcomes. This study evaluates the efficacy of continuous ESP block vs conventional care in reducing opioid consumption and enhancing respiratory function recovery postcardiac surgery over 72 hours. METHODS A retrospective study at a tertiary hospital (January 2021-July 2022) included 262 elective cardiac surgery patients. Fifty-three received a preoperative ESP block, matched 1:1 with a control group (n = 53). The ESP group received 0.5% ropivacaine intraoperatively and 0.16% ropivacaine every 4 hours postoperatively. Outcomes measured were cumulative oral morphine equivalent (OME) dose within 72 hours postextubation, daily maximum numerical rating scale (NRS) ≥3, incentive spirometry volume, and %baseline performance, stratified by surgery type (sternotomy or thoracotomy). RESULTS Significant OME reduction was observed in the ESP group (sternotomy: median decrease of 113 mg, 95% CI: 60-157.5 mg, p < 0.001; thoracotomy: 172.5 mg, 95% CI: 45-285 mg, p = 0.010). The ESP group also had a lower risk of daily maximum NRS ≥3 (adjusted OR sternotomy: 0.22, p < 0.001; thoracotomy: 0.07, p < 0.001), a higher incentive spirometry volumes (sternotomy: mean increase of 149 mL, p = 0.019; thoracotomy: 521 mL, p = 0.017), and enhanced spirometry %baseline (sternotomy: mean increase of 11.5%, p = 0.014; thoracotomy: 26.5%, p < 0.001). CONCLUSION Continuous ESP block was associated with a reduction of postoperative opioid requirements, lower instances of pain scores ≥3, and improve incentive spirometry performance following cardiac surgery. These benefits appear particularly prominent in thoracotomy patients. Further prospective studies with larger sample size are required to validate these findings.
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Affiliation(s)
- Ting-Wei Liang
- Department of Anesthesiology, Show Chwan Memorial Hospital, Changhua, Taiwan, ROC
| | - Ching-Hui Shen
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yung-Szu Wu
- Department of Cardiac Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Yi-Ting Chang
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
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Vetrugno L, Deana C, Colaianni-Alfonso N, Tritapepe F, Fierro C, Maggiore SM. Noninvasive respiratory support in the perioperative setting: a narrative review. Front Med (Lausanne) 2024; 11:1364475. [PMID: 38695030 PMCID: PMC11061466 DOI: 10.3389/fmed.2024.1364475] [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: 01/02/2024] [Accepted: 04/08/2024] [Indexed: 05/04/2024] Open
Abstract
The application of preoperative noninvasive respiratory support (NRS) has been expanding with increasing recognition of its potential role in this setting as a physiological optimization for patients with a high risk of developing atelectasis and postoperative pulmonary complications (PPC). The increased availability of high-performance anesthesia ventilator machines providing an easy way for NRS support in patients with reduced lung function should not be under-evaluated. This support can reduce hypoxia, restore lung volumes and theoretically reduce atelectasis formation after general anesthesia. Therapeutic purposes should also be considered in the perioperative setting, such as preoperative NRS to optimize treatment of patients' pre-existing diseases, e.g., sleep-disordered breathing. Finally, the recent guidelines for airway management suggest preoperative NRS application before anesthesia induction in difficult airway management to prolong the time needed to secure the airway with an orotracheal tube. This narrative review aims to revise all these aspects and to provide some practical notes to maximize the efficacy of perioperative noninvasive respiratory support.
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Affiliation(s)
- Luigi Vetrugno
- Department of Medical, Oral and Biotecnological Science, “G. D’Annunzio” Chieti-Pescara University, Chieti, Italy
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
| | - Cristian Deana
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | | | - Fabrizio Tritapepe
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
| | - Carmen Fierro
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
| | - Salvatore Maurizio Maggiore
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
- Department of Innovative Technologies in Medicine & Dentistry, Section of Anesthesia and Intensive Care, SS. Annunziata Hospital, G. D’Annunzio University, Chieti, Italy
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6
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Ribeiro BM, Tucci MR, Victor Júnior MH, Melo JR, Gomes S, Nakamura MAM, Morais CCA, Beraldo MA, Lima CAS, Alcala GC, Amato MBP. Influence of Fractional Inspired Oxygen Tension on Lung Perfusion Distribution, Regional Ventilation, and Lung Volume during Mechanical Ventilation of Supine Healthy Swine. Anesthesiology 2024; 140:752-764. [PMID: 38207290 DOI: 10.1097/aln.0000000000004903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
BACKGROUND Lower fractional inspired oxygen tension (Fio2) during general anesthesia can reduce lung atelectasis. The objectives are to evaluate the effect of two Fio2 (0.4 and 1) during low positive end-expiratory pressure (PEEP) ventilation over lung perfusion distribution, volume, and regional ventilation. These variables were evaluated at two PEEP levels and unilateral lung atelectasis. METHODS In this exploratory study, 10 healthy female piglets (32.3 ± 3.4 kg) underwent mechanical ventilation in two atelectasis models: (1) bilateral gravitational atelectasis (n = 6), induced by changes in PEEP and Fio2 in three combinations: high PEEP with low Fio2 (Fio2 = 0.4), zero PEEP (PEEP0) with low Fio2 (Fio2 = 0.4), and PEEP0 with high Fio2 (Fio2 = 1); and (2) unilateral atelectasis (n = 6), induced by left bronchial occlusion, with the left lung aerated (Fio2 = 0.21) and low aerated (Fio2 = 1; n = 5 for this step). Measurements were conducted after 10 min in each step, encompassing assessment of respiratory mechanics, oxygenation, and hemodynamics; lung ventilation and perfusion by electrical impedance tomography; and lung aeration and perfusion by computed tomography. RESULTS During bilateral gravitational atelectasis, PEEP reduction increased atelectasis in dorsal regions, decreased respiratory compliance, and distributed lung ventilation to ventral regions with a parallel shift of perfusion to the same areas. With PEEP0, there were no differences between low and high Fio2 in respiratory compliance (23.9 ± 6.5 ml/cm H2O vs. 21.9 ± 5.0; P = 0.441), regional ventilation, and regional perfusion, despite higher lung collapse (18.6 ± 7.6% vs. 32.7 ± 14.5%; P = 0.045) with high Fio2. During unilateral lung atelectasis, the deaerated lung had a lower shunt (19.3 ± 3.6% vs. 25.3 ± 5.5%; P = 0.045) and lower computed tomography perfusion to the left lung (8.8 ± 1.8% vs. 23.8 ± 7.1%; P = 0.007). CONCLUSIONS PEEP0 with low Fio2, compared with high Fio2, did not produce significant changes in respiratory system compliance, regional lung ventilation, and perfusion despite significantly lower lung collapse. After left bronchial occlusion, the shrinkage of the parenchyma with Fio2 = 1 enhanced hypoxic pulmonary vasoconstriction, reducing intrapulmonary shunt and perfusion of the nonventilated areas. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Bruno M Ribeiro
- Laboratorio de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto de Cardiologia (Incor), Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Mauro R Tucci
- Laboratorio de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto de Cardiologia (Incor), Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Marcus H Victor Júnior
- Laboratorio de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto de Cardiologia (Incor), Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil; Electronics Engineering, Aeronautics Institute of Technology, Sao Jose dos Campos, Brazil
| | - Jose R Melo
- Laboratorio de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto de Cardiologia (Incor), Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Susimeire Gomes
- Laboratorio de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto de Cardiologia (Incor), Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Maria A M Nakamura
- Laboratorio de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto de Cardiologia (Incor), Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Caio C A Morais
- Laboratorio de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto de Cardiologia (Incor), Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Marcelo A Beraldo
- Laboratorio de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto de Cardiologia (Incor), Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Cristhiano A S Lima
- Laboratorio de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto de Cardiologia (Incor), Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Glasiele C Alcala
- Laboratorio de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto de Cardiologia (Incor), Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Marcelo B P Amato
- Laboratorio de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto de Cardiologia (Incor), Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
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Sudy R, Dereu D, Lin N, Pichon I, Petak F, Habre W, Albu G. Respiratory effects of pressure support ventilation in spontaneously breathing patients under anaesthesia: Randomised controlled trial. Acta Anaesthesiol Scand 2024; 68:311-320. [PMID: 37923301 DOI: 10.1111/aas.14350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Lung volume loss is a major risk factor for postoperative respiratory complications after general anaesthesia and mechanical ventilation. We hypothesise that spontaneous breathing without pressure support may enhance the risk for atelectasis development. Therefore, we aimed at characterising whether pressure support prevents changes in lung function in patients breathing spontaneously through laryngeal mask airway. METHODS In this randomised controlled trial, adult female patients scheduled for elective gynaecological surgery in lithotomy position were randomly assigned to the continuous spontaneous breathing group (CSB, n = 20) or to the pressure support ventilation group (PSV, n = 20) in a tertiary university hospital. Lung function measurements were carried out before anaesthesia and 1 h postoperatively by a researcher blinded to the group allocation. Lung clearance index calculated from end-expiratory lung volume turnovers as primary outcome variable was assessed by the multiple-breath nitrogen washout technique (MBW). Respiratory mechanics were measured by forced oscillations to assess parameters reflecting the small airway function and respiratory tissue stiffness. RESULTS MBW was successfully completed in 18 patients in both CSB and PSV groups. The decrease in end-expiratory lung volume was more pronounced in the CSB than that in the PSV group (16.6 ± 6.6 [95% CI] % vs. 7.6 ± 11.1%, p = .0259), with no significant difference in the relative changes of the lung clearance index (-0.035 ± 7.1% vs. -0.18 ± 6.6%, p = .963). The postoperative changes in small airway function and respiratory tissue stiffness were significantly lower in the PSV than in the CSB group (p < .05 for both). CONCLUSIONS These results suggest that pressure support ventilation protects against postoperative lung-volume loss without affecting ventilation inhomogeneity in spontaneously breathing patients with increased risk for atelectasis development. TRIAL REGISTRATION NCT02986269.
