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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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Xavier TB, Coelho LV, Ferreira DAL, Cota y Raposeiras JM, Duran MS, Silva LA, da Motta-Ribeiro GC, Camilo LM, Carvalho ARS, Silva PL. Individualized positive end-expiratory pressure reduces driving pressure in obese patients during laparoscopic surgery under pneumoperitoneum: a randomized clinical trial. Front Physiol 2024; 15:1383167. [PMID: 38645690 PMCID: PMC11026699 DOI: 10.3389/fphys.2024.1383167] [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: 02/07/2024] [Accepted: 03/19/2024] [Indexed: 04/23/2024] Open
Abstract
Introduction During pneumoperitoneum (PNP), airway driving pressure (ΔPRS) increases due to the stiffness of the chest wall and cephalic shift of the diaphragm, which favors atelectasis. In addition, depending on the mechanical power (MP) formulas, they may lead to different interpretations. Methods Patients >18 years of age with body mass index >35 kg/m2 were included in a single-center randomized controlled trial during their admission for bariatric surgery by abdominal laparoscopy. Intra-abdominal pressure was set at 15 mmHg at the pneumoperitoneum time point (PNP). After the recruitment maneuver, the lowest respiratory system elastance (ERS) was detected during the positive end-expiratory pressure (PEEP) step-wise decrement. Patients were randomized to the 1) CTRL group: ventilated with PEEP of 5 cmH2O and 2) PEEPIND group: ventilated with PEEP value associated with ERS that is 5% higher than its lowest level. Respiratory system mechanics and mean arterial pressure (MAP) were assessed at the PNP, 5 min after randomization (T1), and at the end of the ventilation protocol (T2); arterial blood gas was assessed at PNP and T2. ΔPRS was the primary outcome. Three MP formulas were used: MPA, which computes static PEEP × volume, elastic, and resistive components; MPB, which computes only the elastic component; and MPC, which computes static PEEP × volume, elastic, and resistive components without inspiratory holds. Results Twenty-eight patients were assessed for eligibility: eight were not included and 20 patients were randomized and allocated to CTRL and PEEPIND groups (n = 10/group). The PEEPIND ventilator strategy reduced ΔPRS when compared with the CTRL group (PEEPIND, 13 ± 2 cmH2O; CTRL, 22 ± 4 cmH2O; p < 0.001). Oxygenation improved in the PEEPIND group when compared with the CTRL group (p = 0.029), whereas MAP was comparable between the PEEPIND and CTRL groups. At the end of surgery, MPA and MPB were correlated in both the CTRL (rho = 0.71, p = 0.019) and PEEPIND (rho = 0.84, p = 0.020) groups but showed different bias (CTRL, -1.9 J/min; PEEPIND, +10.0 J/min). At the end of the surgery, MPA and MPC were correlated in both the CTRL (rho = 0.71, p = 0.019) and PEEPIND (rho = 0.84, p = 0.020) groups but showed different bias (CTRL, -1.9 J/min; PEEPIND, +10.0 J/min). Conclusion Individualized PEEP was associated with a reduction in ΔPRS and an improvement in oxygenation with comparable MAP. The MP, which solely computes the elastic component, better reflected the improvement in ΔPRS observed in the individualized PEEP group. Clinical Trial Registration The protocol was registered at the Brazilian Registry of Clinical Trials (U1111-1220-7296).
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Affiliation(s)
- Tiago Batista Xavier
- Laboratório de Fisiologia da Respiração, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Instituto de Educação, Ciência e Tecnologia do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | | | | | - Leticia Almeida Silva
- Laboratório de Investigação Pulmonar, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Luciana Moisés Camilo
- Instituto de Educação, Ciência e Tecnologia do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Pedro Leme Silva
- Laboratório de Investigação Pulmonar, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Non-invasive ventilation for preoxygenation before general anesthesia: a systematic review and meta-analysis of randomized controlled trials. BMC Anesthesiol 2022; 22:306. [PMID: 36180822 PMCID: PMC9524013 DOI: 10.1186/s12871-022-01842-y] [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: 01/06/2022] [Accepted: 09/07/2022] [Indexed: 11/10/2022] Open
Abstract
Background and objectives Preoxygenation is crucial for providing sufficient oxygen reservoir to a patient before intubation and enables the extension of the period between breathing termination and critical desaturation (safe apnoea time). Conventionally, face mask ventilation is used for preoxygenation. Non-invasive ventilation is a new preoxygenation method. The study objective was to compare the outcomes of non-invasive ventilation and face mask ventilation for preoxygenation. Method PubMed, Embase, Cochrane Library, and the ClinicalTrials.gov registry were searched for eligible studies published from database inception to September 2021. Individual effect sizes were standardized, and a meta-analysis was conducted using random effects models to calculate the pooled effect size. Inclusion criteria were randomised controlled trials of comparing the outcomes of non-invasive ventilation or face mask ventilation for preoxygenation in patients scheduled for surgeries. The primary outcome was safe apnea time, and the secondary outcomes were post-operative complications, number of patients who achieved the expired O2 fraction (FeO2) after 3 min of preoxygenation, minimal SpO2 during tracheal intubation, partial pressure of oxygen in the arterial blood (PaO2) and partial pressure of carbon dioxide (PaCO2) after preoxygenation, and PaO2 and PaCO2 after tracheal intubation. Results 13 trials were eligible for inclusion in this study. Significant differences were observed in safe apnoea time, number of patients who achieved FeO2 90% after preoxygenation for 3 min, and PaO2 and PaCO2 after preoxygenation and tracheal intubation. Only in the non-obese subgroup, no significant difference was observed in safe apnoea time (mean difference: 125.38, 95% confidence interval: − 12.26 to 263.03). Conclusion Non-invasive ventilation appeared to be more effective than conventional methods for preoxygenation. We recommend non-invasive ventilation based on our results. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01842-y.
