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El-Khatib M, Zeeni C, Shebbo FM, Karam C, Safi B, Toukhtarian A, Nafeh NA, Mkhayel S, Shadid CA, Chalhoub S, Beresian J. Intraoperative mechanical power and postoperative pulmonary complications in low-risk surgical patients: a prospective observational cohort study. BMC Anesthesiol 2024; 24:82. [PMID: 38413871 PMCID: PMC10898029 DOI: 10.1186/s12871-024-02449-1] [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: 11/24/2023] [Accepted: 02/08/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Inadequate intraoperative mechanical ventilation (MV) can lead to ventilator-induced lung injury and increased risk for postoperative pulmonary complications (PPCs). Mechanical power (MP) was shown to be a valuable indicator for MV outcomes in critical care patients. The aim of this study is to assess the association between intraoperative MP in low-risk surgical patients undergoing general anesthesia and PPCs. METHODS Two-hundred eighteen low-risk surgical patients undergoing general anesthesia for elective surgery were included in the study. Intraoperative mechanical ventilatory support parameters were collected for all patients. Postoperatively, patients were followed throughout their hospital stay and up to seven days post discharge for the occurrence of any PPCs. RESULTS Out of 218 patients, 35% exhibited PPCs. The average body mass index, tidal volume per ideal body weight, peak inspiratory pressure, and MP were significantly higher in the patients with PPCs than in the patients without PPCs (30.3 ± 8.1 kg/m2 vs. 26.8 ± 4.9 kg.m2, p < 0.001; 9.1 ± 1.9 ml/kg vs. 8.6 ± 1.4 ml/kg, p = 0.02; 20 ± 4.9 cmH2O vs. 18 ± 3.7 cmH2O, p = 0.001; 12.9 ± 4.5 J/min vs. 11.1 ± 3.7 J/min, p = 0.002). A multivariable regression analysis revealed MP as the sole significant predictor for the risk of postoperative pulmonary complications [OR 1.1 (95% CI 1.0-1.2, p = 0.036]. CONCLUSIONS High intraoperative mechanical power is a risk factor for developing postoperative pulmonary complications. Furthermore, intraoperative mechanical power is superior to other traditional mechanical ventilation variables in identifying surgical patients who are at risk for developing postoperative pulmonary complications. CLINICAL TRIAL REGISTRATION NCT03551899; 24/02/2017.
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Affiliation(s)
- Mohamad El-Khatib
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Carine Zeeni
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Fadia M Shebbo
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Cynthia Karam
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Bilal Safi
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Aline Toukhtarian
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Nancy Abou Nafeh
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Samar Mkhayel
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Carol Abi Shadid
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Sana Chalhoub
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jean Beresian
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon.
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Wilson MG, Adams CN, Turnbull MD, Falyar CR, Harris EM, Thompson JA, Simmons VC. Improving Certified Registered Nurse Anesthetists' Adherence to a Standardized Intraoperative Lung Protective Ventilation Protocol. J Perianesth Nurs 2023; 38:845-850. [PMID: 37589630 DOI: 10.1016/j.jopan.2022.12.005] [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: 08/26/2022] [Revised: 12/08/2022] [Accepted: 12/11/2022] [Indexed: 08/18/2023]
Abstract
PURPOSE The use of lung protective ventilation (LPV) during general anesthesia is an effective strategy among certified registered nurse anesthetists (CRNAs) to reduce and prevent the incidence of postoperative pulmonary complications. The purpose of this project was to implement a LPV protocol, assess CRNA provider adherence, and investigate differences in ventilation parameters and postoperative oxygen requirements. DESIGN This quality improvement project was conducted using a pre- and postimplementation design. METHODS Sixty patients undergoing robotic laparoscopic abdominal surgery and 35 CRNAs at a community hospital participated. An evidence-based intraoperative LPV protocol was developed, CRNA education was provided, and the protocol was implemented. Pre- and postimplementation, CRNA knowledge, and confidence were assessed. Ventilation data were collected at 1-minute intervals intraoperatively and oxygen requirements were recorded in the postanesthesia care unit (PACU). FINDINGS Use of intraoperative LPV strategies increased 2.4%. Overall CRNA knowledge (P = .588), confidence (P = .031), and practice (P < .001) improved from pre- to postimplementation. Driving pressures decreased from pre- to postimplementation (P < .001). Supplemental oxygen use on admission to the PACU decreased from 93.3% to 70.0%. CONCLUSIONS Educational interventions and implementation of a standardized protocol can improve the use of intraoperative LPV strategies and patient outcomes.