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Affiliation(s)
- Roberta Sudy
- Unit for Anaesthesiological Investigations, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
| | - Domitille Dereu
- Unit for Obstetrics and Gynaecology Anaesthesia, University Hospitals of Geneva, Geneva, Switzerland
| | - Na Lin
- Department of Anaesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Isabelle Pichon
- Unit for Anaesthesiological Investigations, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
| | - Ferenc Petak
- Department of Medical Physics and Informatics, University of Szeged, Geneva, Hungary
| | - Walid Habre
- Unit for Anaesthesiological Investigations, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
| | - Gergely Albu
- Unit for Anaesthesiological Investigations, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
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Elefterion B, Cirenei C, Kipnis E, Cailliau E, Bruandet A, Tavernier B, Lamer A, Lebuffe G. Intraoperative Mechanical Power and Postoperative Pulmonary Complications in Noncardiothoracic Elective Surgery Patients: A 10-Year Retrospective Cohort Study. Anesthesiology 2024; 140:399-408. [PMID: 38011027 DOI: 10.1097/aln.0000000000004848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND Postoperative pulmonary complications is a major issue that affects outcomes of surgical patients. The hypothesis was that the intraoperative ventilation parameters are associated with occurrence of postoperative pulmonary complications. METHODS A single-center retrospective cohort study was conducted at the Lille University Hospital, France. The study included 33,701 adults undergoing noncardiac, nonthoracic elective surgery requiring general anesthesia with tracheal intubation between January 2010 and December 2019. Intraoperative ventilation parameters were compared between patients with and without one or more postoperative pulmonary complications (respiratory infection, respiratory failure, pleural effusion, atelectasis, pneumothorax, bronchospasm, and aspiration pneumonitis) within 7 days of surgery. RESULTS Among 33,701 patients, 2,033 (6.0%) had one or more postoperative pulmonary complications. The lower tidal volume to predicted body weight ratio (odds ratio per -1 ml·kgPBW-1, 1.08; 95% CI, 1.02 to 1.14; P < 0.001), higher mechanical power (odds ratio per 4 J·min-1, 1.37; 95% CI, 1.26 to 1.49; P < 0.001), dynamic respiratory system compliance less than 30 ml·cm H2O (1.30; 95% CI, 1.15 to 1.46; P < 0.001), oxygen saturation measured by pulse oximetry less than 96% (odds ratio, 2.42; 95% CI, 1.97 to 2.96; P < 0.001), and lower end-tidal carbon dioxide (odds ratio per -3 mmHg, 1.06; 95% CI, 1.00 to 1.13; P = 0.023) were independently associated with postoperative pulmonary complications. Patients with postoperative pulmonary complications were more likely to be admitted to the intensive care unit (odds ratio, 12.5; 95% CI, 6.6 to 10.1; P < 0.001), had longer hospital length of stay (subhazard ratio, 0.43; 95% CI, 0.40 to 0.45), and higher in-hospital (subhazard ratio, 6.0; 95% CI, 4.1 to 9.0; P < 0.001) and 1-yr mortality (subhazard ratio, 2.65; 95% CI, 2.33 to 3.02; P < 0.001). CONCLUSIONS In the study's population, decreased rather than increased tidal volume, decreased compliance, increased mechanical power, and decreased end-tidal carbon dioxide were independently associated with postoperative pulmonary complications. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Bertrand Elefterion
- Lille University Hospital, Surgical Critical Care, Department of Anesthesiology and Critical Care, Lille, France
| | - Cedric Cirenei
- Lille University Hospital, Surgical Critical Care, Department of Anesthesiology and Critical Care, Lille, France
| | - Eric Kipnis
- Lille University Hospital, Surgical Critical Care, Department of Anesthesiology and Critical Care, Lille, France
| | - Emeline Cailliau
- Lille University Hospital, Biostatistics Department, Lille, France
| | - Amélie Bruandet
- Lille University Hospital, Medical Information Department, Lille, France
| | - Benoit Tavernier
- Lille University Hospital, Surgical Critical Care, Department of Anesthesiology and Critical Care, Lille, France; and Lille University F-59000, ULR 2694-METRICS: Health Technology Assessment and Medical Practices Evaluation, Lille, France
| | - Antoine Lamer
- Lille University, Lille University Hospital, ULR 2694-METRICS: Health Technology Assessment and Medical Practices Evaluation, Lille, France
| | - Gilles Lebuffe
- Lille University Hospital, Surgical Critical Care, Department of Anesthesiology and Critical Care, Lille, France: Lille University F-59000, ULR 7365-Research Group on Injectable Forms and Associated Technologies, Lille, France
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9
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Deana C, Vecchiato M, Bellocchio F, Tullio A, Martino A, Ziccarelli A, Patruno V, Pascolo M, Bassi F, Pontoni M, Raimondi P, Cereser L, Vetrugno L, Petri R, Uzzau A. High flow nasal oxygen vs. conventional oxygen therapy over respiratory oxygenation index after esophagectomy: an observational study. J Thorac Dis 2024; 16:997-1008. [PMID: 38505084 PMCID: PMC10944724 DOI: 10.21037/jtd-23-1176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 12/06/2023] [Indexed: 03/21/2024]
Abstract
Background Postoperative pulmonary complications after esophagectomy still represent a matter of concern. High flow nasal cannula (HFNC) early after major abdominal and thoracic surgery has demonstrated some advantages over conventional oxygen therapy. Data about respiratory effect of HFNC after esophagectomy is scarce. The primary aim of this study is to investigate if the early use of HFNC after esophagectomy could enhance patients' postoperative respiratory oxygenation (ROX) index and, ultimately, reduce postoperative pneumonia. Methods In this single center retrospective study all patients undergoing to esophagectomy for cancer from May 2020 to November 2022 were evaluated. Historical cohort (HC) received postoperative oxygen supplementation with Venturi mask or nasal goggles, and a cohort was put under HFNC (HFNC cohort). ROX index, blood gas analysis, radiological atelectasis score (RAS), post-operative complications' data and information on hospital stay have been collected and analyzed. Results Seventy-one patients were included for the final statistical analysis, 31 in the HFNC and 40 in the HC cohort. Mean age was 64±10 years and body mass index (BMI) was 26 [24-29] kg/m2. ROX index was higher in the HFNC patients than in the HC, 20.8 [16.7-25.9] vs. 14.9 [10.8-18.2] (P<0.0001). In the HFNC cohort patients, pH was higher, 7.42 [7.40-7.44] vs. 7.39 [7.37-7.43] than HC, while PaCO2 was lower in HFNC cohort compared with HC, 39 [36-41] vs. 42 [39-45] mmHg, respectively (P=0.01). RAS was similar between the two cohorts of patients, 1.5±0.98 vs. 1.4±1.04 in the HFNC and the HC cohort, respectively (P=0.611). Lower acute respiratory failure (ARF) rate was recorded among HFNC than HC cohort, 0% vs. 13% respectively, P=0.06. No difference in pneumonia frequency between two cohorts was shown. Conclusions HFNC improved the ROX index after esophagectomy through significant respiratory rate reduction. This tool should be considered for early respiratory support after extubation in this category of patients, not only as a rescue therapy for ARF, but also to optimize early postoperative respiratory function. Whether this will improve patients' outcomes requires further large randomized controlled trials.
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Affiliation(s)
- Cristian Deana
- Anesthesia and Intensive Care Department, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Massimo Vecchiato
- Department of Surgery, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | | | - Annarita Tullio
- Hygiene and Clinical Epidemiology Unit, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Antonio Martino
- Department of Surgery, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Antonio Ziccarelli
- Department of Surgery, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Vincenzo Patruno
- Pulmonology Unit, Cardiothoracic Department, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Marika Pascolo
- Department of Surgery, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Flavio Bassi
- Anesthesia and Intensive Care Department, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Marta Pontoni
- Pulmonology Unit, Cardiothoracic Department, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Paola Raimondi
- Pulmonology Unit, Cardiothoracic Department, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Lorenzo Cereser
- Institute of Radiology, Department of Medicine, University of Udine, Udine, Italy
| | - Luigi Vetrugno
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, Chieti, Italy
| | - Roberto Petri
- Department of Surgery, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Alessandro Uzzau
- Department of Surgery, Health Integrated Agency of Friuli Centrale, Udine, Italy
- Department of Medical Area, University of Udine, Udine, Italy
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10
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Li S, Wang Y, Zhang Y, Zhang H, Wang S, Ma K, Jiang L, Mao Y. Effect of ultrasound-guided transversus abdominis plane block in reducing atelectasis after laparoscopic surgery in children: A randomized clinical trial. Heliyon 2024; 10:e26594. [PMID: 38420373 PMCID: PMC10901023 DOI: 10.1016/j.heliyon.2024.e26594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 02/10/2024] [Accepted: 02/15/2024] [Indexed: 03/02/2024] Open
Abstract
Background Atelectasis is a commonly observed postoperative complication of general anesthesia in children. Pulmonary protective ventilation strategies have been reported to have a beneficial effect on postoperative atelectasis in children. Therefore, the present study aimed to evaluate the efficacy of the ultrasound-guided transversus abdominis plane (TAP) block technique in preventing the incidence of postoperative atelectasis in children. Materials and methods This study enrolled 100 consecutive children undergoing elective laparoscopic bilateral hernia repair and randomly divided them into the control and TAP groups. Conventional lung-protective ventilation was initiated in both groups after the induction of general anesthesia. The children in the TAP group received an ultrasound-guided TAP block with 0.3 mL/kg of 0.5% ropivacaine after the induction of anesthesia. Results Anesthesia-induced atelectasis was observed in 24% and 84% of patients in the TAP (n = 50) and control (n = 50) groups, respectively, before discharge from the post-anesthetic care unit (T3; PACU) (odds ratio [OR], 0.062; 95% confidence interval [CI], 0.019-0.179; P < 0.001). No significant difference was observed between the control and TAP groups in terms of the lung ultrasonography (LUS) scores 5 min after endotracheal intubation (T1). However, the LUS scores were lower in the TAP group than those in the control group at the end of surgery (T2, P < 0.01) and before discharge from the PACU (T3, P < 0.001). Moreover, the ace, legs, activity, cry and consolability (FLACC) pain scores in the TAP group were lower than those in the control group at each postoperative time point. Conclusion Ultrasound-guided TAP block effectively reduced the incidence of postoperative atelectasis and alleviated pain in children undergoing laparoscopic surgery.
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Affiliation(s)
- Siyuan Li
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China
| | - Yan Wang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China
| | - Yunqian Zhang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China
| | - Hui Zhang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China
| | - Shenghua Wang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China
| | - Ke Ma
- Department of Pain Medicine, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China
| | - Lai Jiang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China
| | - Yanfei Mao
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China
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11
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Zou J, Wang H, Nan Y, Jin X. Stubborn hypoxemia after mild to moderate sedation and analgesia: A case report. Medicine (Baltimore) 2024; 103:e37059. [PMID: 38363927 PMCID: PMC10869035 DOI: 10.1097/md.0000000000037059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/04/2024] [Indexed: 02/18/2024] Open
Abstract
INTRODUCTION Atelectasis typically denotes the partial or complete collapse of lung segments, lobes, or lobules in individuals, leading to a compromised respiratory function. The prevalence of perioperative atelectasis may be significantly underestimated, particularly among patients subjected to general anesthesia. PATIENT CONCERNS This article conducts a retrospective analysis of a case involving refractory hypoxemia in a patient with a liver tumor who was admitted to Yanbian University Affiliated Hospital (Yanbian Hospital) after undergoing mild-to-moderate sedation and analgesia outside the operating room. DIAGNOSIS Based on the results of CT examination and present history, the patient was diagnosed with intraoperative atelectasis. INTERVENTION After the surgery, the patient was transferred to the recovery ward, where nasal oxygen therapy and nebulized inhalation treatment were administered. Vital signs were closely monitored at the bedside, gradually returning to the preoperative baseline. OUTCOME Postoperatively, the patient developed atelectasis, with the percentage of lung opacity shown in the image decreasing from 9.2% of the total thoracic cage area to 8.4%. CONCLUSION During non-intubated intravenous anesthesia, patients with compromised pulmonary conditions are more susceptible to refractory hypoxemia. Therefore, a personalized approach should be adopted regarding oxygen concentration and the dosage and type of medication. Additionally, preparations for appropriate airway management measures are essential to safeguard patient safety in the event of respiratory issues.
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Affiliation(s)
- Jiayun Zou
- Department of Anesthesiology, Yanbian University, Yanbian University Hospital, Yanji, Jilin, P.R. China
| | - Huazhen Wang
- Department of Anesthesiology, Yanbian University, Yanbian University Hospital, Yanji, Jilin, P.R. China
| | - Yongshan Nan
- Department of Anesthesiology, Yanbian University Hospital, Yanji, Jilin, P.R. China
| | - Xianglan Jin
- Department of Anesthesiology, Yanbian University Hospital, Yanji, Jilin, P.R. China
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12
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Dupont K, Lefrançois V, Delahaye A, Sanz M, Hestin R, Doublet T, Parienti JJ, Hanouz JL. Change in stroke volume during alveolar recruitment maneuvers through transient continuous positive airway pressure or stepwise increase in positive end expiratory pressure in anesthetized patients: a prospective randomized double-blind study. Can J Anaesth 2024; 71:224-233. [PMID: 38017197 DOI: 10.1007/s12630-023-02644-7] [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: 04/14/2023] [Revised: 06/28/2023] [Accepted: 07/23/2023] [Indexed: 11/30/2023] Open
Abstract
PURPOSE Intraoperative alveolar recruitment maneuvers (ARM) used during protective ventilation strategy may have severe adverse hemodynamic effects, reported mainly during abrupt continuous positive airway pressure (CPAP). Stepwise increase and decrease in positive end expiratory pressure (PEEP) may be used. We compared the hemodynamic effects of these two maneuvers. METHODS We enrolled patients scheduled for intermediate to high-risk surgery with continuous arterial pressure and stroke volume (esophageal Doppler) monitoring in a prospective, single-centre, randomized, double-blind study. After induction of anesthesia, we ensured preload independence of stroke volume before an ARM was randomly performed: 30 cm H2O CPAP for 30 sec (CPAP group) or stepwise increase in PEEP from 8 to 20 cm H2O with inspiratory pressure of 10 cm H2O followed by a stepwise decrease in PEEP from 20 to 8 cm H2O (STEP group). The primary outcome was the relative variation in stroke volume. RESULTS Thirty-five patients were included in the CPAP and STEP groups. Mean (standard deviation) relative variation in stroke volume was -57 (24)% in the CPAP group and -32 (24)% in the STEP group (difference, -25; 95% confidence interval, -37 to -14; P < 0.001). Changes in systolic, mean, and diastolic arterial pressure over time were not different between groups. The ARM was stopped because of a systolic arterial pressure < 70 mm Hg in four patients in the CPAP group and in one patient in the STEP group. CONCLUSIONS Alveolar recruitment maneuvers through stepwise increase and decrease in PEEP have a better hemodynamic tolerance than transient CPAP. TRIAL REGISTRATION ClinicalTrials.gov (NCT04802421); first submitted 15 March 2021.
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Affiliation(s)
- Kevin Dupont
- Service Anesthésie Réanimation, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, 14000, Caen, France
| | - Valentin Lefrançois
- Service Anesthésie Réanimation, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, 14000, Caen, France
| | - Antoine Delahaye
- Service Anesthésie Réanimation, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, 14000, Caen, France
| | - Marine Sanz
- Service Anesthésie Réanimation, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, 14000, Caen, France
| | - Rémi Hestin
- Service Anesthésie Réanimation, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, 14000, Caen, France
| | - Théophane Doublet
- Service Anesthésie Réanimation, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, 14000, Caen, France
| | - Jean-Jacques Parienti
- Department of Clinical Research and Biostatistics, Caen University Hospital and Caen Normandy University, Caen, France
- UFR Medecine, Uiversité Caen Normandie, 2 Rue des Rochambelles, 14032 Caen Cedex 5, Caen, France
| | - Jean-Luc Hanouz
- Service Anesthésie Réanimation, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, 14000, Caen, France.
- UFR Medecine, Uiversité Caen Normandie, 2 Rue des Rochambelles, 14032 Caen Cedex 5, Caen, France.
