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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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Aggressive repeat manual pulmonary recruitment maneuver with pure oxygen as a new treatment of venous air embolism. Med Hypotheses 2022. [DOI: 10.1016/j.mehy.2022.110802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Cirrhotic Patients on Mechanical Ventilation Have a Low Rate of Successful Extubation and Survival. Dig Dis Sci 2020; 65:3744-3752. [PMID: 31960201 PMCID: PMC8800450 DOI: 10.1007/s10620-020-06051-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 01/06/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS We hypothesized that mechanically ventilated cirrhotic patients not only have poor outcomes, but also that certain clinical variables are likely to be associated with mortality. We aimed to describe the predictors of mortality in these patients. METHODS This observational study examined 113 mechanically ventilated cirrhotic patients cared for at our institution between July 1, 2014, and February 28, 2018. We performed bivariate and multivariate analyses to identify risk factors for mortality on mechanical ventilation and created an equation to calculate probability of mortality based on these variables. RESULTS Seventy percent of patients had a history of a decompensating event. Altered mental status was the most frequently encountered indication for intubation (46%). 53% patients died on mechanical ventilation. After controlling for variables associated with increased mortality, multivariate analysis revealed that vasopressor use was the strongest predictor of mortality on mechanical ventilation (OR = 9.3) followed by sepsis (OR = 4.1). A formula with an area under the curve of 0.85 was obtained in order to predict the probability of mortality for cirrhotic patients on mechanical ventilation (available at https://medweb.musc.edu/mvcp/ ). This model (AUC = 0.85) outperformed the CLIF-SOFA score (AUC = 0.68) in predicting mortality in this cohort. CONCLUSION Cirrhotic patients requiring mechanical ventilation have an extremely poor prognosis, and in patients requiring vasopressors, having a history of decompensation, sepsis or low albumin, mortality is higher. Our data points to the clinical variables should be considered in the medical management of these patients and provide physicians with a formula to predict the probability of mortality.
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Liu S, do Amaral Campos PPZ, Casoni D, Berger D, Kohler A, Bloch A, Bervini D, Setzer F, Cameron DR, Z'Graggen W, Hana A, Langer R, Corrêa TD, Beldi G, Takala J, Jakob SM. Defense mechanisms to increasing back pressure for hepatic oxygen transport and venous return in porcine fecal peritonitis. Am J Physiol Gastrointest Liver Physiol 2020; 319:G289-G302. [PMID: 32658622 DOI: 10.1152/ajpgi.00216.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
High central venous pressure (CVP) acutely decreases venous return. How this affects hepatic oxygen transport in sepsis remains unclear. The aim of this study was to evaluate the effects of repeated increases in CVP via standard nursing procedures (NPs) on hepato-splanchnic and renal oxygen transport in a prolonged porcine sepsis model. Twenty anesthetized and mechanically ventilated pigs with regional hemodynamics monitored were randomized to fecal peritonitis or controls (n = 10 pigs/group). Resuscitation was started after 8 h of observation and continued for 3 days. NPs were performed at baseline and 8 h, 32 h, 56 h, and 72 h after resuscitation started. NPs increased CVP by 4-7 mmHg in both groups. In controls, this was associated with less decrease in hepatic arterial (Qha; 62 ± 70 mL/min) than portal venous flow (Qpv; 364 ± 151 mL/min). Portal venous oxygen content and hepatic O2 delivery (Do2) and consumption (V̇o2) decreased by 11 ± 6 mL/dL and 0.9 ± 0.3 and 0.4 ± 0.3 mL·min-1·kg-1, respectively. In septic animals, hepatic Do2 decreased more in response to increasing CVP (1.5 ± 0.9 mL·min-1·kg-1), which was attributable to a larger fall in both Qha (88 ± 66 ml/min) and portal O2 content (14 ± 10 mL/dL, all P < 0.05). This resulted in numerically lower hepatic V̇o2 since O2 extraction did not increase significantly. In control conditions, a smaller decrease in Qha compared with Qpv helped to limit the reduction in hepatic V̇o2 in response to acute CVP increase. In sepsis, the contribution of Qha to maintain hepatic Do2 was reduced, which jeopardized hepatic V̇o2 further. Renal arterial flow was similarly affected by CVP increase as Qha.NEW & NOTEWORTHY Sepsis impairs intrinsic mechanisms to attenuate effects of increasing back pressure on hepatic oxygen transport.