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Affiliation(s)
- Megan G Wilson
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC
| | - Cara N Adams
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC
| | - Matthew D Turnbull
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC
| | - Christian R Falyar
- Middle Tennesee Acute Surgical Pain Management Fellowship, Middle Tennesee School of Anesthesia, Madison, TN
| | - Erica M Harris
- Duke University Anesthesia Department, Duke University Medical Center, Durham, NC
| | - Julie A Thompson
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC
| | - Virginia C Simmons
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC.
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Yessenbayeva GA, Yukhnevich YA, Khamitova ZK, Kim SI, Zhumabayev MB, Berdiyarova GS, Shalekenov SB, Mukatova IY, Yaroshetskiy AI. Impact of a positive end-expiratory pressure strategy on oxygenation, respiratory compliance, and hemodynamics during laparoscopic surgery in non-obese patients: a systematic review and meta-analysis of randomized controlled trials. BMC Anesthesiol 2023; 23:371. [PMID: 37950169 PMCID: PMC10638810 DOI: 10.1186/s12871-023-02337-0] [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: 05/15/2023] [Accepted: 11/04/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Higher positive end-expiratory pressure (PEEP) during laparoscopic surgery may increase oxygenation and respiratory compliance. This meta-analysis aimed to compare the impact of different intraoperative PEEP strategies on arterial oxygenation, compliance, and hemodynamics during laparoscopic surgery in non-obese patients. METHODS We searched RCTs in PubMed, Cochrane Library, Web of Science, and Google Scholar from January 2012 to April 2022 comparing the different intraoperative PEEP (Low PEEP (LPEEP): 0-4 mbar; Moderate PEEP (MPEEP): 5-8 mbar; high PEEP (HPEEP): >8 mbar; individualized PEEP - iPEEP) on arterial oxygenation, respiratory compliance (Cdyn), mean arterial pressure (MAP), and heart rate (HR). We calculated mean differences (MD) with 95% confidence intervals (CI), and predictive intervals (PI) using random-effects models. The Cochrane Bias Risk Assessment Tool was applied. RESULTS 21 RCTs (n = 1554) met the inclusion criteria. HPEEP vs. LPEEP increased PaO2 (+ 29.38 [16.20; 42.56] mmHg, p < 0.0001) or PaO2/FiO2 (+ 36.7 [+ 2.23; +71.70] mmHg, p = 0.04). HPEEP vs. MPEEP increased PaO2 (+ 22.00 [+ 1.11; +42.88] mmHg, p = 0.04) or PaO2/FiO2 (+ 42.7 [+ 2.74; +82.67] mmHg, p = 0.04). iPEEP vs. MPEEP increased PaO2/FiO2 (+ 115.2 [+ 87.21; +143.20] mmHg, p < 0.001). MPEEP vs. LPEP, and HPEEP vs. MPEEP increased PaO2 or PaO2/FiO2 significantly with different heterogeneity. HPEEP vs. LPEEP increased Cdyn (+ 7.87 [+ 1.49; +14.25] ml/mbar, p = 0.02). MPEEP vs. LPEEP, and HPEEP vs. MPEEP did not impact Cdyn (p = 0.14 and 0.38, respectively). iPEEP vs. LPEEP decreased driving pressure (-4.13 [-2.63; -5.63] mbar, p < 0.001). No significant differences in MAP or HR were found between any subgroups. CONCLUSION HPEEP and iPEEP during PNP in non-obese patients could promote oxygenation and increase Cdyn without clinically significant changes in MAP and HR. MPEEP could be insufficient to increase respiratory compliance and improve oxygenation. LPEEP may lead to decreased respiratory compliance and worsened oxygenation. PROSPERO REGISTRATION CRD42022362379; registered October 09, 2022.
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Affiliation(s)
| | | | | | - Sergey I Kim
- Multidisciplinary hospitals named after Professor H.J.Makazhanov, Karaganda, Kazakhstan
| | - Murat B Zhumabayev
- National Research Oncology Center, Astana, Kazakhstan
- Astana Medical University, Astana, Kazakhstan
| | | | | | | | - Andrey I Yaroshetskiy
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University, 8/2, Trubetskaya str. 119991, Moscow, Russia.