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13
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Fioccola A, Nicolardi RV, Pozzi T, Fratti I, Romitti F, Collino F, Reupke V, Bassi GL, Protti A, Santini A, Cressoni M, Busana M, Moerer O, Camporota L, Gattinoni L. Estimation of normal lung weight index in healthy female domestic pigs. Intensive Care Med Exp 2024; 12:6. [PMID: 38273120 PMCID: PMC10811311 DOI: 10.1186/s40635-023-00591-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/21/2023] [Indexed: 01/27/2024] Open
Abstract
INTRODUCTION Lung weight is an important study endpoint to assess lung edema in porcine experiments on acute respiratory distress syndrome and ventilatory induced lung injury. Evidence on the relationship between lung-body weight relationship is lacking in the literature. The aim of this work is to provide a reference equation between normal lung and body weight in female domestic piglets. MATERIALS AND METHODS 177 healthy female domestic piglets from previous studies were included in the analysis. Lung weight was assessed either via a CT-scan before any experimental injury or with a scale after autopsy. The animals were randomly divided in a training (n = 141) and a validation population (n = 36). The relation between body weight and lung weight index (lung weight/body weight, g/kg) was described by an exponential function on the training population. The equation was tested on the validation population. A Bland-Altman analysis was performed to compare the lung weight index in the validation population and its theoretical value calculated with the reference equation. RESULTS A good fit was found between the validation population and the exponential equation extracted from the training population (RMSE = 0.060). The equation to determine lung weight index from body weight was: [Formula: see text] At the Bland and Altman analyses, the mean bias between the real and the expected lung weight index was - 0.26 g/kg (95% CI - 0.96-0.43), upper LOA 3.80 g/kg [95% CI 2.59-5.01], lower LOA - 4.33 g/kg [95% CI = - 5.54-(- 3.12)]. CONCLUSIONS This exponential function might be a valuable tool to assess lung edema in experiments involving 16-50 kg female domestic piglets. The error that can be made due to the 95% confidence intervals of the formula is smaller than the one made considering the lung to body weight as a linear relationship.
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Affiliation(s)
- Antonio Fioccola
- Department of Health Sciences, University of Florence, Florence, Italy
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Rosmery Valentina Nicolardi
- IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Tommaso Pozzi
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Isabella Fratti
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Federica Romitti
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Verena Reupke
- Department of Experimental Animal Medicine, University of Göttingen, Göttingen, Germany
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Uniting Care Hospitals, Intensive Care Units St Andrew's War Memorial Hospital and The Wesley Hospital, Brisbane, QLD, Australia
- Wesley Medical Research, Brisbane, QLD, Australia
- Queensland University of Technology, Brisbane, QLD, Australia
| | - Alessandro Protti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Alessandro Santini
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Massimo Cressoni
- Unit of Radiology, IRCCS, Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Luigi Camporota
- Department of Adult Critical Care Guy's & St Thomas' NHS Foundation Trust, London, UK
- Centre for Human & Applied Physiological Sciences, School of Basic & Medical Biosciences, King's College London, London, UK
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany.
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14
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Hu J, Guo R, Li H, Wen H, Wang Y. Perioperative Diaphragm Dysfunction. J Clin Med 2024; 13:519. [PMID: 38256653 PMCID: PMC10816119 DOI: 10.3390/jcm13020519] [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: 11/06/2023] [Revised: 01/07/2024] [Accepted: 01/15/2024] [Indexed: 01/24/2024] Open
Abstract
Diaphragm Dysfunction (DD) is a respiratory disorder with multiple causes. Although both unilateral and bilateral DD could ultimately lead to respiratory failure, the former is more common. Increasing research has recently delved into perioperative diaphragm protection. It has been established that DD promotes atelectasis development by affecting lung and chest wall mechanics. Diaphragm function must be specifically assessed for clinicians to optimally select an anesthetic approach, prepare for adequate monitoring, and implement the perioperative plan. Recent technological advancements, including dynamic MRI, ultrasound, and esophageal manometry, have critically aided disease diagnosis and management. In this context, it is noteworthy that therapeutic approaches for DD vary depending on its etiology and include various interventions, either noninvasive or invasive, aimed at promoting diaphragm recruitment. This review aims to unravel alternative anesthetic and operative strategies that minimize postoperative dysfunction by elucidating the identification of patients at a higher risk of DD and procedures that could cause postoperative DD, facilitating the recognition and avoidance of anesthetic and surgical interventions likely to impair diaphragmatic function.
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Affiliation(s)
- Jinge Hu
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China; (J.H.); (R.G.); (H.L.)
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China;
| | - Ruijuan Guo
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China; (J.H.); (R.G.); (H.L.)
| | - Huili Li
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China; (J.H.); (R.G.); (H.L.)
| | - Hong Wen
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China;
| | - Yun Wang
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China; (J.H.); (R.G.); (H.L.)
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15
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Khan A, Bashour S, Sabath B, Lin J, Sarkiss M, Song J, Sagar AES, Shah A, Casal RF. Severity of Atelectasis during Bronchoscopy: Descriptions of a New Grading System ( Atelectasi sSeverity Scoring System-"ASSESS") and At-Risk-Lung Zones. Diagnostics (Basel) 2024; 14:197. [PMID: 38248073 PMCID: PMC10814045 DOI: 10.3390/diagnostics14020197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/02/2024] [Accepted: 01/04/2024] [Indexed: 01/23/2024] Open
Abstract
Atelectasis during bronchoscopy under general anesthesia is very common and can have a detrimental effect on navigational and diagnostic outcomes. While the intraprocedural incidence and anatomic location have been previously described, the severity of atelectasis has not. We reviewed chest CT images of patients who developed atelectasis in the VESPA trial (Ventilatory Strategy to Prevent Atelectasis). By drawing boundaries at the posterior chest wall (A), the anterior aspect of the vertebral body (C), and mid-way between these two lines (B), we delineated at-risk lung zones 1, 2, and 3 (from posterior to anterior). An Atelectasis Severity Score System ("ASSESS") was created, classifying atelectasis as "mild" (zone 1), "moderate" (zones 1-2), and "severe" (zones 1-2-3). A total of 43 patients who developed atelectasis were included in this study. A total of 32 patients were in the control arm, and 11 were in the VESPA arm; 20 patients (47%) had mild atelectasis, 20 (47%) had moderate atelectasis, and 3 (6%) had severe atelectasis. A higher BMI was associated with increased odds (1.5 per 1 unit change; 95% CI, 1.10-2.04) (p = 0.0098), and VESPA was associated with decreased odds (0.05; 95% CI, 0.01-0.47) (p = 0.0080) of developing moderate to severe atelectasis. ASSESS is a simple method used to categorize intra-bronchoscopy atelectasis, which allows for a qualitative description of this phenomenon to be developed. In the VESPA trial, a higher BMI was not only associated with increased incidence but also increased severity of atelectasis, while VESPA had the opposite effect. Preventive strategies should be strongly considered in patients with risk factors for atelectasis who have lesions located in zones 1 and 2, but not in zone 3.
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Affiliation(s)
- Asad Khan
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA (B.S.); (J.L.)
| | - Sami Bashour
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA (B.S.); (J.L.)
| | - Bruce Sabath
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA (B.S.); (J.L.)
| | - Julie Lin
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA (B.S.); (J.L.)
| | - Mona Sarkiss
- Department of Anesthesia and Peri-Operative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Juhee Song
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ala-Eddin S. Sagar
- Department of Internal Medicine, King Faisal Specialist Hospital and Research Center, Madinah 42523, Saudi Arabia;
| | - Archan Shah
- Department of Onco-Medicine, Banner MD Anderson Cancer Center, Gilbert, AZ 85234, USA;
| | - Roberto F. Casal
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA (B.S.); (J.L.)
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16
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Yi M, Pan Y. Effects of "Timing It Right" nursing on clinical outcome and psychological resilience for lung cancer patients undergoing radical thoracoscopic surgery. Am J Transl Res 2024; 16:179-189. [PMID: 38322558 PMCID: PMC10839382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/23/2023] [Indexed: 02/08/2024]
Abstract
AIM To investigate the effects of "Timing It Right (TIR)" nursing on clinical outcome and psychological resilience in lung cancer patients undergoing radical thoracoscopic surgery. METHODS In this retrospective study, 60 patients from January 2022 to June 2023 were studied. Among them, observation group received TIR intervention (n = 34), while control group received routine nursing intervention (n = 26). The self-care ability, psychological resilience, quality of life (QoL), postoperative recovery, postoperative complications, and postoperative pulmonary function recovery were compared between the two groups. RESULTS The scores of ESCA (Exercise of Self-Care Agency) and CD-RISC (Connor-Davidson Resilience Scale), lung function, and QoL-C30 in observation group were significantly higher than those in control group after discharge, while the incidence of postoperative complications in observation group was significantly lower than that in the control group (all P<0.05). Furthermore, time to first bedtime activity and chest drain removal, and the length of postoperative hospitalization in the observation group were obviously shorter than those in the control group (all P<0.05). CONCLUSION TIR nursing can effectively enhance the self-care ability of lung cancer patients undergoing radical thoracoscopic surgery, improve their psychological elasticity, enhance their quality of life, shorten the hospitalization time, and reduce the incidence of adverse reactions.
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Affiliation(s)
- Meilian Yi
- Operating Room, Yichun People's Hospital Yichun 336000, Jiangxi, China
| | - Yan Pan
- Operating Room, Yichun People's Hospital Yichun 336000, Jiangxi, China
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17
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Longo S, Cheong I, Siri JE, Tamagnone F, Acosta C. Doppler images of intrapulmonary arteries within atelectasis and its impact on right ventricular afterload with transesophageal echocardiography. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:48-53. [PMID: 37678467 DOI: 10.1016/j.redare.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 01/07/2023] [Indexed: 09/09/2023]
Abstract
Video-assisted thoracoscopy (VATS) cardiac surgery requires one-lung ventilation (OLV) and transoesophageal ultrasound (TOE) monitoring. Colour and spectral Doppler make it possible to study the pattern of blood flow in the pulmonary vessels within the atelectatic lung. In this case report we describe how TOE can be used to detect blood flow within the atelectatic lung and to assess pulmonary vascular resistance (PVR) and right ventricular (RV) afterload. FINDINGS: Three anaesthetised, mechanically ventilated adults scheduled for cardiac surgery by VATS were scanned with TOE. After left OLV, the transducer was rotated away from the heart to obtain 2D colour Doppler images of blood flow within the consolidated lung parenchyma. We were able to identify the flow pattern of the intrapulmonary branches of the pulmonary artery. PVR was recorded using pulsed cardiac Doppler at baseline, after induction of general anaesthesia, 20 min after OLV and at the end of OLV, and after performing an alveolar recruitment manoeuvre (ARM) that led to complete resolution of the aforementioned consolidation. CONCLUSIONS: TOE is a semi-invasive imaging tool that can be used to diagnose and study PVR-induced atelectasis and to analyse the resulting pulmonary shunt and its possible effect on PVR.
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Affiliation(s)
- S Longo
- Anestesiología, Hospital Privado Universitario de Córdoba, Argentina; Asociación Argentina de Ultrasonografía Crítica (ASARUC), Argentina.
| | - I Cheong
- Unidad de Cuidados Intensivos, Sanatorio de Los Arcos, Buenos Aires, Argentina; Asociación Argentina de Ultrasonografía Crítica (ASARUC), Argentina
| | - J E Siri
- Anestesiología, Hospital Privado Universitario de Córdoba, Argentina
| | - F Tamagnone
- Asociación Argentina de Ultrasonografía Crítica (ASARUC), Argentina
| | - C Acosta
- Anestesiología, Hospital Privado de la Comunidad de Mar del Plata, Argentina
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18
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Gentili A. Lung-protective strategy during one-lung ventilation: current and future approaches to quantify the role of positive end-expiratory pressure. Minerva Anestesiol 2024; 90:3-5. [PMID: 38088091 DOI: 10.23736/s0375-9393.23.17841-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Andrea Gentili
- Department of Anesthesia and Intensive Care, Villa Laura Hospital, Bologna, Italy -
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19
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Ko E, Kwak JS, Park H, Lim CH. Limited effect of sugammadex on postoperative pulmonary complications in patients undergoing spine surgery in prone position intraoperatively: A retrospective analysis of matched cohort data. Medicine (Baltimore) 2023; 102:e35858. [PMID: 37933001 PMCID: PMC10627630 DOI: 10.1097/md.0000000000035858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/09/2023] [Indexed: 11/08/2023] Open
Abstract
Postoperative pulmonary complications (PPCs) increase postoperative mortality, hospital stays, and healthcare costs. Whether the use of sugammadex could reduce PPCs remains controversial. This study aimed to determine if sugammadex could more effectively reduce PPCs than acetylcholinesterase inhibitor (AChEi) in patients who had undergone spine surgery, in prone position intraoperatively. From March 2019 to February 2021, adult patients who underwent elective spine surgery were eligible. Primary outcomes were PPCs (including atelectasis on chest radiograph, pneumonia, acute respiratory distress syndrome, and aspiration pneumonitis) and respiratory failure that occurred within 28 days after surgery. Secondary outcomes were length of hospital stay, in-hospital death, and readmission rate within 30 days. Patients were divided into 2 groups (Sugammadex group and AChEi group) and compared by 1:1 propensity score matching. Of a total of 823 patients who underwent spinal surgery, 627 were included. After 1:1 propensity matching, 142 patients were extracted for each group. PPCs occurred in 9 (6.3%) patients in both groups (P = 1.000). Respiratory failure occurred in 7 (4.9%) patients in the Sugammadex group and 5 (3.5%) patients in the AChEi group (P = .77). There was no significant difference in secondary outcomes between the 2 groups. Although there have been some evidences showing that the use of sugammadex can attenuate the development of PPCs, this study did not show positive effects of sugammadex on patients who underwent spine surgery in the prone position.