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Marinari G, Foletto M, Nagliati C, Navarra G, Borrelli V, Bruni V, Fantola G, Moroni R, Tritapepe L, Monzani R, Sanna D, Carron M, Cataldo R. Enhanced recovery after bariatric surgery: an Italian consensus statement. Surg Endosc 2022; 36:7171-7186. [PMID: 35953683 PMCID: PMC9485178 DOI: 10.1007/s00464-022-09498-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 12/31/2021] [Indexed: 12/03/2022]
Abstract
Background Enhanced recovery after bariatric surgery (ERABS) is an approach developed to improve outcomes in obese surgical patients. Unfortunately, it is not evenly implemented in Italy. The Italian Society for the Surgery of Obesity and Metabolic Diseases and the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care joined in drafting an official statement on ERABS. Methods To assess the effectiveness and safety of ERABS and to develop evidence-based recommendations with regard to pre-, intra-, and post-operative care for obese patients undergoing ERABS, a 13-member expert task force of surgeons and anesthesiologists from Italian certified IFSO center of excellence in bariatric surgery was established and a review of English-language papers conducted. Oxford 2011 Levels of Evidence and U.S. Preventive Services Task Force Grade Definitions were used to grade the level of evidence and the strength of recommendations, respectively. The supporting evidence and recommendations were reviewed and discussed by the entire group at meetings to achieve a final consensus. Results Compared to the conventional approach, ERABS reduces the length of hospital stay and does not heighten the risk of major post-operative complications, re-operations, and hospital re-admissions, nor does it increase the overall surgical costs. A total of 25 recommendations were proposed, covering pre-operative evaluation and care (7 items), intra-operative management (1 item, 11 sub-items), and post-operative care and discharge (6 items). Conclusions ERABS is an effective and safe approach. The recommendations allow the proper management of obese patients undergoing ERABS for a better outcome.
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Affiliation(s)
- Giuseppe Marinari
- Bariatric Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Mirto Foletto
- Bariatric Surgery Unit, Azienda Ospedale Università Padova, Padua, Italy
| | - Carlo Nagliati
- Department of Surgery, San Giovanni di Dio Hospital, Gorizia, Italy
| | - Giuseppe Navarra
- Department of Human Pathology, University of Messina, Messina, Italy
| | | | - Vincenzo Bruni
- Bariatric Surgery Unit, Campus Bio Medico University of Rome, Rome, Italy
| | - Giovanni Fantola
- Bariatric Surgery Unit, ARNAS, G. Brotzu Hospital, Cagliari, Italy
| | - Roberto Moroni
- Bariatric Surgery Unit, Policlinico Sassarese, Sassari, Italy
| | - Luigi Tritapepe
- Department of Anesthesia and Intensive Care, San Camillo-Forlanini Hospital, Sapienza University of Rome, Rome, Italy
| | - Roberta Monzani
- Department of Anesthesia and Intensive Care Units, Humanitas Research Hospital, Humanitas University Milan, Rozzano, Milan, Italy
| | - Daniela Sanna
- Emergency Department, Section of Anesthesiology and Intensive Care, ARNAS, G. Brotzu Hospital, Cagliari, Italy
| | - Michele Carron
- Department of Medicine-DIMED, Section of Anesthesiology and Intensive Care, University of Padua, Via V. Gallucci, 13, 35121, Padua, Italy.
