Study objective To assess the effects of a protective ventilation strategy during Trendelenburg pneumoperitoneum surgery on postoperative oxygenation. Designs: Parallel-group, randomized trial. Setting: Operating room of a university hospital, Italy. Patients: Morbidly obese patients undergoing Trendelenburg pneumoperitoneum gynaecological surgery. Interventions: Participants were randomized to standard (SV: tidal volume = 10 ml/kg of predicted body weight, PEEP = 5 cmH2O) or protective (PV: tidal volume = 6 ml/kg of predicted body weight, PEEP = 10 cmH2O, recruitment maneuvers) ventilation during anesthesia. Measurements: Primary outcome was PaO2/FiO2 one hour after extubation. Secondary outcomes included day-1 PaO2/FiO2, day-2 respiratory function and intraoperative respiratory/lung mechanics, assessed through esophageal manometry, end-expiratory lung volume (EELV) measurement and pressure-volume curves. Main results: Sixty patients were analyzed (31 in SV group, 29 in PV group). Median [IqR] tidal volume was 350 ml [300–360] in PV group and 525 [500–575] in SV group. Median PaO2/FiO2 one hour after extubation was 280 mmHg [246–364] in PV group vs. 298 [250–343] in SV group (p = 0.64). Day-1 PaO2/FiO2, day-2 forced vital capacity, FEV-1 and Tiffenau Index were not different between groups (all p > 0.10). Intraoperatively, 59% of patients showed complete airway closure during pneumoperitoneum, without difference between groups: median airway opening pressure was 17 cmH2O. In PV group, airway and transpulmonary driving pressure were lower (12 ± 5 cmH2O vs. 17 ± 7, p < 0.001; 9 ± 4 vs. 13 ± 7, p < 0.001), PaCO2 and respiratory rate were higher (48 ± 8 mmHg vs. 42 ± 12, p < 0.001; 23 ± 5 breaths/min vs. 16 ± 4, p < 0.001). Intraoperative EELV was similar between PV and SV group (1193 ± 258 ml vs. 1207 ± 368, p = 0.80); ratio of tidal volume to EELV was lower in PV group (0.45 ± 0.12 vs. 0.32 ± 0.09, p < 0.001). Conclusions: In obese patients undergoing Trendelenburg pneumoperitoneum surgery, PV did not improve postoperative oxygenation nor day-2 respiratory function. PV was associated with intraoperative respiratory mechanics indicating less injurious ventilation. The high prevalence of complete airway closure may have affected study results. Trial registration: Prospectively registered on http://clinicaltrials.gov NCT03157479 on May 17th, 2017.
Grieco, D. L., Russo, A., Anzellotti, G. M., Romano, B., Bongiovanni, F., Dell'Anna, A. M., Mauti, L., Cascarano, L., Gallotta, V., Rosa, T., Varone, F., Menga, L. S., Polidori, L., D'Indinosante, M., Cappuccio, S., Galletta, C., Tortorella, L., Costantini, B., Gueli Alletti, S., Sollazzi, L., Scambia, G., Antonelli, M., Lung-protective ventilation during Trendelenburg pneumoperitoneum surgery: A randomized clinical trial, <<JOURNAL OF CLINICAL ANESTHESIA>>, 2023; 85 (n/a): N/A-N/A. [doi:10.1016/j.jclinane.2022.111037] [https://hdl.handle.net/10807/305399]
Lung-protective ventilation during Trendelenburg pneumoperitoneum surgery: A randomized clinical trial
Grieco, Domenico Luca;Dell'Anna, Antonio Maria;Gallotta, Valerio;Varone, Francesco;Menga, Luca Salvatore;Gueli Alletti, Salvatore;Sollazzi, Liliana;Scambia, Giovanni;Antonelli, Massimo
2023
Abstract
Study objective To assess the effects of a protective ventilation strategy during Trendelenburg pneumoperitoneum surgery on postoperative oxygenation. Designs: Parallel-group, randomized trial. Setting: Operating room of a university hospital, Italy. Patients: Morbidly obese patients undergoing Trendelenburg pneumoperitoneum gynaecological surgery. Interventions: Participants were randomized to standard (SV: tidal volume = 10 ml/kg of predicted body weight, PEEP = 5 cmH2O) or protective (PV: tidal volume = 6 ml/kg of predicted body weight, PEEP = 10 cmH2O, recruitment maneuvers) ventilation during anesthesia. Measurements: Primary outcome was PaO2/FiO2 one hour after extubation. Secondary outcomes included day-1 PaO2/FiO2, day-2 respiratory function and intraoperative respiratory/lung mechanics, assessed through esophageal manometry, end-expiratory lung volume (EELV) measurement and pressure-volume curves. Main results: Sixty patients were analyzed (31 in SV group, 29 in PV group). Median [IqR] tidal volume was 350 ml [300–360] in PV group and 525 [500–575] in SV group. Median PaO2/FiO2 one hour after extubation was 280 mmHg [246–364] in PV group vs. 298 [250–343] in SV group (p = 0.64). Day-1 PaO2/FiO2, day-2 forced vital capacity, FEV-1 and Tiffenau Index were not different between groups (all p > 0.10). Intraoperatively, 59% of patients showed complete airway closure during pneumoperitoneum, without difference between groups: median airway opening pressure was 17 cmH2O. In PV group, airway and transpulmonary driving pressure were lower (12 ± 5 cmH2O vs. 17 ± 7, p < 0.001; 9 ± 4 vs. 13 ± 7, p < 0.001), PaCO2 and respiratory rate were higher (48 ± 8 mmHg vs. 42 ± 12, p < 0.001; 23 ± 5 breaths/min vs. 16 ± 4, p < 0.001). Intraoperative EELV was similar between PV and SV group (1193 ± 258 ml vs. 1207 ± 368, p = 0.80); ratio of tidal volume to EELV was lower in PV group (0.45 ± 0.12 vs. 0.32 ± 0.09, p < 0.001). Conclusions: In obese patients undergoing Trendelenburg pneumoperitoneum surgery, PV did not improve postoperative oxygenation nor day-2 respiratory function. PV was associated with intraoperative respiratory mechanics indicating less injurious ventilation. The high prevalence of complete airway closure may have affected study results. Trial registration: Prospectively registered on http://clinicaltrials.gov NCT03157479 on May 17th, 2017.
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