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Affiliation(s)
- Eunji Ko
- Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Seoul, South Korea
| | - Ji Soo Kwak
- Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Seoul, South Korea
| | - Heechan Park
- Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Seoul, South Korea
| | - Choon Hak Lim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University, Seoul, South Korea
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Edmark L, Englund EK, Jonsson AS, Zilic AT, Cajander P, Östberg E. Pressure-controlled versus manual facemask ventilation for anaesthetic induction in adults: A randomised controlled non-inferiority trial. Acta Anaesthesiol Scand 2023; 67:1356-1362. [PMID: 37476919 DOI: 10.1111/aas.14308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/06/2023] [Accepted: 07/03/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Pressure-controlled face mask ventilation (PC-FMV) with positive end-expiratory pressure (PEEP) after apnoea following induction of general anaesthesia prolongs safe apnoea time and reduces atelectasis formation. However, depending on the set inspiratory pressure, a delayed confirmation of a patent airway might occur. We hypothesised that by lowering the peak inspiratory pressure (PIP) when using PC-FMV with PEEP, confirmation of a patent airway would not be delayed as studied by the first return of CO2 , compared with manual face mask ventilation (Manual FMV). METHODS This was a single-centre, randomised controlled non-inferiority trial. Seventy adult patients scheduled for elective day-case surgery under general anaesthesia with body mass index between 18.5 and 29.9 kg m-2 , American Society of Anesthesiologists (ASA) classes I-III, and without anticipated difficult FMV, were included. Before the start of pre-oxygenation and induction of general anaesthesia, participants were randomly allocated to receive ventilation with either PC-FMV with PEEP, at a PIP of 11 and a PEEP of 6 cmH2 O or Manual FMV, with the adjustable pressure-limiting valve set at 11 cmH2 O. The primary outcome variable was the number of ventilatory attempts needed until confirmation of a patent airway, defined as the return of at least 1.3 kPa CO2 . RESULTS The return of ≥1.3 kPa CO2 on the capnography curve was observed after mean ± SD, 3.6 ± 4.2 and 2.5 ± 1.9 ventilatory attempts/breaths with PC-FMV with PEEP and Manual FMV, respectively. The difference in means (1.1 ventilatory attempts/breaths) had a 99% CI of -1.0 to 3.1, within the accepted upper margin of four breaths for non-inferiority. CONCLUSION Following induction of general anaesthesia, PC-FMV with PEEP was used without delaying a patent airway as confirmed with capnography, if moderate pressures were used.
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Affiliation(s)
- Lennart Edmark
- Department of Anaesthesia and Intensive Care, Västmanland Hospital Köping, Köping, Sweden
- Region Västmanland-Uppsala University, Centre for Clinical Research, Västmanland Hospital Västerås, Västerås, Sweden
| | - Emma-Karin Englund
- Department of Anaesthesia and Intensive Care, Västmanland Hospital Köping, Köping, Sweden
| | | | | | - Per Cajander
- Department of Anaesthesia and Intensive Care, Örebro University Hospital, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Erland Östberg
- Department of Anaesthesia and Intensive Care, Västmanland Hospital Köping, Köping, Sweden
- Region Västmanland-Uppsala University, Centre for Clinical Research, Västmanland Hospital Västerås, Västerås, Sweden
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21
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Qin YJ, Zhang YQ, Chen Q, Wang Y, Li SY. Effect of high-frequency oscillation on reduction of atelectasis in perioperative patients: a prospective randomized controlled study. Ann Med 2023; 55:2272720. [PMID: 37874665 PMCID: PMC10836273 DOI: 10.1080/07853890.2023.2272720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/12/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND Atelectasis affects approximately 90% of anaesthetized patients, with laparoscopic surgery and pneumoperitoneum reported to exacerbate this condition. High-frequency oscillation therapy applies continuous positive pressure pulses to oscillate the airway, creating a pressure difference in small airways obstructed by secretions. This process helps reduce peak airway pressure, open small airways, and decrease atelectasis incidence, while also facilitating respiratory tract clearance. This study examines the efficacy of high-frequency oscillation on reduction of atelectasis in laparoscopic cholecystectomy (LC) patients under general anaesthesia, evaluated using lung ultrasound. METHODS Sixty-four patients undergoing laparoscopic cholecystectomy were randomly divided into a control group and a high-frequency oscillation (HFO) group. Both groups underwent total intravenous anaesthesia under invasive arterial monitoring. The HFO group received a 10-minute continuous high-frequency oscillation therapy during surgery, while the control group received no intervention. Lung ultrasound evaluations were performed three times: five minutes post-intubation (T1), at the end of the surgery (T2), and before leaving the Post-Anaesthesia Care Unit (PACU; T3). Blood gas analysis was performed twice: prior to induction with no oxygen supply and before PACU discharge (oxygen supply off). RESULTS The HFO group displayed a significantly lower incidence of atelectasis at T3 (57.5% vs. 90.3%, OR 6.88, 95%CI (1.74 to 27.24)) compared to the control group. Moreover, the HFO group's PaO2 levels remained consistent with baseline levels before PACU discharge, unlike the control group. Although there was no significant difference in LUS scores between the groups at T1 (8.56 ± 0.15 vs. 8.19 ± 0.18, p = 0.1090), the HFO group had considerably lower scores at T2 (13.41 ± 0.17 vs.7.59 ± 0.17, p < 0.01) and T3 (13.72 ± 0.14 vs.7.25 ± 0.21, p < 0.01). CONCLUSION Our study indicates that high-frequency oscillation effectively reduces atelectasis in patients undergoing laparoscopic cholecystectomy. Additionally, it can mitigate the decline in oxygen partial pressure associated with atelectasis.
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Affiliation(s)
- Yuan-jun Qin
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, China
| | - Yun-qian Zhang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, China
| | - Qi Chen
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, China
| | - Yan Wang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, China
| | - Si-yuan Li
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, China
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22
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Shu B, Zhang Y, Ren Q, Zheng X, Zhang Y, Liu Q, Li S, Chen J, Chen Y, Duan G, Huang H. Optimal positive end-expiratory pressure titration of intraoperative mechanical ventilation in different operative positions of female patients under general anesthesia. Heliyon 2023; 9:e20552. [PMID: 37822628 PMCID: PMC10562915 DOI: 10.1016/j.heliyon.2023.e20552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 09/21/2023] [Accepted: 09/28/2023] [Indexed: 10/13/2023] Open
Abstract
Objective This study aimed to compare the effectiveness and safety of different titrated methods used to determine individual positive end-expiratory pressure (PEEP) for intraoperative mechanical ventilation in female patients undergoing general anesthesia in different operative positions, and provide reference ranges of optimal PEEP values based on the titration. Methods A total of 123 female patients who underwent elective open abdominal surgery under general anesthesia were included in this study. After endotracheal intubation, patients' body position was adjusted to the supine position, Trendelenburg positions at 10° and 20° respectively. PEEP was titrated from 20 cmH2O to 4 cmH2O, decreasing by 2 cmH2O every 1 min. Electrical impedance tomography (EIT), hemodynamic and respiratory mechanics parameters were continuously monitored and recorded. Optimal PEEP values and reference ranges were respectively calculated based on optimal EIT parameters, mean arterial pressure (MAP), and lung dynamic compliance (Cdyn). Results EIT-guided optimal PEEP was found to have higher values than those of the MAP-guided and Cdyn-guided methods for all three body positions (P < 0.001), and it was observed to more significantly inhibit hemodynamics (P < 0.05). The variable coefficients of EIT-guided optimal PEEP values were smaller than those of the other two methods, and this technique could provide better ventilation uniformity for dorsal/ventral lung fields and better balance for pulmonary atelectasis/collapse. The 95% reference ranges of EIT-guided optimal PEEP values were 4.6-13.8 cmH2O, 7.0-15.0 cmH2O and 8.6-17.0 cmH2O for the supine position, Trendelenburg 10°, and Trendelenburg 20° positions, respectively. Conclusion EIT-guided optimal PEEP titration was found to be a superior method for lung protective ventilation in different operative positions under general anesthesia. The calculated reference ranges of PEEP values based on the EIT-guided method can be used as a reference for intraoperative mechanical ventilation.
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Affiliation(s)
- Bin Shu
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Yang Zhang
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Qian Ren
- Department of Anesthesiology, Chongqing University Three Gorges Hospital, Chongqing, 404000, China
| | - Xuemei Zheng
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Yamei Zhang
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Qi Liu
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Shiqi Li
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Jie Chen
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Yuanjing Chen
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Guangyou Duan
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - He Huang
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
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23
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Lim L, Lee J, Hwang SY, Lee H, Oh SY, Kang C, Ryu HG. Early Postoperative Fever and Atelectasis in Patients Undergoing Upper Abdominal Surgery. J Am Coll Surg 2023; 237:606-613. [PMID: 37350477 DOI: 10.1097/xcs.0000000000000789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
BACKGROUND Atelectasis is a common complication after upper abdominal surgery and considered as a cause of early postoperative fever (EPF) within 48 hours after surgery. However, the pathophysiologic mechanism of how atelectasis causes fever remains unclear. STUDY DESIGN Data for adult patients who underwent elective major upper abdominal surgery under general anesthesia at Seoul National University Hospital between January and December of 2021 were retrospectively analyzed. The primary outcome was the association between fever and atelectasis within 2 days after surgery. RESULTS Of 1,624 patients, 810 patients (49.9%) developed EPF. The incidence of atelectasis was similar between the fever group and the no-fever group (51.6% vs 53.9%, p = 0.348). Multivariate analysis showed no significant association between atelectasis and EPF. Culture tests (21.7% vs 8.8%, p < 0.001) and prolonged use of antibiotics (25.9% vs 13.9%, p < 0.001) were more frequent in the fever group compared to the no-fever group. However, the frequency of bacterial growth on culture tests and postoperative pulmonary complications within 7 days were similar between the two groups. CONCLUSIONS EPF after major upper abdominal surgery was not associated with radiologically detected atelectasis. EPF also was not associated with the increased risk of postoperative pulmonary complications, bacterial growth on culture studies, or prolonged length of hospital stay.
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Affiliation(s)
- Leerang Lim
- From the Departments of Anesthesiology and Pain Medicine, Seoul National University Hospital (Lim, Hwang, H Lee, Ryu), Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul, Korea
| | - Jihyuk Lee
- Radiology (J Lee), Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul, Korea
| | - So Yeong Hwang
- From the Departments of Anesthesiology and Pain Medicine, Seoul National University Hospital (Lim, Hwang, H Lee, Ryu), Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul, Korea
| | - Hannah Lee
- From the Departments of Anesthesiology and Pain Medicine, Seoul National University Hospital (Lim, Hwang, H Lee, Ryu), Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul, Korea
| | - Seung-Young Oh
- Critical Care Medicine (Oh, Kang, Ryu), Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul, Korea
- Surgery (Oh), Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul, Korea
| | - Christine Kang
- Critical Care Medicine (Oh, Kang, Ryu), Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul, Korea
| | - Ho Geol Ryu
- From the Departments of Anesthesiology and Pain Medicine, Seoul National University Hospital (Lim, Hwang, H Lee, Ryu), Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul, Korea
- Critical Care Medicine (Oh, Kang, Ryu), Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul, Korea
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Girard J, Zaouter C, Moore A, Carrier FM, Girard M. Effects of an open lung extubation strategy compared with a conventional extubation strategy on postoperative pulmonary complications after general anesthesia: a single-centre pilot randomized controlled trial. Can J Anaesth 2023; 70:1648-1659. [PMID: 37498442 DOI: 10.1007/s12630-023-02533-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 07/28/2023] Open
Abstract
PURPOSE Postoperative pulmonary complications (PPCs) are a common cause of morbidity. Postoperative atelectasis is thought to be a significant risk factor in their development. Recent imaging studies suggest that patients' extubation may result in similar postoperative atelectasis regardless of the intraoperative mechanical ventilation strategy used. In this pilot trial, we hypothesized that a study investigating the effects of an open lung extubation strategy compared with a conventional one on PPCs would be feasible. METHODS We conducted a pilot, single-centre, double-blinded randomized controlled trial. Adult patients at moderate to high risk of PPCs and scheduled for elective surgery were eligible. Patients were randomized to an open lung extubation strategy (semirecumbent position, fraction of inspired oxygen [FIO2] 50%, pressure support ventilation, unchanged positive end-expiratory pressure) or to a conventional extubation strategy (dorsal decubitus position, FIO2 100%, manual bag ventilation). The primary feasibility outcome was global protocol adherence while the primary exploratory efficacy outcome was PPCs. RESULTS We randomized 35 patients to the conventional extubation group and 34 to the open lung extubation group. We observed a global protocol adherence of 96% (95% confidence interval, 88 to 99), which was not different between groups. Eight PPCs occurred (two in the conventional extubation group vs six in the open lung extubation group). Less postoperative supplemental oxygen and better lung aeration were observed in the open lung extubation group. CONCLUSIONS In this single-centre pilot trial, we observed excellent feasibility. A multicentre pilot trial comparing the effect of an open lung extubation strategy with that of a conventional extubation strategy on the occurrence of PPCs is feasible. STUDY REGISTRATION DATE ClinicalTrials.gov (NCT04993001); registered 6 August 2021.