| | - Rita Cataldo
- Unit of Anesthesia, Intensive Care and Pain Management, Campus Bio Medico University of Rome, Rome, Italy
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Pressure Support versus Spontaneous Ventilation during Anesthetic Emergence-Effect on Postoperative Atelectasis: A Randomized Controlled Trial. Anesthesiology 2021; 135:1004-1014. [PMID: 34610099 DOI: 10.1097/aln.0000000000003997] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Despite previous reports suggesting that pressure support ventilation facilitates weaning from mechanical ventilation in the intensive care unit, few studies have assessed its effects on recovery from anesthesia. The authors hypothesized that pressure support ventilation during emergence from anesthesia reduces postoperative atelectasis in patients undergoing laparoscopic surgery using the Trendelenburg position. METHODS In this randomized controlled double-blinded trial, adult patients undergoing laparoscopic colectomy or robot-assisted prostatectomy were assigned to either the pressure support (n = 50) or the control group (n = 50). During emergence (from the end of surgery to extubation), pressure support ventilation was used in the pressure support group versus intermittent manual assistance in the control group. The primary outcome was the incidence of atelectasis diagnosed by lung ultrasonography at the postanesthesia care unit (PACU). The secondary outcomes were Pao2 at PACU and oxygen saturation measured by pulse oximetry less than 92% during 48 h postoperatively. RESULTS Ninety-seven patients were included in the analysis. The duration of emergence was 9 min and 8 min in the pressure support and control groups, respectively. The incidence of atelectasis at PACU was lower in the pressure support group compared to that in the control group (pressure support vs. control, 16 of 48 [33%] vs. 28 of 49 [57%]; risk ratio, 0.58; 95% CI, 0.35 to 0.91; P = 0.024). In the PACU, Pao2 in the pressure support group was higher than that in the control group (92 ± 26 mmHg vs. 83 ± 13 mmHg; P = 0.034). The incidence of oxygen saturation measured by pulse oximetry less than 92% during 48 h postoperatively was not different between the groups (9 of 48 [19%] vs. 11 of 49 [22%]; P = 0.653). There were no adverse events related to the study protocol. CONCLUSIONS The incidence of postoperative atelectasis was lower in patients undergoing either laparoscopic colectomy or robot-assisted prostatectomy who received pressure support ventilation during emergence from general anesthesia compared to those receiving intermittent manual assistance. EDITOR’S PERSPECTIVE
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Farid AM, Taman HI. The Impact of Sevoflurane and Propofol Anesthetic Induction on Bag Mask Ventilation in Surgical Patients with High Body Mass Index. Anesth Essays Res 2021; 14:594-599. [PMID: 34349326 PMCID: PMC8294424 DOI: 10.4103/aer.aer_20_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 11/22/2022] Open
Abstract
Background and Aims: Obesity is associated with restrictive ventilatory pattern which causes rapid oxygen desaturation. Although obesity is considered as a risk factor for difficult airway management, failure to achieve effective bag mask ventilation (BMV) can be catastrophic. This study tried to assess the effect of both propofol and sevoflurane on the efficacy of BMV during anesthetic induction in obese patients. Patients and Methods: A total of 200 cases were included, and they were randomly divided into two equal groups; Group S which included 100 cases who underwent sevoflurane induction, and Group P which included the remaining 100 cases who underwent propofol induction. Results: No statistically significant difference was detected between the two groups regarding patient and air way characteristics (P > 0.05). Difficult BMV (DBMV) was encountered in 19% and 37% of cases in Groups S and P, respectively. The incidence of DBMV was significantly increased in the P group (P = 0.005). Furthermore, the severity of difficulty was more marked in the P group. Logistic regression analysis revealed that thyromental distance, presence of macroglossia, presence of beard, lack of teeth, history of snoring, as well as propofol induction were risk factors for DBMV. Conclusion: Sevoflurane can facilitate BMV and provide better intubation conditions in comparison to propofol during anesthetic induction in morbidly obese patients. Moreover, decreased thyromental distance, presence of macroglossia and beard, lack of teeth, and history of snoring are considered preoperative indicators of DBMV.
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Affiliation(s)
- Ahmed M Farid
- Department of Anesthesia, Surgical Intensive Care and Pain Management, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Hani I Taman
- Department of Anesthesia, Surgical Intensive Care and Pain Management, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Prevention of atelectasis by continuous positive airway pressure in anaesthetised children: A randomised controlled study. Eur J Anaesthesiol 2021; 38:41-48. [PMID: 33009190 DOI: 10.1097/eja.0000000000001351] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Continuous positive airway pressure (CPAP) prevents peri-operative atelectasis in adults, but its effect in children has not been quantified. OBJECTIVE The aim of this study was to evaluate the role of CPAP in preventing postinduction and postoperative atelectasis in children under general anaesthesia. DESIGN A randomised controlled study. SETTING Single-institution study, community hospital, Mar del Plata. Argentina. PATIENTS We studied 42 children, aged 6 months to 7 years, American Society of Anesthesiologists physical status class I, under standardised general anaesthesia. INTERVENTIONS Patients were randomised into two groups: Control group (n = 21): induction and emergence of anaesthesia without CPAP; and CPAP group (n = 21): 5 cmH2O of CPAP during induction and emergence of anaesthesia. Lung ultrasound (LUS) imaging was performed before and 5 min after anaesthesia induction. Children without atelectasis were ventilated in the same manner as the Control group with standard ventilatory settings including 5 cmH2O of PEEP. Children with atelectasis received a recruitment manoeuvre followed by standard ventilation with 8 cmH2O of PEEP. Then, at the end of surgery, LUS images were repeated before tracheal extubation and 60 min after awakening. MAIN OUTCOME MEASURES Lung aeration score and atelectasis assessed by LUS. RESULTS Before anaesthesia, all children were free of atelectasis. After induction, 95% in the Control group developed atelectasis compared with 52% of patients in the CPAP group (P < 0.0001). LUS aeration scores were higher (impaired aeration) in the Control group than the CPAP group (8.8 ± 3.8 vs. 3.5 ± 3.3 points; P < 0.0001). At the end of surgery, before tracheal extubation, atelectasis was observed in 100% of children in the Control and 29% of the CPAP group (P < 0.0001) with a corresponding aeration score of 9.6 ± 3.2 and 1.8 ± 2.3, respectively (P < 0.0001). After surgery, 30% of children in the Control group and 10% in the CPAP group presented with residual atelectasis (P < 0.0001) also corresponding to a higher aeration score in the Control group (2.5 ± 3.1) when compared with the CPAP group (0.5 ± 1.5; P < 0.01). CONCLUSION The use of 5 cmH2O of CPAP in healthy children of the studied age span during induction and emergence of anaesthesia effectively prevents atelectasis, with benefits maintained during the first postoperative hour. TRIAL REGISTRY Clinicaltrials.gov NCT03461770.