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Liao YQ, Min J, Wu ZX, Hu Z. Comparison of the effects of remimazolam and dexmedetomidine on early postoperative cognitive function in elderly patients with gastric cancer. Front Aging Neurosci 2023; 15:1123089. [PMID: 37342357 PMCID: PMC10277633 DOI: 10.3389/fnagi.2023.1123089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 05/16/2023] [Indexed: 06/22/2023] Open
Abstract
Purpose To compare the effects of remimazolam and dexmedetomidine on early postoperative cognitive dysfunction (POCD) in aged gastric cancer patients. Methods From June to December 2022, 104 elderly patients (aged 65-80 years) received laparoscopic radical resection of gastric cancer at the First Affiliated Hospital of Nanchang University. Using the random number table approach, the patients were separated into three groups: remimazolam (Group R), dexmedetomidine (Group D), and saline (Group C). The primary outcome was the incidence of POCD, and secondary outcomes included TNF-α and S-100β protein concentrations, hemodynamics, VAS scores, anesthesia recovery indicators, and the occurrence of adverse events within 48 h postoperatively. Results At 3 and 7 days after surgery, there were no statistically significant differences in the incidence of POCD, the MMSE and MoCA scores between groups R and D (p > 0.05). However, compared to the saline group, both groups had higher MMSE and MoCA scores and decreased incidences of POCD. These differences were statistically significant (p < 0.05). Between group R and group D, there were no statistically significant changes (p > 0.05) in the levels of TNF-α and S-100β protein at the three time points (at the end of the surgery, 1 day later, and 3 days later). Even though neither group's concentration of the two factors was as high as that of the saline group, the differences were statistically significant (p < 0.05). At all three time points-following induction (T2), 30 min into the operation (T3), and at the conclusion of the surgery (T4)-the heart rate and blood pressure in group R were greater than those in groups D and C. Statistics showed that the differences were significant (p < 0.05). The incidence of intraoperative hypotension was highest in group D and lowest in group R (p < 0.05). The dose of propofol and remifentanil, group C > group R > group D. Extubation and PACU residence times did not differ statistically significantly (p > 0.05) between the three groups. There was no significant difference in VAS scores between groups R and D after 24 h postoperatively (p > 0.05), although both had lower scores than group C, and the difference was statistically significant (p < 0.05). The VAS scores between the three groups at 72 h (T6) and 7 days (T7) were not statistically significant (p > 0.05). Adverse reactions such as respiratory depression, hypotension, bradycardia, agitation, drowsiness, and nausea and vomiting had the lowest incidence in group R and the highest incidence in group C (p < 0.05). Conclusion Remimazolam is similarly beneficial as dexmedetomidine in lowering the incidence of early POCD in aged patients after radical gastric cancer resection, probably due to reduced inflammatory response.
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Low tidal volume ventilation for patients undergoing laparoscopic surgery: a secondary analysis of a randomised clinical trial. BMC Anesthesiol 2023; 23:71. [PMID: 36882701 PMCID: PMC9990198 DOI: 10.1186/s12871-023-01998-1] [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: 06/17/2022] [Accepted: 01/30/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND We recently reported the results for a large randomized controlled trial of low tidal volume ventilation (LTVV) versus conventional tidal volume (CTVV) during major surgery when positive end expiratory pressure (PEEP) was equal between groups. We found no difference in postoperative pulmonary complications (PPCs) in patients who received LTVV. However, in the subgroup of patients undergoing laparoscopic surgery, LTVV was associated with a numerically lower rate of PPCs after surgery. We aimed to further assess the relationship between LTVV versus CTVV during laparoscopic surgery. METHODS We conducted a post-hoc analysis of this pre-specified subgroup. All patients received volume-controlled ventilation with an applied PEEP of 5 cmH2O and either LTVV (6 mL/kg predicted body weight [PBW]) or CTVV (10 mL/kg PBW). The primary outcome was the incidence of a composite of PPCs within seven days. RESULTS Three hundred twenty-eight patients (27.2%) underwent laparoscopic surgeries, with 158 (48.2%) randomised to LTVV. Fifty two of 157 patients (33.1%) assigned to LTVV and 72 of 169 (42.6%) assigned to conventional tidal volume developed PPCs within 7 days (unadjusted absolute difference, - 9.48 [95% CI, - 19.86 to 1.05]; p = 0.076). After adjusting for pre-specified confounders, the LTVV group had a lower incidence of the primary outcome than patients receiving CTVV (adjusted absolute difference, - 10.36 [95% CI, - 20.52 to - 0.20]; p = 0.046). CONCLUSION In this post-hoc analysis of a large, randomised trial of LTVV we found that during laparoscopic surgeries, LTVV was associated with a significantly reduced PPCs compared to CTVV when PEEP was applied equally between both groups. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry no: 12614000790640.