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Affiliation(s)
- Shengchen Liu
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
| | | | - Daniela Casoni
- Experimental Surgery Facility, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Kohler
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Bloch
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David Bervini
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Florian Setzer
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David R Cameron
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Werner Z'Graggen
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anisa Hana
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Rupert Langer
- Institue of Pathology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thiago D Corrêa
- Department of Intensive Care Unit, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Guido Beldi
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Chen X, Wang X, Honore PM, Spapen HD, Liu D. Renal failure in critically ill patients, beware of applying (central venous) pressure on the kidney. Ann Intensive Care 2018; 8:91. [PMID: 30238174 PMCID: PMC6146958 DOI: 10.1186/s13613-018-0439-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 09/15/2018] [Indexed: 12/20/2022] Open
Abstract
The central venous pressure (CVP) is traditionally used as a surrogate of intravascular volume. CVP measurements therefore are often applied at the bedside to guide fluid administration in postoperative and critically ill patients. Pursuing high CVP levels has recently been challenged. A high CVP might impede venous return to the heart and disturb microcirculatory blood flow which may cause tissue congestion and organ failure. By imposing an increased "afterload" on the kidney, an elevated CVP will particularly harm kidney hemodynamics and promote acute kidney injury (AKI) even in the absence of volume overload. Maintaining the lowest possible CVP should become routine to prevent and treat AKI, especially when associated with septic shock, cardiac surgery, mechanical ventilation, and intra-abdominal hypertension.
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Affiliation(s)
- Xiukai Chen
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, 200 Lothrop Street, BST E1240, Pittsburgh, PA 15261 USA
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, 100073 China
| | - Patrick M. Honore
- Department of Intensive Care, Centre Hospitalier Universitaire Brugmann, Brugmann University Hospital, 4 Place Van Gehuchtenplein, 1020 Brussels, Belgium
| | - Herbert D. Spapen
- Department of Intensive Care, University Hospital, Vrije Universiteit Brussel (VUB), 101, Laarbeeklaan, Jette 1090 Brussels, Belgium
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, 100073 China
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Doras C, Le Guen M, Peták F, Habre W. Cardiorespiratory effects of recruitment maneuvers and positive end expiratory pressure in an experimental context of acute lung injury and pulmonary hypertension. BMC Pulm Med 2015; 15:82. [PMID: 26228052 PMCID: PMC4521467 DOI: 10.1186/s12890-015-0079-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 07/20/2015] [Indexed: 01/17/2023] Open
Abstract
Background Recruitment maneuvers (RM) and positive end expiratory pressure (PEEP) are the cornerstone of the open lung strategy during ventilation, particularly during acute lung injury (ALI). However, these interventions may impact the pulmonary circulation and induce hemodynamic and respiratory effects, which in turn may be critical in case of pulmonary hypertension (PHT). We aimed to establish how ALI and PHT influence the cardiorespiratory effects of RM and PEEP. Methods Rabbits control or with monocrotaline-induced PHT were used. Forced oscillatory airway and tissue mechanics, effective lung volume (ELV), systemic and right ventricular hemodynamics and blood gas were assessed before and after RM, during baseline and following surfactant depletion by whole lung lavage. Results RM was more efficient in improving respiratory elastance and ELV in the surfactant-depleted lungs when PHT was concomitantly present. Moreover, the adverse changes in respiratory mechanics and ELV following ALI were lessened in the animals suffering from PHT. Conclusions During ventilation with open lung strategy, the role of PHT in conferring protection from the adverse respiratory consequences of ALI was evidenced. This finding advocates the safety of RM and PEEP in improving elastance and advancing lung reopening in the simultaneous presence of PHT and ALI.
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Affiliation(s)
- Camille Doras
- Anesthesiological Investigation, University Medical Centre, University of Geneva, Geneva, Switzerland.
| | - Morgan Le Guen
- Department of Anesthesiology, Hospital Foch, University Versailles Saint-Quentin en Yvelines, Suresnes, France.
| | - Ferenc Peták
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary.
| | - Walid Habre
- Anesthesiological Investigation, University Medical Centre, University of Geneva, Geneva, Switzerland. .,Pediatric Anesthesia Unit, Geneva Children's Hospital, Rue Willy Donzé 6, 1205, Geneva, Switzerland.