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Affiliation(s)
- Julie Girard
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Montreal, QC, Canada
| | - Cédrick Zaouter
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Montreal, QC, Canada
| | - Alex Moore
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Montreal, QC, Canada
| | - François M Carrier
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Montreal, QC, Canada
- Centre de Recherche du Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Martin Girard
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada.
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Montreal, QC, Canada.
- Centre de Recherche du Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada.
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25
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Frassanito L, Grieco DL, Zanfini BA, Catarci S, Rosà T, Settanni D, Fedele C, Scambia G, Draisci G, Antonelli M. Effect of a pre-emptive 2-hour session of high-flow nasal oxygen on postoperative oxygenation after major gynaecologic surgery: a randomised clinical trial. Br J Anaesth 2023; 131:775-785. [PMID: 37543437 DOI: 10.1016/j.bja.2023.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND We aimed at determining whether a 2-h session of high-flow nasal oxygen (HFNO) immediately after extubation improves oxygen exchange after major gynaecological surgery in the Trendelenburg position in adult female patients. METHODS In this single-centre, open-label, randomised trial, patients who underwent major gynaecological surgery were randomised to HFNO or conventional oxygen treatment with a Venturi mask. The primary outcome was the Pao2/FiO2 ratio after 2 h of treatment. Secondary outcomes included lung ultrasound score, diaphragm thickening fraction, dyspnoea, ventilatory frequency, Paco2, the percentage of patients with impaired gas exchange (Pao2/FiO2 ≤40 kPa) after 2 h of treatment, and postoperative pulmonary complications at 30 days. RESULTS A total of 83 patients were included (42 in the HFNO group and 41 in the conventional treatment group). After 2 h of treatment, median (inter-quartile range) Pao2/FiO2 was 52.9 (47.9-65.2) kPa in the HFNO group and 45.7 (36.4 -55.9) kPa in the conventional treatment group (mean difference 8.7 kPa [95% CI: 3.4 to 13.9], P=0.003). The lung ultrasound score was lower in the HFNO group than in the conventional treatment group (9 [6-10] vs 12 [10-14], P<0.001), mostly because of the difference of the score in dorsal areas (7 [6-8] vs 10 [9-10], P<0.001). The percentage of patients with impaired gas exchange was lower in the HFNO group than in the conventional treatment group (5% vs 37%, P<0.001). All other secondary outcomes were not different between groups. CONCLUSIONS In patients who underwent major gynaecological surgery, a pre-emptive 2-h session of HFNO after extubation improved postoperative oxygen exchange and reduced atelectasis compared with a conventional oxygen treatment strategy. CLINICAL TRIAL REGISTRATION NCT04566419.
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Affiliation(s)
- Luciano Frassanito
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Domenico L Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Bruno A Zanfini
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Stefano Catarci
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Tommaso Rosà
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Donatella Settanni
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Camilla Fedele
- Department of Obstetrics and Gynaecology, Catholic University of the Sacred Heart, Rome, Italy; Gynaecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Scambia
- Department of Obstetrics and Gynaecology, Catholic University of the Sacred Heart, Rome, Italy; Gynaecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gaetano Draisci
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Xiang B, Liu Y, Li C, Yuan F. Perioperative management of a patient with morbid obesity and severe cardiomyopathy: a case report and literature review. J Int Med Res 2023; 51:3000605231204500. [PMID: 37848346 PMCID: PMC10586002 DOI: 10.1177/03000605231204500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/13/2023] [Indexed: 10/19/2023] Open
Abstract
As the obesity epidemic continues to escalate, the need for bariatric surgery will increase. Patients with severe cardiomyopathy and heart failure have historically been considered at high risk for perioperative complications and thus excluded from bariatric surgery. We herein describe a patient with morbid obesity, severe cardiomyopathy, and heart failure who successfully and safely underwent bariatric surgery and achieved significant weight loss and overall cardiac function improvement 1 year later. Although data are sparse, there is certainly evidence to suggest that significant weight reduction may confer a mechanism of ventricular reverse remodeling and subsequent clinical improvement.
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Affiliation(s)
- Bingbing Xiang
- Department of Anesthesiology, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Geriatric Diseases Institute of Chengdu/Cancer Prevention and Treatment Institute of Chengdu, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, China
| | - Yiran Liu
- Nursing Department, Chengdu Fifth People’s Hospital, Chengdu, China
| | - Chunyan Li
- Department of Anesthesiology, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Geriatric Diseases Institute of Chengdu/Cancer Prevention and Treatment Institute of Chengdu, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, China
| | - Feng Yuan
- Department of Anesthesiology, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Geriatric Diseases Institute of Chengdu/Cancer Prevention and Treatment Institute of Chengdu, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, China
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Li X, Liu H, Wang J, Ni ZL, Liu ZX, Jiao JL, Han Y, Cao JL. Individualized Positive End-expiratory Pressure on Postoperative Atelectasis in Patients with Obesity: A Randomized Controlled Clinical Trial. Anesthesiology 2023; 139:262-273. [PMID: 37440205 DOI: 10.1097/aln.0000000000004603] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
BACKGROUND Individualized positive end-expiratory pressure (PEEP) guided by dynamic compliance improves oxygenation and reduces postoperative atelectasis in nonobese patients. The authors hypothesized that dynamic compliance-guided PEEP could also reduce postoperative atelectasis in patients undergoing bariatric surgery. METHODS Patients scheduled to undergo laparoscopic bariatric surgery were eligible. Dynamic compliance-guided PEEP titration was conducted in all patients using a downward approach. A recruitment maneuver (PEEP from 10 to 25 cm H2O at 5-cm H2O step every 30 s, with 15-cm H2O driving pressure) was conducted both before and after the titration. Patients were then randomized (1:1) to undergo surgery under dynamic compliance-guided PEEP (PEEP with highest dynamic compliance plus 2 cm H2O) or PEEP of 8 cm H2O. The primary outcome was postoperative atelectasis, as assessed with computed tomography at 60 to 90 min after extubation, and expressed as percentage to total lung tissue volume. Secondary outcomes included Pao2/inspiratory oxygen fraction (Fio2) and postoperative pulmonary complications. RESULTS Forty patients (mean ± SD; 28 ± 7 yr of age; 25 females; average body mass index, 41.0 ± 4.7 kg/m2) were enrolled. Median PEEP with highest dynamic compliance during titration was 15 cm H2O (interquartile range, 13 to 17; range, 8 to 19) in the entire sample of 40 patients. The primary outcome of postoperative atelectasis (available in 19 patients in each group) was 13.1 ± 5.3% and 9.5 ± 4.3% in the PEEP of 8 cm H2O and dynamic compliance-guided PEEP groups, respectively (intergroup difference, 3.7%; 95% CI, 0.5 to 6.8%; P = 0.025). Pao2/Fio2 at 1 h after pneumoperitoneum was higher in the dynamic compliance-guided PEEP group (397 vs. 337 mmHg; group difference, 60; 95% CI, 9 to 111; P = 0.017) but did not differ between the two groups 30 min after extubation (359 vs. 375 mmHg; group difference, -17; 95% CI, -53 to 21; P = 0.183). The incidence of postoperative pulmonary complications was 4 of 20 in both groups. CONCLUSIONS Postoperative atelectasis was lower in patients undergoing laparoscopic bariatric surgery under dynamic compliance-guided PEEP versus PEEP of 8 cm H2O. Postoperative Pao2/Fio2 did not differ between the two groups. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Xiang Li
- Department of Anesthesiology, Eye & Ear, Nose, and Throat Hospital of Fudan University, Shanghai, China; Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China; Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - He Liu
- Department of Anesthesiology, Huzhou Central Hospital, Huzhou, China
| | - Jun Wang
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China; Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zhi-Lin Ni
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China; Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zhong-Xiao Liu
- Department of Radiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Jia-Li Jiao
- Institute of Translational Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuan Han
- Department of Anesthesiology, Eye & Ear, Nose, and Throat Hospital of Fudan University, Shanghai, China; Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
| | - Jun-Li Cao
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China.; NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, China
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Boesing C, Schaefer L, Hammel M, Otto M, Blank S, Pelosi P, Rocco PRM, Luecke T, Krebs J. Individualized Positive End-expiratory Pressure Titration Strategies in Superobese Patients Undergoing Laparoscopic Surgery: Prospective and Nonrandomized Crossover Study. Anesthesiology 2023; 139:249-261. [PMID: 37224406 DOI: 10.1097/aln.0000000000004631] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND Superobesity and laparoscopic surgery promote negative end-expiratory transpulmonary pressure that causes atelectasis formation and impaired respiratory mechanics. The authors hypothesized that end-expiratory transpulmonary pressure differs between fixed and individualized positive end-expiratory pressure (PEEP) strategies and mediates their effects on respiratory mechanics, end-expiratory lung volume, gas exchange, and hemodynamic parameters in superobese patients. METHODS In this prospective, nonrandomized crossover study including 40 superobese patients (body mass index 57.3 ± 6.4 kg/m2) undergoing laparoscopic bariatric surgery, PEEP was set according to (1) a fixed level of 8 cm H2O (PEEPEmpirical), (2) the highest respiratory system compliance (PEEPCompliance), or (3) an end-expiratory transpulmonary pressure targeting 0 cm H2O (PEEPTranspul) at different surgical positioning. The primary endpoint was end-expiratory transpulmonary pressure at different surgical positioning; secondary endpoints were respiratory mechanics, end-expiratory lung volume, gas exchange, and hemodynamic parameters. RESULTS Individualized PEEPCompliance compared to fixed PEEPEmpirical resulted in higher PEEP (supine, 17.2 ± 2.4 vs. 8.0 ± 0.0 cm H2O; supine with pneumoperitoneum, 21.5 ± 2.5 vs. 8.0 ± 0.0 cm H2O; and beach chair with pneumoperitoneum; 15.8 ± 2.5 vs. 8.0 ± 0.0 cm H2O; P < 0.001 each) and less negative end-expiratory transpulmonary pressure (supine, -2.9 ± 2.0 vs. -10.6 ± 2.6 cm H2O; supine with pneumoperitoneum, -2.9 ± 2.0 vs. -14.1 ± 3.7 cm H2O; and beach chair with pneumoperitoneum, -2.8 ± 2.2 vs. -9.2 ± 3.7 cm H2O; P < 0.001 each). Titrated PEEP, end-expiratory transpulmonary pressure, and lung volume were lower with PEEPCompliance compared to PEEPTranspul (P < 0.001 each). Respiratory system and transpulmonary driving pressure and mechanical power normalized to respiratory system compliance were reduced using PEEPCompliance compared to PEEPTranspul. CONCLUSIONS In superobese patients undergoing laparoscopic surgery, individualized PEEPCompliance may provide a feasible compromise regarding end-expiratory transpulmonary pressures compared to PEEPEmpirical and PEEPTranspul, because PEEPCompliance with slightly negative end-expiratory transpulmonary pressures improved respiratory mechanics, lung volumes, and oxygenation while preserving cardiac output. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Christoph Boesing
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany; Theodor-Kutzer-Ufer 1-3, Mannheim, Germany
| | - Laura Schaefer
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany; Theodor-Kutzer-Ufer 1-3, Mannheim, Germany
| | - Marvin Hammel
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany; Theodor-Kutzer-Ufer 1-3, Mannheim, Germany
| | - Mirko Otto
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany; Theodor-Kutzer-Ufer 1-3, Mannheim, Germany
| | - Susanne Blank
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy; Anesthesiology and Critical Care - San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Ilha do Fundao, Rio de Janeiro, Brazil
| | - Thomas Luecke
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany; Theodor-Kutzer-Ufer 1-3, Mannheim, Germany
| | - Joerg Krebs
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany; Theodor-Kutzer-Ufer 1-3, Mannheim, Germany
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Wrigge H, Petroff D, Fernandez-Bustamante A. Pressure for High Positive End-expiratory Pressure in Obese Surgical Patients Is Growing. Anesthesiology 2023; 139:239-243. [PMID: 37552098 PMCID: PMC10662970 DOI: 10.1097/aln.0000000000004665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Affiliation(s)
- Hermann Wrigge
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, Germany
- Medical Faculty, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - David Petroff
- Clinical Trial Centre, University of Leipzig, Leipzig, Germany
| | - Ana Fernandez-Bustamante
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, United States of America
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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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Lee S, Choi JW, Chung IS, Kim DK, Sim WS, Kim TJ. Comparison of high-flow nasal cannula and conventional nasal cannula during sedation for endoscopic submucosal dissection: a retrospective study. Therap Adv Gastroenterol 2023; 16:17562848231189957. [PMID: 37655054 PMCID: PMC10467296 DOI: 10.1177/17562848231189957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 05/27/2023] [Indexed: 09/02/2023] Open
Abstract
Background The high-flow nasal cannula (HFNC) is a relatively recent method that provides high-flow, heated, humidified gas delivery. Objectives We compared HFNC (group HF) and conventional nasal cannula (NC) (group CO) during deep sedation with propofol and remifentanil for endoscopic submucosal dissection (ESD). Design Single-center, retrospective observational cohort study. Methods In this study, a total of 159 cases were analyzed (group CO, 71 and group HF, 88). We collected the data from electronic medical records from September 2020 to June 2021. The lowest oxygen saturation (SpO2), incidence of hypoxia (SpO2 < 90%), rescue interventions, and adverse events between the two groups were investigated. Results There were significant differences between the two groups in lowest SpO2 and incidence of hypoxia [group CO versus group HF; 90.3 ± 9.7% versus 95.7 ± 9.0%, 25 (35.2%) versus 10 (11.4%); p < 0.001, p < 0.001; respectively]. Among the rescue interventions, the number of jaw thrust, patient stimulation, O2 flow increase, and nasal airway insertion were significantly higher in the CO group than in the HF group. However, postprocedural chest X-ray showed higher rates of abnormal findings (atelectasis, aspiration, and pneumoperitoneum) in group HF than in group CO [group CO: 8 (11.3%) versus group HF: 26 (29.5%), p = 0.005]. In multivariable analysis, besides group CO, difficult type of lesion was the risk factor for hypoxia. Conclusions Compared to the conventional NC, HFNC provided adequate oxygenation and a stable procedure without significant adverse events during sedation for ESD. However, caution is needed to avoid complications associated with deep sedation and difficult type of lesions.
