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Background:
Pneumoperitoneum (PNP) and patient positions required for laparoscopy can induce pathophysiological changes that complicate anesthetic management during laparoscopic procedures. This study investigated whether low tidal volume and positive end-expiratory pressure (PEEP) application can improve ventilatory and oxygenation parameters dur...
Context in source publication
Context 1
... characteristics were similar be- tween the groups (p > 0.05, Table 1). There were no statisti- cally significant differences between the hemodynamic parameters (MAP, HR) measured before anesthesia induction (before and after PNP) in each group (p > 0.05, Table 2). Operation characteristics of each group are shown in Table 3, and there were no significant differences between both groups (p ¼ 0.665). ...
Similar publications
Background:
There are increasing studies showing that the use of a lung-protective ventilation strategy has a lung protection effect in patients undergoing abdominal surgery; however, the appropriate positive end-expiratory pressure (PEEP) has not yet defined. Adopting a suitable PEEP may prevent postoperative pulmonary complications. Robot-assist...
Citations
... A higher PEEP may be used in obese patients, as some studies indicate impaired respiratory biomechanics in this group of patients [15,16]. Although low tidal volume has been recognized as a protective tool during surgery, RCTs comparing PEEP levels during laparoscopic surgery have been small and shown conflicting results on the effects of PEEP on oxygenation, respiratory mechanics, and hemodynamic stability [14,18,19,[21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38]. Not a single meta-analysis has examined the effect of PEEP on oxygenation, respiratory mechanics, or hemodynamics in laparoscopic surgery neither in obese nor non-obese patients. ...
... The types of procedures included laparoscopic cholecystectomy, laparoscopic colon cancer resection, laparoscopic radical gastrectomy, laparoscopic gynaecologic surgery, robot-assisted laparoscopic radical prostatectomy, and robot-assisted gynaecologic surgery. Detailed baseline characteristics of the included studies are presented in Table 1 [14,18,19,[21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38]. ...
... Four studies did not report the measurement of the outcome [27,32,36,38] and three studies showed a high risk of measurement of the outcome bias [21,25,33]. Three studies showed an increased risk of "selection of the reported result" bias [21,26,28] and four trials had some concerns [22,23,25,36]. For details see Supplement 1&2. ...
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.
... Specifically, the PNP leads to an elevated intra-abdominal pressure (IAP) with the consequent cranial displacement of the diaphragm, which induces changes in ventilatory and cardiovascular dynamics, such as decreased venous return, increased peripheral vascular resistance, decreased cardiac output, increased resistance to thoracic expansion, and decreased lung volume [17][18][19]. The compression of the pulmonary parenchyma has been related to the appearance of atelectasis and ventilation/perfusion alterations [17,20]. Another critical event is associated with the insufflation of CO 2 and its absorption through the abdominal cavity, which may produce acid-base and cardiorespiratory disturbances [21]. ...
... In relation to the pathophysiological changes that may occur during the laparoscopic surgery both in human [19,20,[30][31][32] and in veterinary medicine [17,21,24,33,34], numerous publications have thoroughly examined these potential alterations. Some studies on animals recorded effects in terms of cardiovascular [24,29,33,35], respiratory [17,[25][26][27]34,36] and metabolic parameters [21,29,37]. ...
... As previously described, noticeable respiratory changes were found in laparoscopy surgeries mainly associated with the increase of IAP, which caused a cranial displacement of the diaphragm, decreasing the pulmonary distension, and reducing the functional residual capacity [17,19,20,52]. In our study, the establishment of PNP during the LAP Ove surgery resulted in a decrease in the compliance and an increase in the Ppeak and Pplat without affecting airway resistance. ...
The aim of this study was to examine the cardiorespiratory and blood changes associated with pneumoperitoneum (PNP) in laparoscopic ovariectomy (LAP Ove), as well as sevoflurane requirements, comparing them to those determined in open surgery (LPT Ove). The study was performed in 16 bitches submitted to LAP or LPT Ove. The cardiorespiratory and end-tidal sevoflurane concentration values were recorded as follows: at the beginning of surgery (T1), after the right ovary resection (T2), after the left ovary resection (T3), and after surgical closure (T4). Blood samples were taken before and after PNP. Among the cardiorespiratory parameters, no differences were observed in the values of end-tidal CO2, minute volume, and heart rate. In the LAP Ove group, a significant increase in inspiratory pressures and a decreased compliance were identified at T2 and T3. Significant higher arterial pressure values were observed in both groups at T2 and T3, with this increase especially marked at T2 in the LPT Ove group. Sevoflurane requirements were significantly higher in the LPT group during ovarian resection. Finally, in terms of the hematochemical parameters, statistical differences were recorded between pre- and post-operative assessments, but not between both surgical groups. The pathophysiological effects associated with PNP seemed to be transient and well-tolerated by healthy dogs.