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Bolther M, Henriksen J, Holmberg MJ, Jessen MK, Vallentin MF, Hansen FB, Holst JM, Magnussen A, Hansen NS, Johannsen CM, Enevoldsen J, Jensen TH, Roessler LL, Carøe Lind P, Klitholm MP, Eggertsen MA, Caap P, Boye C, Dabrowski KM, Vormfenne L, Høybye M, Karlsson M, Balleby IR, Rasmussen MS, Pælestik K, Granfeldt A, Andersen LW. Ventilation Strategies During General Anesthesia for Noncardiac Surgery: A Systematic Review and Meta-Analysis. Anesth Analg 2022; 135:971-985. [PMID: 35703253 DOI: 10.1213/ane.0000000000006106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The optimal ventilation strategy during general anesthesia is unclear. This systematic review investigated the relationship between ventilation targets or strategies (eg, positive end-expiratory pressure [PEEP], tidal volume, and recruitment maneuvers) and postoperative outcomes. METHODS PubMed and Embase were searched on March 8, 2021, for randomized trials investigating the effect of different respiratory targets or strategies on adults undergoing noncardiac surgery. Two investigators reviewed trials for relevance, extracted data, and assessed risk of bias. Meta-analyses were performed for relevant outcomes, and several subgroup analyses were conducted. The certainty of evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS This review included 63 trials with 65 comparisons. Risk of bias was intermediate for all trials. In the meta-analyses, lung-protective ventilation (ie, low tidal volume with PEEP) reduced the risk of combined pulmonary complications (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.28-0.49; 9 trials; 1106 patients), atelectasis (OR, 0.39; 95% CI, 0.25-0.60; 8 trials; 895 patients), and need for postoperative mechanical ventilation (OR, 0.36; 95% CI, 0.13-1.00; 5 trials; 636 patients). Recruitment maneuvers reduced the risk of atelectasis (OR, 0.44; 95% CI, 0.21-0.92; 5 trials; 328 patients). We found no clear effect of tidal volume, higher versus lower PEEP, or recruitment maneuvers on postoperative pulmonary complications when evaluated individually. For all comparisons across targets, no effect was found on mortality or hospital length of stay. No effect measure modifiers were found in subgroup analyses. The certainty of evidence was rated as very low, low, or moderate depending on the intervention and outcome. CONCLUSIONS Although lung-protective ventilation results in a decrease in pulmonary complications, randomized clinical trials provide only limited evidence to guide specific ventilation strategies during general anesthesia for adults undergoing noncardiac surgery.