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Affiliation(s)
- Seungwon Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ji Won Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea
| | - In Sun Chung
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Duk Kyung Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Woo Seog Sim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Tae Jun Kim
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Ramirez-Estrada S, Peña-Lopez Y, Vieceli T, Rello J. Ventilator-associated events: From surveillance to optimizing management. JOURNAL OF INTENSIVE MEDICINE 2023; 3:204-211. [PMID: 37533808 PMCID: PMC10391577 DOI: 10.1016/j.jointm.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/22/2022] [Accepted: 09/20/2022] [Indexed: 08/04/2023]
Abstract
Mechanical ventilation (MV) is a life-support therapy that may predispose to morbid and lethal complications, with ventilator-associated pneumonia (VAP) being the most prevalent. In 2013, the Center for Disease Control (CDC) defined criteria for ventilator-associated events (VAE). Ten years later, a growing number of studies assessing or validating its clinical applicability and the potential benefits of its inclusion have been published. Surveillance with VAE criteria is retrospective and the focus is often on a subset of patients with higher than lower severity. To date, it is estimated that around 30% of ventilated patients in the intensive care unit (ICU) develop VAE. While surveillance enhances the detection of infectious and non-infectious MV-related complications that are severe enough to impact the patient's outcomes, there are still many gaps in its classification and management. In this review, we provide an update by discussing VAE etiologies, epidemiology, and classification. Preventive strategies on optimizing ventilation, sedative and neuromuscular blockade therapy, and restrictive fluid management are warranted. An ideal VAE bundle is likely to minimize the period of intubation. We believe that it is time to progress from just surveillance to clinical care. Therefore, with this review, we have aimed to provide a roadmap for future research on the subject.
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Affiliation(s)
| | - Yolanda Peña-Lopez
- Paediatric Critical Care Department, Hospital Universitari Vall d'Hebron, Barcelona 08035, Spain
- Clinical Research/Epidemiology in Pneumonia and Sepsis (CRIPS), Vall d'Hebron Research Institute, Barcelona 08035, Spain
| | - Tarsila Vieceli
- Infectious Diseases Department, Hospital de Clínicas de Porto Alegre, Porto Alegre RS 90035-007, Brazil
| | - Jordi Rello
- Clinical Research/Epidemiology in Pneumonia and Sepsis (CRIPS), Vall d'Hebron Research Institute, Barcelona 08035, Spain
- Universitat Internacional de Catalunya, Barcelona 08195, Spain
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Waheed Z, Amatul-Hadi F, Kooner A, Afzal M, Ahmed R, Pande H, Alfaro M, Lee A, Bhatti J. General Anesthetic Care of Obese Patients Undergoing Surgery: A Review of Current Anesthetic Considerations and Recent Advances. Cureus 2023; 15:e41565. [PMID: 37554600 PMCID: PMC10405976 DOI: 10.7759/cureus.41565] [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] [Accepted: 07/08/2023] [Indexed: 08/10/2023] Open
Abstract
Obesity has long been linked to adverse health effects over time. As the prevalence of obesity continues to rise, it is important to anticipate and minimize the complications that obesity brings in the anesthesia setting during surgery. Anesthetic departments must recognize the innumerable risks when managing patients with obesity undergoing surgery, including anatomical and physiological changes as well as comorbidities such as diabetes, cardiovascular diseases, and malignancies. Therefore, the purpose of this review is to analyze the current literature and evaluate the current and recent advances in anesthetic care of obese patients undergoing surgery, to better understand the specific challenges this patient population faces. A greater understanding of the differences between anesthetic care for obese patients can help to improve patient care and the specificity of treatment. The examination of the literature will focus on differing patient outcomes and safety precautions in obese patients as compared to the general population. Specifically highlighting the differences in pre-operative, intra-operative, and post-operative care, with the aim to identify issues and present possible solutions.
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Affiliation(s)
- Zahra Waheed
- Anesthesia, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | | | - Amritpal Kooner
- Medical School, Midwestern University Chicago College of Osteopathic Medicine, Downers Grove, USA
| | - Muhammad Afzal
- Medical School, St. George's University School of Medicine, True Blue, GRD
| | - Rahma Ahmed
- Medical School, Kennesaw State University, Kennesaw, USA
| | | | - Moses Alfaro
- Medical School, Long School of Medicine at University of Texas Health Science Center San Antonio, San Antonio, USA
| | - Amber Lee
- Medical School, Arkansas College of Osteopathic Medicine, Fort Smith, USA
| | - Joravar Bhatti
- Medical School, Midwestern University Chicago College of Osteopathic Medicine, Downers Grove, USA
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Zhou X, Pan J, Wang H, Xu Z, Zhao L, Chen B. Prophylactic noninvasive respiratory support in the immediate postoperative period after cardiac surgery - a systematic review and network meta-analysis. BMC Pulm Med 2023; 23:233. [PMID: 37380968 DOI: 10.1186/s12890-023-02525-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 06/17/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Noninvasive respiratory support has been increasingly applied in the immediate postoperative period to prevent postoperative pulmonary complications (PPCs). However, the optimal approach remains uncertain. We sought to evaluate the comparative effectiveness of various noninvasive respiratory strategies used in the immediate postoperative period after cardiac surgery. METHODS We conducted a frequentist random-effect network meta-analysis (NMA) of randomized controlled trials (RCTs) comparing the prophylactic use of noninvasive ventilation (NIV), continuous positive airway pressure (CPAP), high flow nasal cannula (HFNC), or postoperative usual care (PUC) in the immediate postoperative period after cardiac surgery. Databases were systematically searched through September 28, 2022. Study selection, data extraction, and quality assessment were performed in duplicate. The primary outcome was the incidence of PPCs. RESULTS Sixteen RCTs enrolling 3011 patients were included. Compared with PUC, NIV significantly reduced the incidence of PPCs [relative risk (RR) 0.67, 95% confidence interval (CI): 0.49 to 0.93; absolute risk reduction (ARR) 7.6%, 95% CI: 1.6-11.8%; low certainty] and the incidence of atelectasis (RR 0.65, 95% CI: 0.45 to 0.93; ARR 19.3%, 95% CI: 3.9-30.4%; moderate certainty); however, prophylactic NIV was not associated with a decreased reintubation rate (RR 0.82, 95% CI: 0.29 to 2.34; low certainty) or reduced short-term mortality (RR 0.64, 95% CI: 0.16 to 2.52; very low certainty). As compared to PUC, the preventive use of CPAP (RR 0.85, 95% CI: 0.60 to 1.20; very low certainty) or HFNC (RR 0.74, 95% CI: 0.46 to 1.20; low certainty) had no significant beneficial effect on the incidence of PPCs, despite exhibiting a downward trend. Based on the surface under the cumulative ranking curve, the highest-ranked treatment for reducing the incidence of PPCs was NIV (83.0%), followed by HFNC (62.5%), CPAP (44.3%), and PUC (10.2%). CONCLUSIONS Current evidence suggest that the prophylactic use of NIV in the immediate postoperative period is probably the most effective noninvasive respiratory approach to prevent PPCs in patients undergoing cardiac surgery. Given the overall low certainty of the evidence, further high-quality research is warranted to better understand the relative benefits of each noninvasive ventilatory support. CLINICAL TRIAL REGISTRATION PROSPERO, https://www.crd.york.ac.uk/prospero/ , registry number: CRD42022303904.
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Affiliation(s)
- Xiaoyang Zhou
- Department of Intensive Care Medicine, Ningbo No.2 Hospital, Ningbo, 315000, Zhejiang, China
| | - Jianneng Pan
- Department of Intensive Care Medicine, Ningbo No.2 Hospital, Ningbo, 315000, Zhejiang, China
| | - Hua Wang
- Department of Intensive Care Medicine, Ningbo No.2 Hospital, Ningbo, 315000, Zhejiang, China
| | - Zhaojun Xu
- Department of Intensive Care Medicine, Ningbo No.2 Hospital, Ningbo, 315000, Zhejiang, China
| | - Long Zhao
- Department of Cardiovascular Surgery, Ningbo No.2 Hospital, Ningbo, Ningbo, 315000, Zhejiang, China
| | - Bixin Chen
- Department of Intensive Care Medicine, Ningbo No.2 Hospital, Ningbo, 315000, Zhejiang, China.
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Lee BH, Qiao WP, McCracken S, Singleton MN, Goman M. Regional Anesthesia Techniques for Shoulder Surgery in High-Risk Pulmonary Patients. J Clin Med 2023; 12:jcm12103483. [PMID: 37240589 DOI: 10.3390/jcm12103483] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/01/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
Patients with pre-existing pulmonary conditions are at risk for experiencing perioperative complications and increased morbidity. General anesthesia has historically been used for shoulder surgery, though regional anesthesia techniques are increasingly used to provide anesthesia and improved pain control after surgery. Relative to regional anesthesia, patients who undergo general anesthesia may be more prone to risks of barotrauma, postoperative hypoxemia, and pneumonia. High-risk pulmonary patients, in particular, may be exposed to these risks of general anesthesia. Traditional regional anesthesia techniques for shoulder surgery are associated with high rates of phrenic nerve paralysis which significantly impairs pulmonary function. Newer regional anesthesia techniques have been developed, however, that provide effective analgesia and surgical anesthesia while having much lower rates of phrenic nerve paralysis, thereby preserving pulmonary function.
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Affiliation(s)
- Bradley H Lee
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY 10021, USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10021, USA
| | - William P Qiao
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY 10021, USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10021, USA
| | - Stephen McCracken
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY 10021, USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10021, USA
| | - Michael N Singleton
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY 10021, USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10021, USA
| | - Mikhail Goman
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY 10021, USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10021, USA
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Jaber S, De Jong A, Schaefer MS, Zhang J, Ma X, Hao X, Zhou S, Lv S, Banner-Goodspeed V, Niu X, Sfara T, Talmor D. Preoxygenation with standard facemask combining apnoeic oxygenation using high flow nasal cannula versuss standard facemask alone in patients with and without obesity: the OPTIMASK international study. Ann Intensive Care 2023; 13:26. [PMID: 37014462 PMCID: PMC10073359 DOI: 10.1186/s13613-023-01124-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 03/25/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND Combining oxygen facemask with apnoeic oxygenation using high-flow-nasal-oxygen (HFNO) for preoxygenation in the operating room has not been studied against standard oxygen facemask alone. We hypothesized that facemask-alone would be associated with lower levels of lowest end-tidal oxygen (EtO2) within 2 min after intubation in comparison with facemask combined with HFNO. METHODS In an international prospective before-after multicentre study, we included adult patients intubated in the operating room from September 2022 to December 2022. In the before period, preoxygenation was performed with facemask-alone, which was removed during laryngoscopy. In the after period, facemask combined with HFNO was used for preoxygenation and HFNO for apnoeic oxygenation during laryngoscopy. HFNO was maintained throughout intubation. The primary outcome was the lowest EtO2 within 2 min after intubation. The secondary outcome was SpO2 ≤ 95% within 2 min after intubation. Subgroup analyses were performed in patients without and with obesity. This study was registered 10 August 2022 with ClinicalTrials.gov, number NCT05495841. RESULTS A total of 450 intubations were evaluated, 233 with facemask-alone and 217 with facemask combined with HFNO. In all patients, the lowest EtO2 within 2 min after intubation was significantly lower with facemask-alone than with facemask combined with HFNO, 89 (85-92)% vs 91 (88-93)%, respectively (mean difference - 2.20(- 3.21 to - 1.18), p < 0.001). In patients with obesity, similar results were found [87(82-91)% vs 90(88-92)%, p = 0.004]; as in patients without obesity [90(86-92)% vs 91(89-93)%, p = 0.001)]. SpO2 ≤ 95% was more frequent with facemask-alone (14/232, 6%) than with facemask combined with HFNO (2/215, 1%, p = 0.004). No severe adverse events were recorded. CONCLUSIONS Combining facemask with HFNO for preoxygenation and apnoeic oxygenation was associated with increased levels of lowest EtO2 within 2 min after intubation and less desaturation.