... Pinheiro de Oliveira et al. [21] showed that the ventilation mode of small tidal volume combined with proper positive end-expiratory pressure (PEEP) could improve mechanical stress, inhibit the production of pulmonary inflammatory mediators, and therefore, effectively reduce postoperative pulmonary complications. In addition, CPAP can be applied for the nonventilated lung to improve oxygenation by expanding the collapsed lung and improving the ventilation/perfusion ratio of the nonventilated lung [22]. Relevant studies have Values are mean ± SD or n (%). ...
Objective:
To study the effect of a care bundle combined with continuous positive airway pressure (CPAP) in the postanesthesia care unit (PACU) on rapid recovery after pulmonary tumor resection.
Methods:
A total of 135 patients requiring anesthesia resuscitation after pulmonary tumor resection in our hospital from June 2020 to February 2021 were selected. They were randomly divided into three groups: the PACU experimental group, PACU control group, and operating room resuscitation (OR) group. Subsequently, their intraoperative clinical symptoms, parameters in monitoring postoperative respiratory status, and follow-up results were compared among the three groups.
Results:
The PACU experimental group had the highest number of right lesions, while the OR group had the highest intraoperative blood transfusion volume, urine volume, intraoperative colloid volume, intrapulmonary shunt, and intraoperative physician handover rate (P < 0.05). Before surgery, serum potassium (K) in the PACU experimental group was significantly higher than that in the OR group but lower than that in the PACU control group (P < 0.01). During the time in the PACU, blood partial pressure of oxygen (PO2) and oxygen index (OI) levels in the PACU experimental group were significantly higher than those in the other groups (P < 0.01). After surgery, total PACU stay time, time from PACU to extubation, and stay after extubation were markedly reduced in the PACU experimental group (P < 0.05). The highest number of patients with drainage was found in the PACU experimental group, while the highest number of patients without drainage was found in the PACU control group.
Conclusion:
A care bundle combined with CPAP in the PACU can improve the monitoring time of respiratory status and improve blood gas parameters, thus accelerating the postoperative rehabilitation process of patients undergoing pulmonary tumor resection.
... Pressure-controlled ventilation (PCV) is one of the suggested methods to be used during general anesthesia. Mechanical ventilation with Positive End-Expiratory Pressure (PEEP) can affect respiration and hemodynamics during pneumoperitoneum by increasing FRC and reducing atelectasis (10,15,16). It is not common to use PEEP routinely in the surgical situation, and it is preferred to be used in high-risk patients such as CO 2 embolization cases (1). ...
Background:
During gynecologic laparoscopy, pneumoperitoneum, and the position of the patient's head can lead to pathophysiologic changes in cardiovascular and respiratory systems, complicating the management of anesthesia in these patients. One of the strategies for improving the respiratory status of patients undergoing laparoscopy is the use of Positive End-Expiratory Pressure (PEEP).
Objectives:
This study aimed to evaluate the effect of different levels of PEEP on the respiratory status of patients undergoing gynecologic laparoscopy.
Methods:
In this clinical trial, 60 patients with ASA I were randomly assigned to three groups to control anesthesia: ZEEP (PEEP 0 cmH2O; 20 cases), PEEP5 (PEEP 5 cmH2O; 20 cases), and PEEP10 (PEEP 10 cmH2O; 20 cases). Respiratory and hemodynamic variables of patients were compared before general anesthetic induction and immediately after CO2 insufflation at intervals of 5, 10, 20, 30, and 60 min and the end of the operation in the three study groups.
Results:
The PEEP application improved pH, PaCO2, and PaO2 levels at the end of pneumoperitoneum compared to baseline when compared with the non-use of PEEP (ZEEP group). Also, the frequency of dysrhythmia in the use of PEEP in controlled ventilation was significantly lower in patients with PEEP10 (P < 0.05). The application of PEEP5 resulted in similar effects to PEEP10 in the levels of respiratory variables.
Conclusions:
The PEEP application is associated with improved arterial blood gas in patients with gynecologic laparoscopy. The use of PEEP10 has a greater effect on the improvement of respiratory parameters and complications of pneumoperitoneum.
... • We recommend a strict control of tidal vol- ume, which must not exceed 6-8 ml/kg iBW (Protective tidal Volume), a close monitoring of ventilation pressure (P plat <30 cmH 2 o) 132 and the application of lung-protective ventilation during robotic surgery. [132][133][134] (level a, i) table Vi summarizes the consensus state- ments about intraoperative phase. 7, 74-88, 96, 98, 99, 101, 104, 109, 111, 113, 132-134, 137-141 5. Postoperative period ...