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Hedenstierna G, Rothen HU. Respiratory function during anesthesia: effects on gas exchange. Compr Physiol 2013; 2:69-96. [PMID: 23728971 DOI: 10.1002/cphy.c080111] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Anaesthesia causes a respiratory impairment, whether the patient is breathing spontaneously or is ventilated mechanically. This impairment impedes the matching of alveolar ventilation and perfusion and thus the oxygenation of arterial blood. A triggering factor is loss of muscle tone that causes a fall in the resting lung volume, functional residual capacity. This fall promotes airway closure and gas adsorption, leading eventually to alveolar collapse, that is, atelectasis. The higher the oxygen concentration, the faster will the gas be adsorbed and the aleveoli collapse. Preoxygenation is a major cause of atelectasis and continuing use of high oxygen concentration maintains or increases the lung collapse, that typically is 10% or more of the lung tissue. It can exceed 25% to 40%. Perfusion of the atelectasis causes shunt and cyclic airway closure causes regions with low ventilation/perfusion ratios, that add to impaired oxygenation. Ventilation with positive end-expiratory pressure reduces the atelectasis but oxygenation need not improve, because of shift of blood flow down the lung to any remaining atelectatic tissue. Inflation of the lung to an airway pressure of 40 cmH2O recruits almost all collapsed lung and the lung remains open if ventilation is with moderate oxygen concentration (< 40%) but recollapses within a few minutes if ventilation is with 100% oxygen. Severe obesity increases the lung collapse and obstructive lung disease and one-lung anesthesia increase the mismatch of ventilation and perfusion. CO2 pneumoperitoneum increases atelectasis formation but not shunt, likely explained by enhanced hypoxic pulmonary vasoconstriction by CO2. Atelectasis may persist in the postoperative period and contribute to pneumonia.
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Affiliation(s)
- Göran Hedenstierna
- Department of Medical Sciences, Clinical Physiology, Uppsala University Hospital, Uppsala, Sweden.
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Jakob SM, Bracht H, Porta F, Balsiger BM, Brander L, Knuesel R, Feng HQ, Kolarova A, Ma Y, Takala J. Effects of cardiac preload reduction and dobutamine on hepatosplanchnic blood flow regulation in porcine endotoxemia. Am J Physiol Gastrointest Liver Physiol 2012; 303:G247-55. [PMID: 22556139 DOI: 10.1152/ajpgi.00433.2011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Insufficient cardiac preload and impaired contractility are frequent in early sepsis. We explored the effects of acute cardiac preload reduction and dobutamine on hepatic arterial (Qha) and portal venous (Qpv) blood flows during endotoxin infusion. We hypothesized that the hepatic arterial buffer response (HABR) is absent during preload reduction and reduced by dobutamine. In anesthetized pigs, endotoxin or vehicle (n = 12, each) was randomly infused for 18 h. HABR was tested sequentially by constricting superior mesenteric artery (SMA) or inferior vena cava (IVC). Afterward, dobutamine at 2.5, 5.0, and 10.0 μg/kg per minute or another vehicle (n = 6, each) was randomly administered in endotoxemic and control animals, and SMA was constricted during each dose. Systemic (cardiac output, thermodilution) and carotid, splanchnic, and renal blood flows (ultrasound Doppler) and blood pressures were measured before and during administration of each dobutamine dose. HABR was expressed as hepatic arterial pressure/flow ratio. Compared with controls, 18 h of endotoxin infusion was associated with decreased mean arterial blood pressure [49 ± 11 mmHg vs. 58 ± 8 mmHg (mean ± SD); P = 0.034], decreased renal blood flow, metabolic acidosis, and impaired HABR during SMA constriction [0.32 (0.18-1.32) mmHg/ml vs. 0.22 (0.08-0.60) mmHg/ml; P = 0.043]. IVC constriction resulted in decreased Qpv in both groups; whereas Qha remained unchanged in controls, it decreased after 18 h of endotoxemia (P = 0.031; constriction-time-group interaction). One control and four endotoxemic animals died during the subsequent 6 h. The maximal increase of cardiac output during dobutamine infusion was 47% (22-134%) in controls vs. 53% (37-85%) in endotoxemic animals. The maximal Qpv increase was significant only in controls [24% (12-47%) of baseline (P = 0.043) vs. 17% (-7-32%) in endotoxemia (P = 0.109)]. Dobutamine influenced neither Qha nor HABR. Our data suggest that acute cardiac preload reduction is associated with preferential hepatic arterial perfusion initially but not after established endotoxemia. Dobutamine had no effect on the HABR.
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Affiliation(s)
- Stephan M Jakob
- Dept. of Intensive Care Medicine, Bern Univ. Hospital, Inselspital, CH-3010 Bern, Switzerland.
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Kessler U, Grau T, Gronchi F, Berger S, Brandt S, Bracht H, Marcucci C, Zachariou Z, Jakob SM. Comparison of porcine and human coagulation by thrombelastometry. Thromb Res 2011; 128:477-82. [DOI: 10.1016/j.thromres.2011.03.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2010] [Revised: 03/15/2011] [Accepted: 03/17/2011] [Indexed: 10/18/2022]
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What's New in Shock, November 2010? Shock 2010. [DOI: 10.1097/shk.0b013e3181f54a98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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