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Affiliation(s)
- Samir Jaber
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, 1; 80 avenue Augustin Fliche, Montpellier cedex 5, Montpellier, France.
- Centre Hospitalier Universitaire Montpellier, 34295, Montpellier, France.
| | - Audrey De Jong
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, 1; 80 avenue Augustin Fliche, Montpellier cedex 5, Montpellier, France
- Centre Hospitalier Universitaire Montpellier, 34295, Montpellier, France
| | - Maximilian S Schaefer
- Center for Anesthesia Research Exellence, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
| | - Jiaqiang Zhang
- Department of Anesthesiology and Perioperative Medicine, People's Hospital of Zhengzhou University, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Xiaowen Ma
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Xinrui Hao
- Department of Anesthesiology and Perioperative Medicine, People's Hospital of Zhengzhou University, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Shujing Zhou
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Shang Lv
- Department of Anesthesiology and Perioperative Medicine, People's Hospital of Zhengzhou University, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Valerie Banner-Goodspeed
- Center for Anesthesia Research Exellence, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
| | - Xiuhua Niu
- Shenzhen Mindray Bio-Medical Electronics Co., Ltd. Mindray Building, Keji 12th Road South, High-tech Industrial Park, Nanshan, Shenzhen, 518057, People's Republic of China
| | - Thomas Sfara
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, 1; 80 avenue Augustin Fliche, Montpellier cedex 5, Montpellier, France
- Centre Hospitalier Universitaire Montpellier, 34295, Montpellier, France
| | - Daniel Talmor
- Center for Anesthesia Research Exellence, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
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Broberg E, Pierre L, Fakhro M, Malmsjö M, Lindstedt S, Hyllén S. Releasing high positive end-expiratory pressure to a low level generates a pronounced increase in particle flow from the airways. Intensive Care Med Exp 2023; 11:12. [PMID: 36929361 PMCID: PMC10020405 DOI: 10.1186/s40635-023-00498-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 02/04/2023] [Indexed: 03/18/2023] Open
Abstract
OBJECTIVES Detecting particle flow from the airways by a non-invasive analyzing technique might serve as an additional tool to monitor mechanical ventilation. In the present study, we used a customized particles in exhaled air (PExA) technique, which is an optical particle counter for the monitoring of particle flow in exhaled air. We studied particle flow while increasing and releasing positive end-expiratory pressure (PEEP). The aim of this study was to investigate the impact of different levels of PEEP on particle flow in exhaled air in an experimental setting. We hypothesized that gradually increasing PEEP will reduce the particle flow from the airways and releasing PEEP from a high level to a low level will result in increased particle flow. METHODS Five fully anesthetized domestic pigs received a gradual increase of PEEP from 5 cmH2O to a maximum of 25 cmH2O during volume-controlled ventilation. The particle count along with vital parameters and ventilator settings were collected continuously and measurements were taken after every increase in PEEP. The particle sizes measured were between 0.41 µm and 4.55 µm. RESULTS A significant increase in particle count was seen going from all levels of PEEP to release of PEEP. At a PEEP level of 15 cmH2O, there was a median particle count of 282 (154-710) compared to release of PEEP to a level of 5 cmH2O which led to a median particle count of 3754 (2437-10,606) (p < 0.009). A decrease in blood pressure was seen from baseline to all levels of PEEP and significantly so at a PEEP level of 20 cmH2O. CONCLUSIONS In the present study, a significant increase in particle count was seen on releasing PEEP back to baseline compared to all levels of PEEP, while no changes were seen when gradually increasing PEEP. These findings further explore the significance of changes in particle flow and their part in pathophysiological processes within the lung.
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Affiliation(s)
- Ellen Broberg
- Department of Clinical Sciences, Lund University, Lund, Sweden. .,Department of Cardiothoracic Anaesthesia and Intensive Care, Skåne University Hospital, Entrégatan 8, Level 8, 22241, Lund, Sweden.
| | - Leif Pierre
- Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Cardiothoracic Anaesthesia and Intensive Care, Skåne University Hospital, Entrégatan 8, Level 8, 22241, Lund, Sweden
| | - Mohammed Fakhro
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark
| | - Malin Malmsjö
- Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Ophthalmology, Skåne University Hospital, Lund, Sweden
| | - Sandra Lindstedt
- Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Cardiothoracic Surgery, Skåne University Hospital, Lund, Sweden.,Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
| | - Snejana Hyllén
- Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Cardiothoracic Anaesthesia and Intensive Care, Skåne University Hospital, Entrégatan 8, Level 8, 22241, Lund, Sweden
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Ko E, Yoo KY, Lim CH, Jun S, Lee K, Kim YH. Is atelectasis related to the development of postoperative pneumonia? a retrospective single center study. BMC Anesthesiol 2023; 23:77. [PMID: 36906539 PMCID: PMC10007747 DOI: 10.1186/s12871-023-02020-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/14/2023] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND Atelectasis may play a substantial role in the development of pneumonia. However, pneumonia has never been evaluated as an outcome of atelectasis in surgical patients. We aimed to determine whether atelectasis is related to an increased risk of postoperative pneumonia, intensive care unit (ICU) admission and hospital length of stay (LOS). METHODS The electronic medical records of adult patients who underwent elective non-cardiothoracic surgery under general anesthesia between October 2019 and August 2020 were reviewed. They were divided into two groups: one who developed postoperative atelectasis (atelectasis group) and the other who did not (non-atelectasis group). The primary outcome was the incidence of pneumonia within 30 days after the surgery. The secondary outcomes were ICU admission rate and postoperative LOS. RESULTS Patients in the atelectasis group were more likely to have risk factors for postoperative pneumonia including age, body mass index, a history of hypertension or diabetes mellitus and duration of surgery, compared with those in the non-atelectasis. Among 1,941 patients, 63 (3.2%) developed postoperative pneumonia; 5.1% in the atelectasis group and 2.8% in the non-atelectasis (P = 0.025). In multivariable analysis, atelectasis was associated with an increased risk of pneumonia (adjusted odds ratio, 2.33; 95% CI: 1.24 - 4.38; P = 0.008). Median postoperative LOS was significantly longer in the atelectasis group (7 [interquartile range: 5-10 days]) than in the non-atelectasis (6 [3-8] days) (P < 0.001). Adjusted median duration was also 2.19 days longer in the atelectasis group (β, 2.19; 95% CI: 0.821 - 2.834; P < 0.001). ICU admission rate was higher in the atelectasis group (12.1% vs. 6.5%; P < 0.001), but it did not differ between the groups after adjustment for confounders (adjusted odds ratio, 1.52; 95% CI: 0.88 - 2.62; P = 0.134). CONCLUSION Among patients undergoing elective non-cardiothoracic surgery, patients with postoperative atelectasis were associated with a 2.33-fold higher incidence of pneumonia and a longer LOS than those without atelectasis. This finding alerts the need for careful management of perioperative atelectasis to prevent or reduce the adverse events including pneumonia and the burden of hospitalizations. TRIAL REGISTRATION None.
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Affiliation(s)
- Eunji Ko
- grid.411134.20000 0004 0474 0479Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, 73, Goryeodae-ro, Seongbuk-gu, Seoul, 02841 Republic of Korea
| | - Kyung Yeon Yoo
- grid.411597.f0000 0004 0647 2471Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital, 42 , Jebong-ro, Dong-gu, Gwangju, 58128 Republic of Korea
| | - Choon Hak Lim
- grid.222754.40000 0001 0840 2678Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University, 73, Goryeodae-ro, Seongbuk-gu, Seoul, 02841 Republic of Korea
| | - Seungwoo Jun
- grid.411134.20000 0004 0474 0479Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, 73, Goryeodae-ro, Seongbuk-gu, Seoul, 02841 Republic of Korea
| | - Kaehong Lee
- grid.411134.20000 0004 0474 0479Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, 73, Goryeodae-ro, Seongbuk-gu, Seoul, 02841 Republic of Korea
| | - Yun Hee Kim
- grid.49606.3d0000 0001 1364 9317Department of Anesthesiology and Pain Medicine, Hanyang University Changwon Hanmaeum Hospital, 57, Yongdong-Ro, Uichang-Gu, Gyeongsangnam-Do, Changwon-Si, 51139 Republic of Korea
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Bajon F, Gauthier V. Management of refractory hypoxemia using recruitment maneuvers and rescue therapies: A comprehensive review. Front Vet Sci 2023; 10:1157026. [PMID: 37065238 PMCID: PMC10098094 DOI: 10.3389/fvets.2023.1157026] [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: 02/02/2023] [Accepted: 03/14/2023] [Indexed: 04/18/2023] Open
Abstract
Refractory hypoxemia in patients with acute respiratory distress syndrome treated with mechanical ventilation is one of the most challenging conditions in human and veterinary intensive care units. When a conventional lung protective approach fails to restore adequate oxygenation to the patient, the use of recruitment maneuvers and positive end-expiratory pressure to maximize alveolar recruitment, improve gas exchange and respiratory mechanics, while reducing the risk of ventilator-induced lung injury has been suggested in people as the open lung approach. Although the proposed physiological rationale of opening and keeping open previously collapsed or obstructed airways is sound, the technique for doing so, as well as the potential benefits regarding patient outcome are highly controversial in light of recent randomized controlled trials. Moreover, a variety of alternative therapies that provide even less robust evidence have been investigated, including prone positioning, neuromuscular blockade, inhaled pulmonary vasodilators, extracorporeal membrane oxygenation, and unconventional ventilatory modes such as airway pressure release ventilation. With the exception of prone positioning, these modalities are limited by their own balance of risks and benefits, which can be significantly influenced by the practitioner's experience. This review explores the rationale, evidence, advantages and disadvantages of each of these therapies as well as available methods to identify suitable candidates for recruitment maneuvers, with a summary on their application in veterinary medicine. Undoubtedly, the heterogeneous and evolving nature of acute respiratory distress syndrome and individual lung phenotypes call for a personalized approach using new non-invasive bedside assessment tools, such as electrical impedance tomography, lung ultrasound, and the recruitment-to-inflation ratio to assess lung recruitability. Data available in human medicine provide valuable insights that could, and should, be used to improve the management of veterinary patients with severe respiratory failure with respect to their intrinsic anatomy and physiology.
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Su H, Zhang J, Liu Y, Peng H, Zhang L. Pre and postoperative nurse-guided incentive spirometry versus physiotherapist-guided pre and postoperative breathing exercises in patients undergoing cardiac surgery: An evaluation of postoperative complications and length of hospital stay. Medicine (Baltimore) 2022; 101:e32443. [PMID: 36596066 PMCID: PMC9803493 DOI: 10.1097/md.0000000000032443] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Atelectasis is the most occurring postoperative complication after cardiac surgeries. Postoperative respiratory exercises and incentive spirometry led to decrease in postoperative complications, especially atelectasis and hospital stay. The objectives of the study were to evaluate postoperative complications and length of hospital stay of patients who received pre and postoperative nurse-guided incentive spirometry against those of patients who received pre and postoperative breathing exercises by the physiotherapist in patients who underwent cardiac surgery. Data of patients who received 2 days preoperative and 2 days postoperative nurse-guided incentive spirometry with a spirometer (PPN cohort, n = 102) or received 2 days preoperative and 2 days postoperative breathing exercises by physiotherapist without spirometer (PPP cohort, n = 105), or 2 days postoperative physiotherapist-guided breathing exercises only without spirometer (PPB cohort, n = 114) were collected and analyzed. The acute or chronic collapse of part or entire lung was defined as atelectasis. The length of stay in the hospital was from the day of admission to discharge. Patients of the PPN cohort had fewer numbers of incidences of atelectasis, dyspnea, and sweating >1 day after operations compared to those of the PPB and the PPP cohorts (P < .05 for all). The partial pressure of oxygen and oxygen saturation of arterial blood ≥6 hours after operations reported higher, the duration of ventilation was shorter, and numbers of re-intubation processes reported fewer for patients of the PPN cohort than those of the PPB and the PPP cohorts (P < .05 for all). The hospital length of the stay of patients in the PPN cohort was fewer than those of the PPB and the PPP (P < .0001 for both) cohorts. Pre and postoperative nurse-guided incentive spirometry with a spirometer following cardiac surgeries would have better postoperative pulmonary outcomes and fewer hospital stays than those of postoperative-only or pre and postoperative physiotherapist-guided breathing exercises (level of evidence: IV; technical efficacy stage: 5).
