PROTECTIVE VENTILATION IMPROVES GAS EXCHANGE, REDUCES INCIDENCE OF ATELECTASES AND HOSPITAL LENGTH OF STAY IN MAJOR PANCREATODUODENAL SURGERY
Keywords:
protective ventilation, postoperative pulmonary complications,, atelectasis, permissive hypercapnia, pancreatoduodenal surgeryAbstract
Background: Protective perioperative ventilation has been shown to improve outcomes and reduce the incidence of postoperative pulmonary complications (PPC). The goal of this study was to assess the effects of ventilation with low tidal volume (VT) either alone or in a combination with moderate permissive hypercapnia in major pancreatoduodenal interventions. Materials and methods: Sixty adult patients scheduled for elective pancreatoduodenal surgery with duration >2 hrs were enrolled into a prospective single-center study. All patients were randomized to three groups receiving high VT (10 mL/kg of predicted body weight (PBW), the HVT group, n=20), low VT (6 mL/ kg PBW, the LVT group, n=20), and low VT combined with a moderate hypercapnia and hypercapnic acidosis (6 mL/kg PBW, PaCO2 45–60 mm Hg, the LVT+HC group, n=20). Cardiopulmonary parameters and the incidence of complications were registered during surgery and postoperatively. Results and Discussion: The values of VT were 619 (570–716), 370 (321–403), and 340 (312–430) mL/kg for the HVT, the LVT and the LVT+HC groups, respectively (p<0.001). Compared to the HVT group, PaO2/FiO2 ratio was increased in the LVT group: 392 (349–437) vs. 321 (289–358) mm Hg at 24 hrs postperatively (p<0.05). The HVT group had higher incidence of atelectases (n=6) despite lower incidence of smoking compared with the LVT (n=1) group (p=0.017) and demonstrated longer length of hospital stay. The patients of the LVT+HC group had lower arterial lactate and bicarbonate excess values by the end of surgery. Conclusions: In major pancreatoduodenal interventions, preventively protective tidal volume improves postoperative oxygenation, reduces the incidence of atelectases, and shortens length of hospital stay. The combination of low tidal volume and permissive hypercapnia results in hypercapnic acidosis decreasing the lactate concentration but adding no additional benefits and warrants further investigations.
References
Canet J. Postoperative respiratory failure: pathogenesis, prediction, and prevention / J. Canet, L. Gallart // Curr Opin Crit Care. – 2014. – N 20. – P. 56–62.
Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome // N Engl J Med. – 2000. – N 342. – P. 1301–1308.
Meta-analysis: ventilation strategies and outcomes of the acute respiratory distress syndrome and acute lung injury / C. Putensen, N. Theuerkauf, J. Zinserling [et al.] // Ann Intern Med. – 2009. – N 151. – P. 566–642.
Gonga M. N. Acute respiratory distress syndrome: shifting the emphasis from treatment to prevention / M. N. Gonga, B. T. Thompson // Curr Opin Crit Care. – 2016. – N 22. – P. 21–37.
Permissive hypercapnia — role in protective lung ventilator strategies / J. G. Laffey, D. O’Croinin, P. McLoughlin, B. P. Kavanagh // Intensive Care Med. – 2004. – N 30. – P. 347–356.
Ismaiel N. M. Effects of hypercapnia and hypercapnic acidosis on attenuation of ventilatorassociated lung injury / N. M. Ismaiel, D. Henzler // Minerva Anestesiol. – 2011. – N 77. – P. 723–733.
Hypercapnic acidosis is protective in an in vivo model of ventilator-induced lung injury / S. E. Sinclair, D. A. Kregnow, W. J. E. Lamm [et al.] // Am J Respir Crit Care Med. – 2002. – N 166. – P. 403–408.
Neto A. S.Ventilation with lower tidal volumes for critically ill patients without the acute respiratory distress syndrome: a systematic translational review and meta-analysis / A. S. Neto, L. Nagtzaam, M. J. Schultz // Curr Opin Crit Care. – 2014. – N 20. – P. 25–32.
Protective versus Conventional Ventilation for Surgery: A Systematic Review and Individual Patient Data Meta-analysis / A. S. Neto, S. N. Hemmes, C. S. Barbas [et al.] // Anesthesiology. – 2015. – N 123. – P. 66–78.
Protective mechanical ventilation during general anesthesia for open abdominal surgery improves postoperative pulmonary function / P. Severgnini, G. Selmo, C. Lanza [et al.] // Anesthesiology. – 2013. – N 118. – P. 1307–1328.
Futier E. Protective lung ventilation in operating room: a systematic review / E. Futier, J. M. Constantin, S. Jaber // Minerva Anestesiol. – 2014. – N 80. – P. 726–735.
PROVE Network Investigators. Association between driving pressure and development of postoperative pulmonary complications in patients undergoing mechanical ventilation for general anaesthesia: a meta-analysis of individual patient data / A. S. Neto, S. N. Hemmes, C. S. Barbas [et al.] // Lancet Respir Med. – 2016. – N 4. – P. 272–280.