... • reabsorption of co 2 : when combined with ventilation difficulty and increased dead space, can lead to respiratory acidosis. [123][124][125][126][127][128][129][130][131][132][133][134][135] a tidal volume of 6-8 ml/kg of ideal body weight (iBW) minimizes stress and strain, as well as reducing postoperative respiratory complica- tions. applying a positive end-expiratory pres- sure (PeeP) is effective in improving dynamic intratidal compliance, with beneficial effects on damage from alveolar opening-closing. ...
... We recommend a strict control of tidal volume, which must not exceed 6-8 ml/kg iBW (Protective tidal Volume), a close monitoring of ventilation pressure (P plat <30 cmH 2 o) 132 and the application of lung-protective ventilation during robotic surgery. [132][133][134] level a i developing PONV, despite conflicting data for other types of surgery. 80,160,161 • We recommend the assessment of addition- al known risk factors for PoNV according to a risk stratification scheme (e.g., eras protocol). ...
Background:
Minimally invasive surgical procedures have revolutionized the world of surgery in the past decades. While laparoscopy, the first minimally invasive surgical technique to be developed, is widely used and has been addressed by several guidelines and recommendations, the implementation of robotic-assisted surgery is still hindered by the lack of consensus documents that support healthcare professionals in the management of this novel surgical procedure. Here we summarize the available evidence and provide expert opinion aimed at improving the implementation and resolution of issues derived from robotic abdominal surgery procedures.
Methods:
A joint task force of Italian surgeons, anaesthesiologists and clinical epidemiologists reviewed the available evidence on robotic abdominal surgery. Recommendations were graded according to the strength of evidence.
Results:
Statements and recommendations are provided for general issues regarding robotic abdominal surgery, operating theatre organisation, preoperative patient assessment and preparation, intraoperative management, and postoperative procedures and discharge.
Conclusions:
The consensus document provides evidence-based recommendations and expert statements aimed at improving the implementation and management of robotic abdominal surgery.
... Several studies have suggested the benefits of LPV during surgery [8,9]. During laparoscopic surgery, LPV is associated with a relatively low incidence of pulmonary complications and better oxygenation [10][11][12]. The benefits of LPV have also been demonstrated in obese patients [13,14]. ...
... Factors that affected V T settings were determined by regression analysis. Multiple regression analysis included variables such as laparoscopic surgery, obesity, and prone position during surgery, which have been shown to affect LPV in previous studies [10][11][12][13][14][15][16]. All statistical analyses were performed using SPSS Statistics 23 (IBM SPSS Statistics for Windows, IBM Corp, Armonk, NY, USA). ...
Background:
The benefits of lung-protective ventilation (LPV) with a low tidal volume (6 mL/kg of ideal body weight [IBW]), limited plateau pressure (< 28-30 cm H2O), and appropriate positive end-expiratory pressure (PEEP) in patients with acute respiratory distress syndrome have become apparent and it is now widely adopted in intensive care units. Recently evidence for LPV in general anaesthesia has been accumulated, but it is not yet generally applied by anaesthesiologists in the operating room.
Methods:
This study investigated the perception about intraoperative LPV among 82 anaesthesiologists through a questionnaire survey and identified the differences in ventilator settings according to recognition of lung-protective ventilation. Furthermore, we investigated the changes in the trend for using this form of ventilation during general anaesthesia in the past 10 years.
Results:
Anaesthesiologists who had received training in LPV were more knowledgeable about this approach. Anaesthesiologists with knowledge of the concept behind LPV strategies applied a lower tidal volume (median (IQR [range]), 8.2 (8.0-9.2 [7.1-10.3]) vs. 9.2 (9.1-10.1 [7.6-10.1]) mL/kg; p = 0.033) and used PEEP more frequently (69/72 [95.8%] vs. 5/8 [62.5%]; p = 0.012; odds ratio, 13.8 [2.19-86.9]) for laparoscopic surgery than did those without such knowledge. Anaesthesiologists who were able to answer a question related to LPV correctly (respondents who chose 'height' to a multiple choice question asking what variables should be considered most important in the initial setting of tidal volume) applied a lower tidal volume in cases of laparoscopic surgery and obese patients. There was an increase in the number of patients receiving LPV (VT < 10 mL/kgIBW and PEEP ≥5 cm H2O) between 2004 and 2014 (0/818 [0.0%] vs. 280/818 [34.2%]; p < 0.001).
Conclusions:
Our study suggests that the knowledge of LPV is directly related to its implementation, and can explain the increase in LPV use in general anaesthesia. Further studies should assess the impact of using intraoperative LPV on clinical outcomes and should determine the efficacy of education on intraoperative LPV implementation.
... Sixteen references (n ¼ 1063) were included in the final analysis ( Fig. 1) that compared conventional ventilation (n ¼ 532) with low volume ventilation (n ¼ 531) strategies. [17][18][19][21][22][23][24][25][26][27][28][29][30][31][32][33] Study Characteristics Table 1 summarizes the study characteristics including design, total patients, surgery type, ventilation strategies, and primary outcome of interest. For the purposes of analysis, we combined the data from 3 studies that used the same series of patients (n ¼ 40). ...