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Abstract
Respiratory function is fundamental in the practice of anesthesia. Knowledge of basic physiologic principles of respiration assists in the proper implementation of daily actions of induction and maintenance of general anesthesia, delivery of mechanical ventilation, discontinuation of mechanical and pharmacologic support, and return to the preoperative state. The current work provides a review of classic physiology and emphasizes features important to the anesthesiologist. The material is divided in two main sections, gas exchange and respiratory mechanics; each section presents the physiology as the basis of abnormal states. We review the path of oxygen from air to the artery and of carbon dioxide the opposite way, and we have the causes of hypoxemia and of hypercarbia based on these very footpaths. We present the actions of pressure, flow, and volume as the normal determinants of ventilation, and we review the resulting abnormalities in terms of changes of resistance and compliance.
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Carron M, Safaee Fakhr B, Ieppariello G, Foletto M. Perioperative care of the obese patient. Br J Surg 2020; 107:e39-e55. [DOI: 10.1002/bjs.11447] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/07/2019] [Indexed: 12/17/2022]
Abstract
Abstract
Background
Obesity has become an increasing problem worldwide during the past few decades. Hence, surgeons and anaesthetists will care for an increasing number of obese patients in the foreseeable future, and should be prepared to provide optimal management for these individuals. This review provides an update of recent evidence regarding perioperative strategies for obese patients.
Methods
A search for papers on the perioperative care of obese patients (English language only) was performed in July 2019 using the PubMed, Scopus, Web of Science and Cochrane Library electronic databases. The review focused on the results of RCTs, although observational studies, meta-analyses, reviews, guidelines and other reports discussing the perioperative care of obese patients were also considered. When data from obese patients were not available, relevant data from non-obese populations were used.
Results and conclusion
Obese patients require comprehensive preoperative evaluation. Experienced medical teams, appropriate equipment and monitoring, careful anaesthetic management, and an adequate perioperative ventilation strategy may improve postoperative outcomes. Additional perioperative precautions are necessary in patients with severe morbid obesity, metabolic syndrome, untreated or severe obstructive sleep apnoea syndrome, or obesity hypoventilation syndrome; patients receiving home ventilatory support or postoperative opioid therapy; and obese patients undergoing open operations, long procedures or revisional surgery.
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Affiliation(s)
- M Carron
- Department of Medicine – DIMED, Section of Anaesthesiology and Intensive Care, University of Padua, Padua, Italy
| | - B Safaee Fakhr
- Department of Medicine – DIMED, Section of Anaesthesiology and Intensive Care, University of Padua, Padua, Italy
| | - G Ieppariello
- Department of Medicine – DIMED, Section of Anaesthesiology and Intensive Care, University of Padua, Padua, Italy
| | - M Foletto
- Department of Surgical, Oncological and Gastroenterological Sciences, Section of Surgery, University of Padua, Padua, Italy
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10
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Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations. Br J Anaesth 2019; 123:898-913. [DOI: 10.1016/j.bja.2019.08.017] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/22/2019] [Accepted: 08/04/2019] [Indexed: 12/16/2022] Open
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Aceto P, Beretta L, Cariello C, Claroni C, Esposito C, Forastiere EM, Guarracino F, Perucca R, Romagnoli S, Sollazzi L, Cela V, Ercoli A, Scambia G, Vizza E, Ludovico GM, Sacco E, Vespasiani G, Scudeller L, Corcione A. Joint consensus on anesthesia in urologic and gynecologic robotic surgery: specific issues in management from a task force of the SIAARTI, SIGO, and SIU. Minerva Anestesiol 2019; 85:871-885. [PMID: 30938121 DOI: 10.23736/s0375-9393.19.13360-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Proper management of patients undergoing robotic-assisted urologic and gynecologic surgery must consider a series of peculiarities in the procedures for anesthesiology, critical care medicine, respiratory care, and pain management. Although the indications for robotic-assisted urogynecologic surgeries have increased in recent years, specific guidance documents are still lacking. EVIDENCE ACQUISITION A multidisciplinary group including anesthesiologists, gynecologists, urologists, and a clinical epidemiologist systematically reviewed the relevant literature and provided a set of recommendations and unmet needs on peculiar aspects of anesthesia in this field. EVIDENCE SYNTHESIS Nine core contents were identified, according to their requirements in urogynecologic robotic-assisted surgery: patient position, pneumoperitoneum and ventilation strategies, hemodynamic variations and fluid therapy, neuromuscular block, renal surgery and prevention of acute kidney injury, monitoring the Department of anesthesia, postoperative delirium and cognitive dysfunction, prevention of postoperative nausea and vomiting, and pain management in endometriosis. CONCLUSIONS This consensus document provides guidance for the management of urologic and gynecologic patients scheduled for robotic-assisted surgery. Moreover, the identified unmet needs highlight the requirement for further prospective randomized studies.