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Affiliation(s)
- Hui Su
- Department of Cardiac Surgery, Xingtai People’s Hospital, Xingtai, Hebei, China
- * Correspondence: Hui Su, Department of Cardiac Surgery, Xingtai People’s Hospital, No. 818 of Xiangdu North Road, Xingtai, Hebei 054001, China (e-mail: )
| | - Jun Zhang
- Department of Cardiac Surgery, Xingtai People’s Hospital, Xingtai, Hebei, China
| | - Yunxue Liu
- Department of Cardiac Surgery, Xingtai People’s Hospital, Xingtai, Hebei, China
| | - Hui Peng
- Department of Cardiac Surgery, Xingtai People’s Hospital, Xingtai, Hebei, China
| | - Longfei Zhang
- Department of Cardiac Surgery, Xingtai People’s Hospital, Xingtai, Hebei, China
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Liu W, Zhang X, Liu K, Kang Z. Lung ultrasound for the diagnosis of pulmonary atelectasis in both adults and pediatrics: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e28397. [PMID: 36401459 PMCID: PMC9678594 DOI: 10.1097/md.0000000000031519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The use of lung ultrasound for the diagnosis of pulmonary atelectasis remains controversial. Therefore, we performed a protocol for systematic review and meta-analysis to evaluate the diagnostic accuracy of lung ultrasound for the diagnosis of pulmonary atelectasis both in adults and pediatrics. METHODS A comprehensive search of several databases from 1966 to October 2022 will be conducted. The databases include Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid PsycINFO, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and PubMed. After screening and diluting out the articles that met inclusion criteria to be used for statistical analysis, the pooled evaluation indexes including sensitivity and specificity as well as hierarchical summary receiver operating characteristic curves with 95% confidence interval were calculated. All statistical analyses were calculated with STATA, version 12.0 (StataCorp, College Station, TX). RESULT We will synthesize the current studies to evaluate the diagnostic accuracy of lung ultrasound for the diagnosis of pulmonary atelectasis. CONCLUSION The result of this review will provide more reliable references to help clinicians make decisions for the diagnosis of pulmonary atelectasis.
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Affiliation(s)
- Wenlong Liu
- Ultrasonic Center, the Affiliated Hospital of Guizhou Medical University, Guizhou, China
| | - Xu Zhang
- Department of Medical Records, First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Heilongjiang, China
| | - Kai Liu
- Endoscopy Room, Shengjing Hospital Affiliated to China Medical University, Liaoning, China
| | - Zhongjing Kang
- Department of Radiology, Songshan General Hospital, Chongqing, China
- * Correspondence: Zhongjing Kang, Department of Radiology, Songshan General Hospital, Chongqing 401438, China (e-mail: )
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Li S, Luo Z, Li K, Li Y, Yang D, Cao G, Zhang X, Zhou Y, Chi S, Tang S. Robotic approach for pediatric pulmonary resection: preliminary investigation and comparative study with thoracoscopic approach. J Thorac Dis 2022; 14:3854-3864. [PMID: 36389324 PMCID: PMC9641347 DOI: 10.21037/jtd-22-526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 09/09/2022] [Indexed: 08/11/2023]
Abstract
BACKGROUND Minimal invasive pulmonary resection in children is challenging, irrespective of whether it is conducted using a robot or a thoracoscope. This study presents the preliminary results of pediatric robotic pulmonary resection (RPR) and comparison outcomes with conventional thoracoscopic pulmonary resection (TPR). METHODS This is a retrospective study conducted in patients underwent RPR (RPR group; n=30) and TPR (TPR group; n=44). The clinical data, including operative time, post-operative body temperature, surgical complications, surgeon's workload (by NASA-TLX), postoperative hospital stay, and scar score (using the SCAR scale), of both the RPR and TPR groups were collected and compared. RESULTS Both groups had similar age and weight. The youngest patient belonged to the RPR group and was 6 months old and weighed 8 kg. One case in the RPR group and two in the TPR group were converted to thoracotomy. RPR had a longer total operative time (148.3±36.8 min), but a shorter pure operative time (103.9±28.5 min) than those of the TPR group [118.3±22.5 (P<0.001) and 111.4±18.3 min (P=0.045), respectively]. Compared to the TPR group, fewer patients in the RPR group reported fever postoperatively (2/29 vs. 11/42, P=0.039). The workload of the surgeons was also lower in the RPR group (55.2±4.7 vs. 62.9±6.0, P<0.01). No significant difference was observed in perioperative complications, drainage length, postoperative hospital stays, and scar score of the two groups. CONCLUSIONS The safety and effectiveness of the robotic approach are similar to those of the thoracoscopic surgery for pediatric pulmonary resection in children heavier than 8 kg. In addition, the robotic approach shows improved operative dissection efficiency and accuracy for patients and reduced workload for surgeons. Hence, it is beneficial to both surgeons and patients.
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Affiliation(s)
- Shuai Li
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhibin Luo
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kang Li
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yan Li
- Operation Room, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dehua Yang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guoqing Cao
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xi Zhang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ying Zhou
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuiqing Chi
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shaotao Tang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Influences of Ultrasonic Image-Guided Erector Spinae Plane Block on Postoperative Pulmonary Air Content of Lung Carcinoma Patients Undergoing Thoracoscopic Surgery. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:1301361. [PMID: 36110570 PMCID: PMC9470334 DOI: 10.1155/2022/1301361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 06/26/2022] [Accepted: 08/01/2022] [Indexed: 11/18/2022]
Abstract
To investigate the influences of ultrasonic image-guided erector spinae plane block (ESPB) on postoperative pulmonary air content of lung carcinoma patients undergoing thoracoscopic surgery, 42 patients performed with thoracoscopic radical surgery for lung carcinoma were selected. The patients in the experimental group were performed with ultrasound-guided unilateral ESPB and intravenous general anesthesia. The patients in the control group only underwent intravenous anesthesia. The changes in postoperative pulmonary air content between the two groups were compared. After that, all included patients were divided into the experimental (senior) group (13 cases), the experimental (adult) group (8 cases), the control (senior) group (11 cases), and the control (adult) group (10 cases) according to age. The changes in postoperative pulmonary air content of patients in the four groups were compared. The results showed that lung ultrasound score (LUS) of patients in experimental group was
points 0.5 hour after catheter extraction and LUS was
points 20 to 30 hours. Both scores were remarkably lower than those of patients in control group (
). LUS of lower left anterior area, upper left posterior area, lower left posterior area, upper right posterior area, and lower right posterior area of patients in experimental group was all apparently lower than those in control group 0.5 hour after catheter extraction (
). LUS of upper left posterior area, lower left posterior area, lower right anterior area, upper right posterior area, and lower right posterior area of patients in experimental group was all remarkably lower than those in control group 20 to 30 hours after surgery (
). LUS of senile patients and middle-aged patients in experimental group 0.5 hour after catheter extraction was
points and
points, respectively, which were both notably lower than those in control group (
). Ultrasound-guided ESPB exerted fewer influences on lung and could effectively improve postoperative pulmonary air content among patients. Hence, it was worthy of clinical promotion.
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Perioperative Pulmonary Atelectasis: Reply. Anesthesiology 2022; 137:126-127. [PMID: 35486838 PMCID: PMC9870666 DOI: 10.1097/aln.0000000000004232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Proteomics of lung tissue reveals differences in inflammation and alveolar-capillary barrier response between atelectasis and aerated regions. Sci Rep 2022; 12:7065. [PMID: 35487970 PMCID: PMC9053128 DOI: 10.1038/s41598-022-11045-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 04/14/2022] [Indexed: 11/19/2022] Open
Abstract
Atelectasis is a frequent clinical condition, yet knowledge is limited and controversial on its biological contribution towards lung injury. We assessed the regional proteomics of atelectatic versus normally-aerated lung tissue to test the hypothesis that immune and alveolar-capillary barrier functions are compromised by purely atelectasis and dysregulated by additional systemic inflammation (lipopolysaccharide, LPS). Without LPS, 130 proteins were differentially abundant in atelectasis versus aerated lung, mostly (n = 126) with less abundance together with negatively enriched processes in immune, endothelial and epithelial function, and Hippo signaling pathway. Instead, LPS-exposed atelectasis produced 174 differentially abundant proteins, mostly (n = 108) increased including acute lung injury marker RAGE and chemokine CCL5. Functional analysis indicated enhanced leukocyte processes and negatively enriched cell-matrix adhesion and cell junction assembly with LPS. Additionally, extracellular matrix organization and TGF-β signaling were negatively enriched in atelectasis with decreased adhesive glycoprotein THBS1 regardless of LPS. Concordance of a subset of transcriptomics and proteomics revealed overlap of leukocyte-related gene-protein pairs and processes. Together, proteomics of exclusively atelectasis indicates decreased immune response, which converts into an increased response with LPS. Alveolar-capillary barrier function-related proteomics response is down-regulated in atelectasis irrespective of LPS. Specific proteomics signatures suggest biological mechanistic and therapeutic targets for atelectasis-associated lung injury.
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Pastene B, Labarriere A, Lopez A, Charvet A, Culver A, Fiocchi D, Cluzel A, Brioude G, Einav S, Tankel J, Hamidou Z, D’Journo XB, Thomas P, Leone M, Zieleskiewicz L. OUP accepted manuscript. BJS Open 2022; 6:6590976. [PMID: 35607804 PMCID: PMC9127337 DOI: 10.1093/bjsopen/zrac063] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/08/2022] [Indexed: 11/28/2022] Open
Abstract
Background Physiotherapy is a major cornerstone of enhanced rehabilitation after surgery (ERAS) and reduces the development of atelectasis after thoracic surgery. By initiating physiotherapy in the post-anaesthesia care unit (PACU), the aim was to evaluate whether the ultra-early initiation of rehabilitation (in the first hour following tracheal extubation) would improve the outcomes of patients undergoing elective thoracic surgery. Methods A case–control study with a before-and-after design was conducted. From a historical control group, patients were paired at a 3:1 ratio with an intervention group. This group consisted of patients treated with the ultra-early rehabilitation programme after elective thoracic surgery (clear fluids, physiotherapy, and ambulation). The primary outcome was the incidence of postoperative atelectasis and/or pneumonia during the hospital stay. Results After pairing, 675 patients were allocated to the historical control group and 225 patients to the intervention group. A significant decrease in the incidence of postoperative atelectasis and/or pneumonia was found in the latter (11.4 versus 6.7 per cent respectively; P = 0.042) and remained significant on multivariate analysis (OR 0.53, 95 per cent c.i. 0.26 to 0.98; P = 0.045). A subgroup analysis of the intervention group showed that early ambulation during the PACU stay was associated with a further significant decrease in the incidence of postoperative atelectasis and/or pneumonia (2.2 versus 9.5 per cent; P = 0.012). Conclusions Ultra-early rehabilitation in the PACU was associated with a decrease in the incidence of postoperative atelectasis and/or pneumonia after major elective thoracic surgery.
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Affiliation(s)
- Bruno Pastene
- Correspondence to: Bruno Pastene, Département d’Anesthésie et de Reanimation, Hôpital Nord, Chemin des Bourrely, 13015 Marseille, France (e-mail: )
| | - Ambroise Labarriere
- Department of Anaesthesiology and Intensive Care Medicine, Hôpital Nord, Hôpitaux Universitaires de Marseille, Aix Marseille University, Marseille, France
| | - Alexandre Lopez
- Department of Anaesthesiology and Intensive Care Medicine, Hôpital Nord, Hôpitaux Universitaires de Marseille, Aix Marseille University, Marseille, France
| | - Aude Charvet
- Department of Anaesthesiology and Intensive Care Medicine, Hôpital Nord, Hôpitaux Universitaires de Marseille, Aix Marseille University, Marseille, France
| | - Aurélien Culver
- Department of Anaesthesiology and Intensive Care Medicine, Hôpital Nord, Hôpitaux Universitaires de Marseille, Aix Marseille University, Marseille, France
| | - David Fiocchi
- Department of Anaesthesiology and Intensive Care Medicine, Hôpital Nord, Hôpitaux Universitaires de Marseille, Aix Marseille University, Marseille, France
| | - Armand Cluzel
- Department of Thoracic Surgery, Hôpital Nord, Hôpitaux Universitaires de Marseille, Aix Marseille University, Marseille, France
| | - Geoffrey Brioude
- Department of Thoracic Surgery, Hôpital Nord, Hôpitaux Universitaires de Marseille, Aix Marseille University, Marseille, France
| | - Sharon Einav
- Intensive Care Unit of the Shaare Zedek Medical Medical Centre, Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - James Tankel
- Division of Thoracic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Zeinab Hamidou
- Centre d’Études et de Recherches sur les Services de Santé et Qualité de Vie CEReSS/EA 3279, Hôpitaux Universitaires de Marseille, Aix Marseille University, Marseille, France
| | - Xavier Benoit D’Journo
- Department of Thoracic Surgery, Hôpital Nord, Hôpitaux Universitaires de Marseille, Aix Marseille University, Marseille, France
| | - Pascal Thomas
- Department of Thoracic Surgery, Hôpital Nord, Hôpitaux Universitaires de Marseille, Aix Marseille University, Marseille, France
| | - Marc Leone
- Department of Anaesthesiology and Intensive Care Medicine, Hôpital Nord, Hôpitaux Universitaires de Marseille, Aix Marseille University, Marseille, France
- Centre for Cardiovascular and Nutrition Research (C2VN), INRA, Aix Marseille Université, INSERM, Marseille, France
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