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Affiliation(s)
- Maria Bolther
- From the Department of Anesthesiology and Intensive Care
| | | | - Mathias J Holmberg
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Cardiology, Viborg Regional Hospital, Viborg, Denmark
| | - Marie K Jessen
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mikael F Vallentin
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
| | | | | | | | | | | | | | - Thomas H Jensen
- Department of Internal Medicine, University Hospital of North Norway, Narvik, Norway
| | - Lara L Roessler
- Department of Emergency Medicine, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | | | - Mark A Eggertsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Philip Caap
- From the Department of Anesthesiology and Intensive Care
| | - Caroline Boye
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Lasse Vormfenne
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Maria Høybye
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Mathias Karlsson
- Anesthesiology and Intensive Care, Aalborg University Hospital, Denmark
| | - Ida R Balleby
- National Hospital of the Faroe Islands, Torshavn, Faroe Islands
| | - Marie S Rasmussen
- Anesthesiology and Intensive Care, Aalborg University Hospital, Denmark
| | - Kim Pælestik
- Department of Anesthesiology and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
| | - Asger Granfeldt
- From the Department of Anesthesiology and Intensive Care.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lars W Andersen
- From the Department of Anesthesiology and Intensive Care.,Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
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Pei S, Wei W, Yang K, Yang Y, Pan Y, Wei J, Yao S, Xia H. Recruitment Maneuver to Reduce Postoperative Pulmonary Complications after Laparoscopic Abdominal Surgery: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11195841. [PMID: 36233708 PMCID: PMC9573602 DOI: 10.3390/jcm11195841] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 11/09/2022] Open
Abstract
Background: Lung-protective ventilation strategies are recommended for patients undergoing mechanical ventilation. However, there are currently no guidelines to follow regarding recruitment maneuvers (RMs). We attempted to identify the effects of RMs on patients undergoing laparoscopic abdominal surgery. Methods: We searched for randomized controlled trials (RCTs) in PubMed, the Cochrane Library databases, Embase, Web of Science and the ClinicalTrials.gov registry for trials published up to December 2021. The primary outcome was postoperative pulmonary complications (PPCs). The secondary outcomes consisted of the static lung compliance, driving pressure (DP), intraoperative oxygenation index (OI), OI in the post-anesthesia care unit (PACU), mean arterial pressure (MAP) and heart rate (HR). Seventeen RCTs with a total of 3480 patients were examined. Results: Patients who received RMs showed a considerable reduction in PPCs (risk ratio (RR) = 0.70; 95% confidence interval (CI): 0.62 to 0.79; p < 0.01), lower DP (weighted mean difference (WMD) = −3.96; 95% CI: −5.97 to −1.95; p < 0.01), elevated static lung compliance (WMD = 10.42; 95% CI: 6.13 to 14.71; p < 0.01) and improved OI (intraoperative: WMD = 53.54; 95% CI: 21.77 to 85.31; p < 0.01; PACU: WMD = 59.40; 95% CI: 39.10 to 79.69; p < 0.01) without substantial changes in MAP (WMD = −0.16; 95% CI −1.35 to 1.03; p > 0.05) and HR (WMD = −1.10; 95% CI: −2.29 to 0.10; p > 0.05). Conclusions: Recruitment maneuvers reduce postoperative pulmonary complications and improve respiratory mechanics and oxygenation in patients undergoing laparoscopic abdominal surgery. More data are needed to elucidate the effect of recruitment maneuver on the circulatory system.
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Affiliation(s)
- Shuaijie Pei
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Wei Wei
- Department of Anesthesiology, The People’s Hospital of Honghu, Honghu 433200, China
| | - Kai Yang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yiyi Yang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yu Pan
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Jinrui Wei
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Shanglong Yao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Correspondence: (S.Y.); (H.X.)
| | - Haifa Xia
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Department of Anesthesiology, The People’s Hospital of Honghu, Honghu 433200, China
- Department of Critical Care Medicine, The People’s Hospital of Honghu, Honghu 433200, China
- Correspondence: (S.Y.); (H.X.)
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Xu Q, Guo X, Liu J, Li SX, Ma HR, Wang FX, Lin JY. Effects of dynamic individualized PEEP guided by driving pressure in laparoscopic surgery on postoperative atelectasis in elderly patients: a prospective randomized controlled trial. BMC Anesthesiol 2022; 22:72. [PMID: 35296253 PMCID: PMC8925066 DOI: 10.1186/s12871-022-01613-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 03/07/2022] [Indexed: 11/16/2022] Open
Abstract
Background Driving pressure (ΔP = Plateau pressure-PEEP) is highly correlated with postoperative pulmonary complications (PPCs) and appears to be a promising indicator for optimizing ventilator settings. We hypothesized that dynamic, individualized positive end-expiratory pressure (PEEP) guided by ΔP could reduce postoperative atelectasis and improve intraoperative oxygenation, respiratory mechanics, and reduce the incidence of PPCs on elderly patients undergoing laparoscopic surgery. Methods Fifty-one elderly patients who were subject to laparoscopic surgery participated in this randomized trial. In the PEEP titration group (DV group), the PEEP titration was decremented to the lowest ΔP and repeated every 1 h. Additional procedures were also performed when performing predefined events that may be associated with lung collapse. In the constant PEEP group (PV group), a PEEP of 6 cmH2O was used throughout the surgery. Moreover, zero PEEP was applied during the entire procedure in the conventional ventilation group (CV group). The primary objective of this study was lung ultrasound score noted at the end of surgery and 15 min after admission to the post-anesthesia care unit (PACU) at 12 lung areas bilaterally. The secondary endpoints were perioperative oxygenation function, expiratory mechanics, and the incidence of the PPCs. Results The lung ultrasound scores of the DV group were significantly lower than those in the PV group and CV group (P < 0.05), whereas there was no significant difference between the PV group and CV group (P > 0.05). The lung static compliance (Cstat) and ΔP at all the intraoperative time points in the DV group were significantly better compared to the PV group and the CV group (p < 0.05). Conclusions Intraoperative titrated PEEP reduced postoperative lung atelectasis and improved respiratory mechanics in elderly patients undergoing laparoscopic surgery. Meanwhile, standard PEEP strategy is not superior to conventional ventilation in reducing postoperative pulmonary atelectasis in laparoscopic surgery.