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Affiliation(s)
- Paola Aceto
- A. Gemelli University Polyclinic, IRCSS Foundation, Rome, Italy.,Sacred Heart Catholic University, Rome, Italy
| | - Luigi Beretta
- Unit of Anesthesiology and Intensive Care, IRCCS San Raffaele Hospital, Milan, Italy
| | - Claudia Cariello
- Department of Anesthesia and Critical Care Medicine, Cardiothoracic Anesthesia and Intensive Care, University Hospital of Pisa, Pisa, Italy
| | - Claudia Claroni
- Department of Anesthesiology, Regina Elena National Cancer Institute, Rome, Italy
| | - Clelia Esposito
- Department of Critical Care Area Monaldi Hospital, Ospedali dei Colli, Naples, Italy
| | - Ester M Forastiere
- Department of Anesthesiology, Regina Elena National Cancer Institute, Rome, Italy
| | - Fabio Guarracino
- Department of Anesthesia and Critical Care Medicine, Cardiothoracic Anesthesia and Intensive Care, University Hospital of Pisa, Pisa, Italy
| | - Raffaella Perucca
- Department of Anesthesia and Intensive Care, Maggiore della Carità Hospital, Novara, Italy
| | - Stefano Romagnoli
- Section of Anesthesia and Critical Care, Health Science Department, University of Florence, Florence, Italy.,Department of Anesthesia and Critical Care, Careggi Hospital, Florence, Italy
| | - Liliana Sollazzi
- A. Gemelli University Polyclinic, IRCSS Foundation, Rome, Italy.,Sacred Heart Catholic University, Rome, Italy
| | - Vito Cela
- Department of Clinical and Experimental Medicine, Obstetrics and Gynecology, Pisa University Hospital, Pisa, Italy
| | - Alfredo Ercoli
- Department of Obstetrics and Gynecology, Amedeo Avogadro University of Eastern Piedmont, Maggiore Hospital, Novara, Italy
| | - Giovanni Scambia
- A. Gemelli University Polyclinic, IRCSS Foundation, Rome, Italy.,Sacred Heart Catholic University, Rome, Italy
| | - Enrico Vizza
- Unit of Gynecologic Oncology, Department of Experimental Clinical Oncology, IRCCS - Regina Elena National Cancer Institute, Rome, Italy
| | - Giuseppe M Ludovico
- Department of Urology, F. Miulli Regional Hospital, Acquavivadelle Fonti, Bari, Italy
| | - Emilio Sacco
- Department of Urology, Sacred Heart Catholic University, A. Gemelli University Polyclinic, IRCSS Foundation, Rome, Italy
| | - Giuseppe Vespasiani
- Department of Experimental Medicine and Surgery, University Hospital of Tor Vergata, Rome, Italy
| | - Luigia Scudeller
- Unit of Clinical Epidemiology, San Matteo IRCSS Foundation, Pavia, Italy -
| | - Antonio Corcione
- Department of Critical Care Area Monaldi Hospital, Ospedali dei Colli, Naples, Italy
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Intraoperative ventilation settings and their associations with postoperative pulmonary complications in obese patients. Br J Anaesth 2018; 121:899-908. [DOI: 10.1016/j.bja.2018.04.021] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 03/05/2018] [Accepted: 04/18/2018] [Indexed: 11/22/2022] Open
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13
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Perioperative considerations for airway management and drug dosing in obese children. Curr Opin Anaesthesiol 2018; 31:320-326. [PMID: 29697466 DOI: 10.1097/aco.0000000000000600] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW Childhood obesity, a phenomenon that is increasing globally, holds substantial relevance for pediatric anesthesia. In particular, understanding the nuances of airway management and drug dosing in obese children can be daunting. RECENT FINDINGS Respiratory adverse events and challenges in managing the airway may be anticipated. In addition, drug-dosing strategies for the obese child are complex and poorly understood although recent advances have clarified the optimal dosing for anesthetics in these children. SUMMARY Theoretical knowledge, practical skills, meticulous risk stratification and optimal drug regimens are crucial to ensure the safe conduct of anesthesia for obese children.
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Abstract
PURPOSE OF REVIEW This article provides the reader with recent findings on the pathophysiology of comorbidities in the obese, as well as evidence-based treatment options to deal with perioperative respiratory challenges. RECENT FINDINGS Our understanding of obesity-associated asthma, obstructive sleep apnea, and obesity hypoventilation syndrome is still expanding. Routine screening for obstructive sleep apnea using the STOP-Bang score might identify high-risk patients that benefit from perioperative continuous positive airway pressure and close postoperative monitoring. Measures to most effectively support respiratory function during induction of and emergence from anesthesia include optimal patient positioning and use of noninvasive positive pressure ventilation. Appropriate mechanical ventilation settings are under investigation, so that only the use of protective low tidal volumes could be currently recommended. A multimodal approach consisting of adjuvants, as well as regional anesthesia/analgesia techniques reduces the need for systemic opioids and related respiratory complications. SUMMARY Anesthesia of obese patients for nonbariatric surgical procedures requires knowledge of typical comorbidities and their respective treatment options. Apart from cardiovascular diseases associated with the metabolic syndrome, awareness of any pulmonary dysfunction is of paramount. A multimodal analgesia approach may be useful to reduce postoperative pulmonary complications.
