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Multimodal non-invasive monitoring to apply an open lung approach strategy in morbidly obese patients during bariatric surgery

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Abstract

To evaluate the use of non-invasive variables for monitoring an open-lung approach (OLA) strategy in bariatric surgery. Twelve morbidly obese patients undergoing bariatric surgery received a baseline protective ventilation with 8 cmH2O of positive-end expiratory pressure (PEEP). Then, the OLA strategy was applied consisting in lung recruitment followed by a decremental PEEP trial, from 20 to 8 cmH2O, in steps of 2 cmH2O to find the lung’s closing pressure. Baseline ventilation was then resumed setting open lung PEEP (OL-PEEP) at 2 cmH2O above this pressure. The multimodal non-invasive variables used for monitoring OLA consisted in pulse oximetry (SpO2), respiratory compliance (Crs), end-expiratory lung volume measured by a capnodynamic method (EELVCO2), and esophageal manometry. OL-PEEP was detected at 15.9 ± 1.7 cmH2O corresponding to a positive end-expiratory transpulmonary pressure (PL,ee) of 0.9 ± 1.1 cmH2O. ROC analysis showed that SpO2 was more accurate (AUC 0.92, IC95% 0.87–0.97) than Crs (AUC 0.76, IC95% 0.87–0.97) and EELVCO2 (AUC 0.73, IC95% 0.64–0.82) to detect the lung’s closing pressure according to the change of PL,ee from positive to negative values. Compared to baseline ventilation with 8 cmH2O of PEEP, OLA increased EELVCO2 (1309 ± 517 vs. 2177 ± 679 mL) and decreased driving pressure (18.3 ± 2.2 vs. 10.1 ± 1.7 cmH2O), estimated shunt (17.7 ± 3.4 vs. 4.2 ± 1.4%), lung strain (0.39 ± 0.07 vs. 0.22 ± 0.06) and lung elastance (28.4 ± 5.8 vs. 15.3 ± 4.3 cmH2O/L), respectively; all p < 0.0001. The OLA strategy can be monitored using noninvasive variables during bariatric surgery. This strategy decreased lung strain, elastance and driving pressure compared with standard protective ventilatory settings.

Clinical trial number NTC03694665.

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Funding

Support was provided from institutional sources.

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Authors and Affiliations

  1. Department of Anesthesiology, Hospital Privado de Comunidad, 7600 Mar del Plata, Buenos Aires, Argentina

    Gerardo Tusman, Cecilia M. Acosta & Marcos Ochoa

  2. Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany

    Stephan H. Böhm

  3. Argentinian’s Intensive Care Society, Buenos Aires, Argentina

    Emiliano Gogniat

  4. Bioengineering Laboratory, Electronic Department, School of Engineering, Mar del Plata University, Mar del Plata, Argentina

    Jorge Martinez Arca & Adriana Scandurra

  5. Instituto Tecnológico Buenos Aires (ITBA), Buenos Aires, Argentina

    Matías Madorno

  6. Deparment of Anesthesiology and Critical Care, Hospital Clínic of Barcelona, Barcelona, Spain

    Carlos Ferrando

  7. CIBERES, Madrid, Spain

    Fernando Suarez Sipmann

  8. Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden

    Fernando Suarez Sipmann

  9. Department of Critical Care, Hospital Universitario de La Princesa, Universidad Autonoma de Madrid, Madrid, Spain

    Fernando Suarez Sipmann

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  1. Gerardo Tusman
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  2. Cecilia M. Acosta
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  3. Marcos Ochoa
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  9. Carlos Ferrando
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  10. Fernando Suarez Sipmann
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Correspondence to Gerardo Tusman.

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Conflict of interest

Gerardo Tusman and Fernando Suarez Sipmann perform consultant services for Maquet Critical Care Matías Madorno who is partner and manager of MBMed S.A; a company that produce respiratory monitoring equipments. GT and FSS perform consultant services for Getinge/Maquet Critical Care.

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Tusman, G., Acosta, C.M., Ochoa, M. et al. Multimodal non-invasive monitoring to apply an open lung approach strategy in morbidly obese patients during bariatric surgery. J Clin Monit Comput 34, 1015–1024 (2020). https://doi.org/10.1007/s10877-019-00405-w

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  • DOI: https://doi.org/10.1007/s10877-019-00405-w

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