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Affiliation(s)
- Qi Xu
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Xiao Guo
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Jiang Liu
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Si-Xun Li
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Hai-Rui Ma
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Fei-Xiang Wang
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Jing-Yan Lin
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, Sichuan, China. .,Department of Anesthesiology, North Sichuan Medical College, Nanchong, 637000, Sichuan, China.
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Zhou J, Wang C, Lv R, Liu N, Huang Y, Wang W, Yu L, Xie J. Protective mechanical ventilation with optimal PEEP during RARP improves oxygenation and pulmonary indexes. Trials 2021; 22:351. [PMID: 34011404 PMCID: PMC8135157 DOI: 10.1186/s13063-021-05310-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 05/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This trial aimed to evaluate the effects of a protective ventilation strategy on oxygenation/pulmonary indexes in patients undergoing robot-assisted radical prostatectomy (RARP) in the steep Trendelenburg position. METHODS In phase 1, the most optimal positive end-expiratory pressure (PEEP) was determined in 25 patients at 11 cmH2O. In phase 2, 64 patients were randomized to the traditional ventilation group with tidal volume (VT) of 9 ml/kg of predicted body weight (PBW) and the protective ventilation group with VT of 7 ml/kg of PBW with optimal PEEP and recruitment maneuvers (RMs). The primary endpoint was the intraoperative and postoperative PaO2/FiO2. The secondary endpoints were the PaCO2, SpO2, modified clinical pulmonary infection score (mCPIS), and the rate of complications in the postoperative period. RESULTS Compared with controls, PaO2/FiO2 in the protective group increased after the second RM (P=0.018), and the difference remained until postoperative day 3 (P=0.043). PaCO2 showed transient accumulation in the protective group after the first RM (T2), but this phenomenon disappeared with time. SpO2 in the protective group was significantly higher during the first three postoperative days. Lung compliance was significantly improved after the second RM in the protective group (P=0.025). The mCPIS was lower in the protective group on postoperative day 3 (0.59 (1.09) vs. 1.46 (1.27), P=0.010). CONCLUSION A protective ventilation strategy with lower VT combined with optimal PEEP and RMs could improve oxygenation and reduce mCPIS in patients undergoing RARP. TRIAL REGISTRATION ChiCTR ChiCTR1800015626 . Registered on 12 April 2018.
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Affiliation(s)
- Jianwei Zhou
- Department of Anesthesia, Lishui Hospital, School of Medicine, Zhejiang University, kuocang Road 289, Lishui, 323000, Zhejiang, China
| | - Chuanguang Wang
- Department of Anesthesia, Lishui Hospital, School of Medicine, Zhejiang University, kuocang Road 289, Lishui, 323000, Zhejiang, China
| | - Ran Lv
- Department of Anesthesia, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, East Qingchun Road 3, Hangzhou, 310016, Zhejiang, China
| | - Na Liu
- Department of Anesthesia, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, East Qingchun Road 3, Hangzhou, 310016, Zhejiang, China
| | - Yan Huang
- Department of Anesthesia, Lishui Hospital, School of Medicine, Zhejiang University, kuocang Road 289, Lishui, 323000, Zhejiang, China
| | - Wu Wang
- Department of Anesthesia, Lishui Hospital, School of Medicine, Zhejiang University, kuocang Road 289, Lishui, 323000, Zhejiang, China
| | - Lina Yu
- Department of Anesthesia, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, Zhejiang, China
| | - Junran Xie
- Department of Anesthesia, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, East Qingchun Road 3, Hangzhou, 310016, Zhejiang, China.