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Chacon MM, Cheruku SR, Neuburger PJ, Lester L, Shillcutt SK. Perioperative Care of the Obese Cardiac Surgical Patient. J Cardiothorac Vasc Anesth 2017; 32:1911-1921. [PMID: 29358013 DOI: 10.1053/j.jvca.2017.12.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Indexed: 02/06/2023]
Abstract
Morbid obesity is associated with impairment of cardiovascular, pulmonary, gastrointestinal, and renal physiology with significant perioperative consequences and has been linked with higher morbidity and mortality after cardiac surgery. Cardiac surgery patients have a higher incidence of difficult airway and difficult laryngoscopy than general surgery patients do, and obesity is associated with difficult mask ventilation and direct laryngoscopy. Positioning injuries occur more frequently because obese patients are at greater risk of pressure injury, such as rhabdomyolysis and compartment syndrome. Despite the association between obesity and several chronic disease states, the effects of obesity on perioperative outcomes are conflicting. Studies examining outcomes of overweight and obese patients in cardiac surgery have reported varying results. An "obesity paradox" has been described, in which the mortality for overweight and obese patients is lower compared with patients of normal weight. This review describes the physiologic abnormalities and clinical implications of obesity in cardiac surgery and summarizes recommendations for anesthesiologists to optimize perioperative care of the obese cardiac surgical patient.
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Are we fully utilizing the functionalities of modern operating room ventilators? Curr Opin Anaesthesiol 2017; 30:698-704. [PMID: 28938301 DOI: 10.1097/aco.0000000000000527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The modern operating room ventilators have become very sophisticated and many of their features are comparable with those of an ICU ventilator. To fully utilize the functionality of modern operating room ventilators, it is important for clinicians to understand in depth the working principle of these ventilators and their functionalities. RECENT FINDINGS Piston ventilators have the advantages of delivering accurate tidal volume and certain flow compensation functions. Turbine ventilators have great ability of flow compensation. Ventilation modes are mainly volume-based or pressure-based. Pressure-based ventilation modes provide better leak compensation than volume-based. The integration of advanced flow generation systems and ventilation modes of the modern operating room ventilators enables clinicians to provide both invasive and noninvasive ventilation in perioperative settings. Ventilator waveforms can be used for intraoperative neuromonitoring during cervical spine surgery. SUMMARY The increase in number of new features of modern operating room ventilators clearly creates the opportunity for clinicians to optimize ventilatory care. However, improving the quality of ventilator care relies on a complete understanding and correct use of these new features. VIDEO ABSTRACT: http://links.lww.com/COAN/A47.
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Choi ES, Oh AY, In CB, Ryu JH, Jeon YT, Kim HG. Effects of recruitment manoeuvre on perioperative pulmonary complications in patients undergoing robotic assisted radical prostatectomy: A randomised single-blinded trial. PLoS One 2017; 12:e0183311. [PMID: 28877238 PMCID: PMC5587235 DOI: 10.1371/journal.pone.0183311] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 07/20/2017] [Indexed: 01/28/2023] Open
Abstract
Robotic-assisted laparoscopic radical prostatectomy (RARP) needs a steep Trendelenburg position and a relatively high CO2 insufflation pressure, and patients undergoing RARP are usually elderly. These factors make intraoperative ventilatory care difficult and increase the risk of perioperative pulmonary complications. The aim was to determine the efficacy of recruitment manoeuvre (RM) on perioperative pulmonary complications in elderly patients undergoing RARP. A total of 60 elderly patients scheduled for elective RARP were randomly allocated to two groups after induction of anaesthesia; positive end expiratory pressure (PEEP) was applied during the operation without RM in the control group (group C) and after RM in the recruitment group (group R). The total number of patients who developed intraoperative desaturation or postoperative atelectasis was significantly higher in group C compared to group R (43.3% vs. 17.8%, P = 0.034). Intraoperative respiratory mechanics, perioperative blood gas analysis, and pulmonary function testing did not show differences between the groups. Adding RM to PEEP compared to PEEP alone significantly reduced perioperative pulmonary complications in elderly patients undergoing RARP.
