Med., 12, 5402

The recent article published in this journal by Matsumoto et al. [...].

Effect of Lung Compliance-Based Optimum Pressure Versus Fixed Positive End-Expiratory Pressure on Lung Atelectasis Assessed by Modified Lung Ultrasound Score in Laparoscopic Gynecological Surgery: A Prospective Randomized Controlled Trial

BACKGROUND

 Lung protective ventilation during the intraoperative period is now well established. However, the additional role of positive end-expiratory pressure (PEEP) during the intraoperative period remains uncertain in major laparoscopic gynecological surgery. The authors hypothesized that compliance-based optimum PEEP titration reduces postoperative lung atelectasis and improves outcomes.

METHODS

 Patients undergoing major laparoscopic pelvic gynecological surgeries with healthy lungs were randomized to the fixed PEEP group (PEEP 5 cm H₂O and recruitment maneuver {RM}) and optimum PEEP group (compliance-based PEEP and RM). Lung ultrasound and arterial blood gas analysis were performed at four time points. Modified lung ultrasound scoring was done, and the same was used as means of assessing lung aeration and the amount of lung atelectasis. Postoperative supplemental oxygen requirement and duration were also assessed and compared.

RESULTS

Lung ultrasound score (LUS) 30 minutes after extubation in fixed (Group F) and optimum (Group O) PEEP groups were median (interquartile range {IQR}) 3 (2-3) versus 1 (1-2), p=0.0001. Ventilatory parameters between Group F and Group O after lung recruitment were tidal volume (mean 357 mL {SD: 35} versus 362 mL {SD: 22}, p=0.46), PEEP (median, 5 cm H₂O {IQR: 5-5} versus median 16 cm H₂O {IQR: 14-18}), peak airway pressure (median 26 cm H₂O {IQR: 24-28} versus median 30 cm H₂O {IQR: 28-32} p<0.0001), plateau pressure (median 22 cm H₂O {IQR: 20-24} versus median 26 cm H₂O {IQR: 24-28} p<0.0001), static compliance (32.07±8.36 mL cm H₂O-1 versus 39.58±8.99 mL cm H₂O-1, p=0.0002). The number of patients requiring postoperative oxygen therapy to maintain SpO₂ >94% after extubation in postanesthesia care unit (PACU) was statistically significantly greater in group F (39/41 {95%} versus 30/41 {73%}, p=0.007). Median (IQR) duration of oxygenation therapy in the first 24 hours of the postoperative period between Group F and Group O differed with statistical significance, with the median (IQR) values being 25 (20-30) minutes versus 10 (0-15) minutes (p<0.0001).

CONCLUSIONS

 The modified lung ultrasound score significantly differed intraoperatively between the two groups, with lower scores in the optimum PEEP group. This has reflected improved postoperative outcomes in optimum PEEP group patients, with fewer patients requiring postoperative oxygen supplementation and reduced supplemental oxygen requirement duration.

Relationship between the Use of Fentanyl-Based Intravenous Patient-Controlled Analgesia and Clinically Significant Events in Laparoscopic Gynecological Surgery: A Single-Center Retrospective Cohort Study

Background: This study examined the relationship between the use of fentanyl-based intravenous patient-controlled analgesia (ivPCA) and the incidence of a clinically significant event (CSE), while considering both the analgesic effects and side effects in laparoscopic gynecological surgery. Methods: This study included 816 patients undergoing laparoscopic gynecological surgery under general anesthesia at Kyoto University Hospital between 2012 and 2018. The primary exposure was the use of fentanyl-based ivPCA. We defined an outcome measure—CSE—that integrates severe wound pain and vomiting assumed to negatively affect patient recovery. We performed multivariable logistic regression analysis to assess the independent relationship between ivPCA use and CSE. Results: Multivariable logistic regression analysis revealed that fentanyl-based ivPCA was independently associated with increased CSE (adjusted odds ratio (95% confidence interval): 1.80 (1.24−2.61), p = 0.002). Use of ivPCA was associated with a reduced incidence of postoperative severe wound pain (adjusted odds ratio (95% confidence interval): 0.50 (0.27−0.90), p = 0.022), but was also associated with an increased incidence of vomiting (adjusted odds ratio (95% confidence interval): 2.65 (1.79−3.92), p < 0.001). Conclusion: The use of fentanyl-based ivPCA in laparoscopic gynecological surgery is associated with increased CSE.

Inhalation of low-dose desflurane prevents the hemodynamic instability caused by target-controlled infusion of remifentanil and propofol during laparoscopic gynecological surgery: A randomized controlled trial

The objective of the present study was to determine whether the addition of inhaled desflurane is superior to remifentanil-propofol total intravenous anesthesia (TIVA) alone in patients undergoing laparoscopic gynecological surgery. A total of 60 patients who were scheduled to undergo laparoscopic gynecological surgery were prospectively enrolled and randomly allocated to receive either propofol-remifentanil (PR group; n=30) or combined propofol-remifentanil and low-dose desflurane (PRD group; n=30) for the maintenance of anesthesia. Hemodynamics [mean arterial pressure (MAP); heart rate (HR)], recovery parameters and complications were recorded. The results of the present study indicated that the addition of desflurane significantly reduced the amount of propofol and remifentanil that was administered in the PRD group, compared with that in the PR group. MAP and HR were significantly higher at T3 (5 min post-pneumoperitoneum), but significantly lower at T4 (removal of pneumoperitoneum needle) and T5 (post-operation immediately) in the PR group, compared with the PRD group. Moreover, MAP and HR were significantly altered at multiple time points within the PR group; however, they were relatively stable in the PRD group. There were no significant differences in the recovery parameters and complications between the two groups. In conclusion, combining low-dose desflurane with PR may represent an efficient anesthesia regimen to prevent the hemodynamic instability of TIVA in patients undergoing laparoscopic gynecological surgery.

Efficacy of Low-dose Ketamine as Sole Analgesic Agent in Maintaining Analgesia and Intraoperative Hemodynamics During Laparoscopic Gynecological Surgeries

BACKGROUND

Ketamine, in low doses, is known to possess intense analgesic properties. The available literature shows wide variation regarding the time and dose of administration of ketamine during surgery.

AIM

The aim of this study was to evaluate the effect of intraoperative administration of ketamine when used as sole analgesic in low doses, on hemodynamics and postoperative analgesia in patients undergoing laparoscopic gynecological surgery and compared on the basis of duration of surgery.

SETTINGS AND DESIGN

This prospective, observational study was conducted from July to December 2015, over a period of 6 months in a tertiary care medical college and hospital.

MATERIALS AND METHODS

Seventy patients between 23 and 55 years planned for laparoscopic gynecological surgery were recruited. Ketamine was given in a dose of 0.5 mg/kg preoperatively and then repeated every ½ hourly in a dose of 0.25 mg/kg throughout the surgery. Hemodynamic parameters, time to the first rescue analgesia and complications were recorded for the first 8 h. Statistical evaluation was done and result expressed as percentage. Paired t-test was employed for the comparison of numerical variables within the group.

RESULTS

Seventy percent of the patients did not require any postoperative rescue analgesia during the first 8 h after surgery. None of the patients complained of pain immediately after extubation, and 16% of the patients had minor postoperative complications. The intraoperative hemodynamic profile was significantly altered. Duration of surgery and dose of ketamine required did not affect the duration of analgesia.

CONCLUSION

Ketamine in low dose proved to be an efficacious analgesic even in the long duration laparoscopic gynecological surgeries. It stabilizes intraoperative hemodynamics thereby reducing the requirement of other anesthetic and antihypertensive agents.