Background:
The clinical benefits of intraoperative low tidal volume (LTV) mechanical ventilation with concomittent positive end expiratory pressure (PEEP) and intermittent recruitment maneuvers-termed "protective lung ventilation" (PLV)-have not been investigated systematically in otherwise healthy patients undergoing general anesthesia.
Methods:
Our group performed a meta-analysis of 16 studies (n = 1054) comparing LTV (n = 521) with conventional lung ventilation (n = 533) for associated postoperative incidence of atelectasis, lung infection, acute lung injury (ALI), and length of hospital stay. A secondary analysis of 3 studies comparing PLV (n = 248) with conventional lung ventilation (n = 247) was performed.
Results:
Although intraoperative LTV ventilation was associated with a decreased incidence of postoperative lung infection (odds ratio [OR] = 0.33; 95% confidence interval [CI], 0.16-0.68; P = 0.003) compared with a conventional strategy, no difference was noted between groups in incidence of postoperative ALI (OR = 0.38; 95% CI, 0.10-1.52; P = 0.17) or atelectasis (OR = 0.86; 95% CI, 0.26-2.81; P = 0.80). Analysis of trials involving protective ventilation (LTV + PEEP + recruitment maneuvers) showed a statistically significant reduction in incidence of postoperative lung infection (OR = 0.21; 95% CI, 0.09-0.50; P = 0.0003), atelectasis (OR = 0.36; 95% CI, 0.20-0.64; P = 0.006), and ALI (OR = 0.15; 95% CI, 0.04-0.61; P = 0.008) and length of hospital stay (Mean Difference = -2.08; 95% CI, -3.95 to -0.21; P = 0.03) compared with conventional ventilation.
Conclusions:
Intraoperative LTV ventilation in conjunction with PEEP and intermittent recruitment maneuvers is associated with significantly improved clinical pulmonary outcomes and reduction in length of hospital stay in otherwise healthy patients undergoing general surgery. Providers should consider application of all the 3 elements for a comprehensive protective ventilation strategy.
... These studies were focused mainly on laparoscopic surgery only [56e60] and laparoscopic or open major abdominal surgery [10,11,13,61]. The results are conflicting: in several small studies, a strategy combining lower tidal volume, higher PEEP and RMs improved intraoperative gas exchange [56e60] and respiratory mechanics [10,57,59,61]; however, only some studies showed improved post-operative outcomes [10,58,59], whereas others did not find differences [57,61] or did not investigate the patients postoperatively [56,60]. A large retrospective analysis on 29,343 patients found that the use of lower intraoperative tidal volume increased from 2008 to 2011, and that the use of a low T V (6e8 mL/kg PBW) and minimal PEEP seem to be associated with a higher risk of 30-day mortality [62]. ...
Most patients undergoing surgical procedures need to be mechanically ventilated, because of the impact of several drugs administered at induction and during maintenance of general anaesthesia on respiratory function. Optimization of intraoperative mechanical ventilation can reduce the incidence of post-operative pulmonary complications and improve the patient's outcome. Preoxygenation at induction of general anaesthesia prolongs the time window for safe intubation, reducing the risk of hypoxia and overweighs the potential risk of reabsorption atelectasis. Non-invasive positive pressure ventilation delivered through different interfaces should be considered at the induction of anaesthesia morbidly obese patients. Anaesthesia ventilators are becoming increasingly sophisticated, integrating many functions that were once exclusive to intensive care. Modern anaesthesia machines provide high performances in delivering the desired volumes and pressures accurately and precisely, including assisted ventilation modes. Therefore, the physicians should be familiar with the potential and pitfalls of the most commonly used intraoperative ventilation modes: volume-controlled, pressure-controlled, dual-controlled and assisted ventilation. Although there is no clear evidence to support the advantage of any one of these ventilation modes over the others, protective mechanical ventilation with low tidal volume and low levels of positive end-expiratory pressure (PEEP) should be considered in patients undergoing surgery. The target tidal volume should be calculated based on the predicted or ideal body weight rather than on the actual body weight. To optimize ventilation monitoring, anaesthesia machines should include end-inspiratory and end-expiratory pause as well as flow-volume loop curves. The routine administration of high PEEP levels should be avoided, as this may lead to haemodynamic impairment and fluid overload. Higher PEEP might be considered during surgery longer than 3 h, laparoscopy in the Trendelenburg position and in patients with body mass index >35 kg/m(2). Large randomized trials are warranted to identify subgroups of patients and the type of surgery that can potentially benefit from specific ventilation modes or ventilation settings.