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Affiliation(s)
- Eun-Su Choi
- Department of Anesthesiology and Pain Medicine, Nowon Eulji Medical Center, Eulji University, Seoul, Republic of Korea
| | - Ah-Young Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Chi-Bum In
- Department of Anesthesiology and Pain Medicine, Konyang University Hospital, Daejeon, Republic of Korea
| | - Jung-Hee Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Young-Tae Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hyoung-Gyun Kim
- Department of Anesthesiology and Pain Medicine, Nowon Eulji Medical Center, Eulji University, Seoul, Republic of Korea
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Ferrando C, Soro M, Unzueta C, Canet J, Tusman G, Suarez-Sipmann F, Librero J, Peiró S, Pozo N, Delgado C, Ibáñez M, Aldecoa C, Garutti I, Pestaña D, Rodríguez A, García del Valle S, Diaz-Cambronero O, Balust J, Redondo FJ, De La Matta M, Gallego L, Granell M, Martínez P, Pérez A, Leal S, Alday K, García P, Monedero P, Gonzalez R, Mazzinari G, Aguilar G, Villar J, Belda FJ. Rationale and study design for an individualised perioperative open-lung ventilatory strategy with a high versus conventional inspiratory oxygen fraction (iPROVE-O2) and its effects on surgical site infection: study protocol for a randomised controlled trial. BMJ Open 2017; 7:e016765. [PMID: 28760799 PMCID: PMC5642673 DOI: 10.1136/bmjopen-2017-016765] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Surgical site infection (SSI) is a serious postoperative complication that increases morbidity and healthcare costs. SSIs tend to increase as the partial pressure of tissue oxygen decreases: previous trials have focused on trying to reduce them by comparing high versus conventional inspiratory oxygen fractions (FIO2) in the perioperative period but did not use a protocolised ventilatory strategy. The open-lung ventilatory approach restores functional lung volume and improves gas exchange, and therefore it may increase the partial pressure of tissue oxygen for a given FIO2. The trial presented here aims to compare the efficacy of high versus conventional FIO2 in reducing the overall incidence of SSIs in patients by implementing a protocolised and individualised global approach to perioperative open-lung ventilation. METHODS AND ANALYSIS This is a comparative, prospective, multicentre, randomised and controlled two-arm trial that will include 756 patients scheduled for abdominal surgery. The patients will be randomised into two groups: (1) a high FIO2 group (80% oxygen; FIO2 of 0.80) and (2) a conventional FIO2 group (30% oxygen; FIO2 of 0.30). Each group will be assessed intra- and postoperatively. The primary outcome is the appearance of postoperative SSI complications. Secondary outcomes are the appearance of systemic and pulmonary complications. ETHICS AND DISSEMINATION The iPROVE-O2 trial has been approved by the Ethics Review Board at the reference centre (the Hospital Clínico Universitario in Valencia). Informed consent will be obtained from all patients before their participation. If the approach using high FIO2 during individualised open-lung ventilation decreases SSIs, use of this method will become standard practice for patients scheduled for future abdominal surgery. Publication of the results is anticipated in early 2019. TRIAL REGISTRATION NUMBER NCT02776046; Pre-results.
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Affiliation(s)
- Carlos Ferrando
- Department of Anesthesiology and Critical Care, Hospital Clínico Universitario, Valencia, Spain
| | - Marina Soro
- Department of Anesthesiology and Critical Care, Hospital Clínico Universitario, Valencia, Spain
| | - Carmen Unzueta
- Department of Anesthesiology and Critical Care, Hospital de la Santa Creu i Sant Pau, Valencia, Spain
| | - Jaume Canet
- Department of Anesthesiology and Critical Care, Hospital Germans Tries i Pujol, Badalona, Spain
| | - Gerardo Tusman
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar de Plata, Argentina
| | - Fernando Suarez-Sipmann
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Department of Surgical Sciences, Hedenstierna Laboratory, Uppsala University Hospital, Uppsala, Sweden
| | - Julian Librero
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Navarrabiomed Fundación Miguel Servet, Pamplona, Spain
| | - Salvador Peiró
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Centro Superior de Investigación en Salud Pública (CSISP FISABIO), Valencia, Spain
| | - Natividad Pozo
- Department of Anesthesiology and Critical Care, Hospital Clínico Universitario, Valencia, Spain
| | - Carlos Delgado
- Department of Anesthesiology and Critical Care, Hospital Clínico Universitario, Valencia, Spain
| | - Maite Ibáñez
- Department of Anesthesiology, Hospital de Villajoyosa, Villajoyosa, Spain
| | - César Aldecoa
- Department of Anesthesiology and Critical Care, Hospital de Villajoyosa, Villajoyosa, Spain
| | - Ignacio Garutti
- Department of Anesthesiology and Critical Care, Hospital General Gregorio Marañon, Madrid, Spain
| | - David Pestaña
- Anesthesiology and Critical Care, Hospital Ramón y Cajal, Madrid, Spain
| | - Aurelio Rodríguez
- Anesthesiology and Critical Care, Hospital Dr. Negrín, Gran Canaria, Spain
| | | | | | - Jaume Balust
- Anesthesiology and Critical Care, Hospital Clínic i Provincial, Barcelona, Spain
| | | | - Manuel De La Matta
- Anesthesiology and Critical Care, Hospital Vírgen del Rocio, Seville, Spain
| | - Lucía Gallego
- Anesthesiology and Critical Care, Hospital Miguel Servet, Zaragoza, Spain
| | - Manuel Granell
- Anesthesiology and Critical Care, Hospital General, Valencia, Spain
| | - Pascual Martínez
- Anesthesiology and Critical Care, Hospital de Albacete, Albacete, Spain
| | - Ana Pérez
- Anesthesiology and Critical Care, Hospital of Elche, Elche, Spain
| | - Sonsoles Leal
- Anesthesiology and Critical Care, Hospital Povisa, Vigo, Spain
| | - Kike Alday
- Anesthesiology and Critical Care, Hospital La Princesa, Madrid, Spain
| | - Pablo García
- Anesthesiology and Critical Care, Hospital 12 de Octubre, Madrid, Spain
| | - Pablo Monedero