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10
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Nguyen TK, Mai DH, Le AN, Nguyen QH, Nguyen CT, Vu TA. A review of intraoperative lung-protective mechanical ventilation strategy. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.1016/j.tacc.2020.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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11
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Nguyen TK, Nguyen VL, Nguyen TG, Mai DH, Nguyen NQ, Vu TA, Le AN, Nguyen QH, Nguyen CT, Nguyen DT. Lung-protective mechanical ventilation for patients undergoing abdominal laparoscopic surgeries: a randomized controlled trial. BMC Anesthesiol 2021; 21:95. [PMID: 33784987 PMCID: PMC8008676 DOI: 10.1186/s12871-021-01318-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 03/17/2021] [Indexed: 11/10/2022] Open
Abstract
Background Pneumoperitoneum and Trendelenburg position in laparoscopic surgeries could contribute to postoperative pulmonary dysfunction. In recent years, intraoperative lung-protective mechanical ventilation (LPV) has been reportedly able to attenuate ventilator-induced lung injuries (VILI). Our objectives were to test the hypothesis that LPV could improve intraoperative oxygenation function, pulmonary mechanics and early postoperative atelectasis in laparoscopic surgeries. Methods In this randomized controlled clinical trial, 62 patients indicated for elective abdominal laparoscopic surgeries with an expected duration of greater than 2 h were randomly assigned to receive either lung-protective ventilation (LPV) with a tidal volume (Vt) of 7 ml kg− 1 ideal body weight (IBW), 10 cmH2O positive end-expiratory pressure (PEEP) combined with regular recruitment maneuvers (RMs) or conventional ventilation (CV) with a Vt of 10 ml kg− 1 IBW, 0 cmH2O in PEEP and no RMs. The primary endpoints were the changes in the ratio of PaO2 to FiO2 (P/F). The secondary endpoints were the differences between the two groups in PaO2, alveolar-arterial oxygen gradient (A-aO2), intraoperative pulmonary mechanics and the incidence of atelectasis detected on chest x-ray on the first postoperative day. Results In comparison to CV group, the intraoperative P/F and PaO2 in LPV group were significantly higher while the intraoperative A-aO2 was clearly lower. Cdyn and Cstat at all the intraoperative time points in LPV group were significantly higher compared to CV group (p < 0.05). There were no differences in the incidence of atelectasis on day one after surgery between the two groups. Conclusions Lung protective mechanical ventilation significantly improved intraoperative pulmonary oxygenation function and pulmonary compliance in patients experiencing various abdominal laparoscopic surgeries, but it could not ameliorate early postoperative atelectasis and oxygenation function on the first day after surgery. Trial registration https://www.clinicaltrials.gov/identifier: NCT04546932 (09/05/2020).
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Affiliation(s)
- Trung Kien Nguyen
- Center of Emergency, Critical Care Medicine and Clinical Toxicology, 103 Military Hospital, Vietnam Military Medical University, 261 Phung Hung road, Ha Dong District, Hanoi City, Vietnam
| | - Viet Luong Nguyen
- Critical Care Unit, National Burn Hospital, Vietnam Military Medical University, Hanoi, Vietnam
| | - Truong Giang Nguyen
- Department of Cardiothoracic surgery, 103 Military Hospital, Vietnam Military Medical University, Hanoi, Vietnam
| | - Duc Hanh Mai
- Department of Anesthesia and Pain Medicine, 103 Military Hospital, Vietnam Military Medical University, Hanoi, Vietnam
| | - Ngoc Quynh Nguyen
- Department of Anesthesia and Pain Medicine, Vietnam National Cancer Hospital, Hanoi, Vietnam
| | - The Anh Vu
- Department of Anesthesia and Pain Medicine, 103 Military Hospital, Vietnam Military Medical University, Hanoi, Vietnam.