Masterson C. Hypercapnia: clinical relevance and mechanisms of action / C. Masterson, G. Otulakowski, B. P. Kavanagh // Curr Opin Crit Care. – 2015. – N 21. – P. 7–12.
Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. The National Veterans Administration Surgical Quality Improvement Program / A. M. Arozullah, J. Daley, W. G. Henderson, S. F. Khuri // Ann Surg. – 2000. – N 232. – P. 242–295.
Major pancreatic resections for suspected cancer in a community-based teaching hospital: lessons learned / R. E. Metreveli, K. Sahm, R. Abdel–Misih, N. J. Petrelli // J Surg Oncol. – 2007. – N 95. – P. 201–206.
ARISCAT Group. Prediction of postoperative pulmonary complications in a populationbased surgical cohort / J. Canet, L. Gallart, C. Gomar [et al.] // Anesthesiology. – 2010. – N 113. – P. 1338–1350.
Ventilation with low tidal volumes during upper abdominal surgery does not improve postoperative lung function / T. A. Treschan, W. Kaisers, M. S. Schaefer [et al.] // Br J Anaesth. – 2012. – N 109. – P. 263–271.
The effects of different ventilatory settings on pulmonary and systemic inflammatory responses during major surgery / H. Wrigge, U. Uhlig, J. Zinserling [et al.] // Anesth Analg. – 2004. – N 98. – P. 775–781.
Lung epithelial injury markers are not influenced by use of lower tidal volumes during elective surgery in patients without preexisting lung injury / R. M. Determann, E. K. Wolthuis, G. Choi [et al.] // Am J Physiol Lung Cell Mol Physiol. – 2008. – N 294. – P. 344–350.
Effect of low tidal volume ventilation on atelectasis in patients during general anesthesia: a computed tomographic scan / H. Cai, H. Gong, L. Zhang [et al.] // J Clin Anesth. – 2007. – N 19. – P. 125–129.
European Surgical Outcomes Study (EuSOS) group for the Trials groups of the European Society of Intensive Care Medicine and the European Society of Anaethesiology: Mortality after surgery in Europe: a 7 day cohort study / R. M. Pearse, R. P. Moreno, P. Bauer [et al.] // Lancet. – 2012. – N 380. – P. 1059–1065.
Comparison of two ventilatory strategies in elderly patients undergoing major abdominal surgery / T. N. Weingarten, F. X. Whalen, D. O. Warner [et al.] // Br J Anaesth. – 2010. – N 104. – P. 16–22.
Hypercapnic acidosis is protective in an In vivo model of ventilator-induced lung injury / S. E. Sinclair, D. A. Kregnow, W. J. E. Lamm [et al.] // Am J Respir Crit Care Med. – 2002. – N 166. – P. 403–408.
Hypercapnic acidosis attenuates edotoxin-induced nuclear factor-kappa B activation / K. Takeshita, Y. Suzuki, K. Nishio [et al.] // Am J Respir Cell Mol Biol. – 2003. – N 29. – P. 124–132.
Hypercapnic acidosis attenuates shock and lung injury in early and prolonged systemic sepsis / J. Costello, B. Higgins, M. Contreras [et al.] // Crit Care Med. – 2009. – N 37. – P. 2412–2420.
Low mortality rate in adult respiratory distress syndrome using low-volume, pressure-limited ventilation with permissive hypercapnia: a prospective study / K. G. Hickling, J. Walsh, S. Henderson, R. Jackson // Crit Care Med. – 1994. – N 22. – P. 1568–1578.
Protective effects of Hypercapnic acidosis on ventilator-induced lung injury / A. F. Broccard, J. R. Hotchkiss, C. Vannay [et al.] // Am J Resp Crit Care Med. – 2001. – N 164. – P. 802–806.
Marhong J. Carbon dioxide in the critically ill: too much or too little of a good thing? / J. Marhong, E. Fan // Respir Care. – 2014. – N 59. – P. 1597–1605.
Hypercapnia and acidosis in sepsis: a double-edged sword? / G. Curley, M. M. Contreras, A. D. Nichol [et al.] // Anesthesiology. – 2010. – N 112. – P. 462–472.
Cullen D. J. Cardiovascular effects of carbon dioxide in man / D. J. Cullen, E. I. Eger // Anesthesiology. – 1974. – N 41. – P. 345–349.
The effects of hypercapnia on the metabolic response to progressive exhaustive work / T. E. Graham, B. A. Wilson, M. Sample [et al.] // Med Sci Sports Exerc. – 1980. – N 14. – P. 278–284.
Graham T. E. Skeletal muscle lactate release and glycolitic intermediates during hypercapnia / T. E. Graham, J. K. Barclay, B. A. Wilson // J Appl Physiol. – 1986. – N 60. – P. 568–575.
Effects of acidosis on rat muscle metabolism and per formance during heavy exercise / L. L. Spriet, C. G. Matsos, S. J. Peters [et al.] // Am J Physiol Cell Physiol. – 1985. – N 248. – P. 337–C347.