- Anesthesiology and Critical Care, Clínica Universidad de Navarra, Pamplona, Spain
| | - Rafael Gonzalez
- Anesthesiology and Critical Care, Hospital Universitario de León, León, Spain
| | - Guido Mazzinari
- Anesthesiology and Critical Care, Hospital de Manises, Manises, Spain
| | - Gerardo Aguilar
- Department of Anesthesiology and Critical Care, Hospital Clínico Universitario, Valencia, Spain
| | - Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Gran Canaria, Spain
- Keenan Research Center for Biomedical Science at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Francisco Javier Belda
- Department of Anesthesiology and Critical Care, Hospital Clínico Universitario, Valencia, Spain
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Östberg E, Auner U, Enlund M, Zetterström H, Edmark L. Minimizing atelectasis formation during general anaesthesia-oxygen washout is a non-essential supplement to PEEP. Ups J Med Sci 2017; 122:92-98. [PMID: 28434271 PMCID: PMC5441378 DOI: 10.1080/03009734.2017.1294635] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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
BACKGROUND Following preoxygenation and induction of anaesthesia, most patients develop atelectasis. We hypothesized that an immediate restoration to a low oxygen level in the alveoli would prevent atelectasis formation and improve oxygenation during the ensuing anaesthesia. METHODS We randomly assigned 24 patients to either a control group (n = 12) or an intervention group (n = 12) receiving an oxygen washout procedure directly after intubation. Both groups were, depending on body mass index, ventilated with a positive end-expiratory pressure (PEEP) of 6-8 cmH2O during surgery. The atelectasis area was studied by computed tomography before emergence. Oxygenation levels were evaluated by measuring blood gases and calculating estimated venous admixture (EVA). RESULTS The atelectasis areas expressed as percentages of the total lung area were 2.0 (1.5-2.7) (median [interquartile range]) and 1.8 (1.4-3.3) in the intervention and control groups, respectively. The difference was non-significant, and also oxygenation was similar between the two groups. Compared to oxygenation before the start of anaesthesia, oxygenation at the end of surgery was improved in the intervention group, mean (SD) EVA from 7.6% (6.6%) to 3.9% (2.9%) (P = .019) and preserved in the control group, mean (SD) EVA from 5.0% (5.3%) to 5.6% (7.1%) (P = .59). CONCLUSION Although the oxygen washout restored a low pulmonary oxygen level within minutes, it did not further reduce atelectasis size. Both study groups had small atelectasis and good oxygenation. These results suggest that a moderate PEEP alone is sufficient to minimize atelectasis and maintain oxygenation in healthy patients.
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Affiliation(s)
- Erland Östberg
- Department of Anaesthesia and Intensive Care, Västerås and Köping Hospital, Västerås, Sweden
- CONTACT Erland Östberg Department of Anaesthesia and Intensive Care, Västerås and Köping Hospital, 721 89 Västerås, Sweden
| | - Udo Auner
- Department of Radiology, Västerås Hospital, Västerås, Sweden
| | - Mats Enlund
- Centre for Clinical Research, Västerås, Sweden
| | - Henrik Zetterström
- Department of Surgical Sciences, Anaesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Lennart Edmark
- Department of Anaesthesia and Intensive Care, Västerås and Köping Hospital, Västerås, Sweden
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Maia LDA, Silva PL, Pelosi P, Rocco PRM. Controlled invasive mechanical ventilation strategies in obese patients undergoing surgery. Expert Rev Respir Med 2017; 11:443-452. [PMID: 28436715 DOI: 10.1080/17476348.2017.1322510] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The obesity prevalence is increasing in surgical population. As the number of obese surgical patients increases, so does the demand for mechanical ventilation. Nevertheless, ventilatory strategies in this population are challenging, since obesity results in pathophysiological changes in respiratory function. Areas covered: We reviewed the impact of obesity on respiratory system and the effects of controlled invasive mechanical ventilation strategies in obese patients undergoing surgery. To date, there is no consensus regarding the optimal invasive mechanical ventilation strategy for obese surgical patients, and no evidence that possible intraoperative beneficial effects on oxygenation and mechanics translate into better postoperative pulmonary function or improved outcomes. Expert commentary: Before determining the ideal intraoperative ventilation strategy, it is important to analyze the pathophysiology and comorbidities of each obese patient. Protective ventilation with low tidal volume, driving pressure, energy, and mechanical power should be employed during surgery; however, further studies are required to clarify the most effective ventilation strategies, such as the optimal positive end-expiratory pressure and whether recruitment maneuvers minimize lung injury. In this context, an ongoing trial of intraoperative ventilation in obese patients (PROBESE) should help determine the mechanical ventilation strategy that best improves clinical outcome in patients with body mass index≥35kg/m2.
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Affiliation(s)
- Lígia de Albuquerque Maia
- a Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute , Federal University of Rio de Janeiro , Rio de Janeiro , Brazil
| | - Pedro Leme Silva
- a Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute , Federal University of Rio de Janeiro , Rio de Janeiro , Brazil.,b National Institute of Science and Technology for Regenerative Medicine , Rio de Janeiro , Brazil
| | - Paolo Pelosi
- c Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino-IST , University of Genoa , Genoa , Italy
| | - Patricia Rieken Macedo Rocco
- a Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute , Federal University of Rio de Janeiro , Rio de Janeiro , Brazil.,b National Institute of Science and Technology for Regenerative Medicine , Rio de Janeiro , Brazil
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