| | - Anh Nguyet Le
- Department of Urology, 103 Military Hospital, Vietnam Military Medical University, Hanoi, Vietnam
| | - Quang Huy Nguyen
- Center of Emergency, Critical Care Medicine and Clinical Toxicology, 103 Military Hospital, Vietnam Military Medical University, 261 Phung Hung road, Ha Dong District, Hanoi City, Vietnam
| | - Chi Tue Nguyen
- Center of Emergency, Critical Care Medicine and Clinical Toxicology, 103 Military Hospital, Vietnam Military Medical University, 261 Phung Hung road, Ha Dong District, Hanoi City, Vietnam
| | - Dang Thu Nguyen
- Department of Anesthesia and Pain Medicine, 103 Military Hospital, Vietnam Military Medical University, Hanoi, Vietnam
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12
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Ruszkai Z, Kiss E, László I, Bokrétás GP, Vizserálek D, Vámossy I, Surány E, Buzogány I, Bajory Z, Molnár Z. Effects of intraoperative positive end-expiratory pressure optimization on respiratory mechanics and the inflammatory response: a randomized controlled trial. J Clin Monit Comput 2020; 35:469-482. [PMID: 32388650 PMCID: PMC7222900 DOI: 10.1007/s10877-020-00519-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 05/04/2020] [Indexed: 12/18/2022]
Abstract
Applying lung protective mechanical ventilation (LPV) during general anaesthesia even in patients with non-injured lungs is recommended. However, the effects of an individual PEEP-optimisation on respiratory mechanics, oxygenation and their potential correlation with the inflammatory response and postoperative complications have not been evaluated have not been compared to standard LPV in patients undergoing major abdominal surgery. Thirty-nine patients undergoing open radical cystectomy were enrolled in this study. In the study group (SG) optimal PEEP was determined by a decremental titration procedure and defined as the PEEP value resulting the highest static pulmonary compliance. In the control group (CG) PEEP was set to 6 cmH2O. Primary endpoints were intraoperative respiratory mechanics and gas exchange parameters. Secondary outcomes were perioperative procalcitonin kinetics and postoperative pulmonary complications. Optimal PEEP levels (median = 10, range: 8–14 cmH2O), PaO2/FiO2 (451.24 ± 121.78 mmHg vs. 404.15 ± 115.87 mmHg, P = 0.005) and static pulmonary compliance (52.54 ± 13.59 ml cmH2O-1 vs. 45.22 ± 9.13 ml cmH2O-1, P < 0.0001) were significantly higher, while driving pressure (8.26 ± 1.74 cmH2O vs. 9.73 ± 4.02 cmH2O, P < 0.0001) was significantly lower in the SG as compared to the CG. No significant intergroup differences were found in procalcitonin kinetics (P = 0.076). Composite outcome results indicated a non-significant reduction of postoperative complications in the SG. Intraoperative PEEP-optimization resulted in significant improvement in gas exchange and pulmonary mechanics as compared to standard LPV. Whether these have any effect on short and long term outcomes require further investigations. Trial registration: Clinicaltrials.gov, identifier: NCT02931409.
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Affiliation(s)
- Zoltán Ruszkai
- Department of Anaesthesiology and Intensive Therapy, Pest Megyei Flór Ferenc Hospital, Semmelweis Square 1, Kistarcsa, 2143, Hungary.
| | - Erika Kiss
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Semmelweis Street 6, Szeged, 6725, Hungary
| | - Ildikó László
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Semmelweis Street 6, Szeged, 6725, Hungary
| | - Gergely Péter Bokrétás
- Department of Anaesthesiology and Intensive Therapy, Péterfy Sándor Hospital, Péterfy Sándor Street 8-20, Budapest, 1076, Hungary
| | - Dóra Vizserálek
- Department of Anaesthesiology and Intensive Therapy, Péterfy Sándor Hospital, Péterfy Sándor Street 8-20, Budapest, 1076, Hungary
| | - Ildikó Vámossy
- Department of Anaesthesiology and Intensive Therapy, Péterfy Sándor Hospital, Péterfy Sándor Street 8-20, Budapest, 1076, Hungary
| | - Erika Surány
- Department of Anaesthesiology and Intensive Therapy, Péterfy Sándor Hospital, Péterfy Sándor Street 8-20, Budapest, 1076, Hungary
| | - István Buzogány
- Department of Urology, Péterfy Sándor Hospital, Péterfy Sándor Street 8-20, Budapest, 1076, Hungary
| | - Zoltán Bajory
- Department of Urology, University of Szeged, Kálvária Avenue 57, Szeged, 6725, Hungary
| | - Zsolt Molnár
- Centre for Translational Medicine, University of Pécs, Szigeti Street 12, Pécs, 7624, Hungary
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