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Does Lung Compliance Optimization Through PEEP Manipulations Reduce the Incidence of Postoperative Hypoxemia in Laparoscopic Bariatric Surgery? A Randomized Trial

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Abstract

Background

In obese patients (OP), the best intraoperative ventilation strategy remains to be defined. Dynamic lung compliance (Cdyn) and dead space fraction are indicators of efficient ventilation at an optimal positive end-expiratory pressure (PEEP). Herein, we investigated whether intraoperative dynamic lung compliance optimization through PEEP manipulations affects the incidence of postoperative hypoxemia (SpO2 < 90%) in OP undergoing laparoscopic bariatric surgery (LBS).

Methods

This was a single-center, prospective, randomized controlled study conducted from July 2013 to December 2015. After obtaining institutional review board approval and informed consent, 100 OP undergoing LBS under volume-controlled ventilation (tidal volume 8 mL/kg of ideal body weight) were randomized according to the PEEP level maintained during the surgery. In the control group, a PEEP of 10 cm H2O was maintained, while in the intervention group, the PEEP was adapted to achieve the best dynamic lung compliance. Anesthesia and analgesia were standardized. The patients received supplemental nasal oxygen on the first postoperative day and were monitored up to the second postoperative day with a portable pulse oximeter.

Results

Demographics were similar between groups. There was no difference in the incidence of hypoxemia during the first 2 postoperative days (control: 1.3%; intervention: 2.1%; p = 0.264).

Conclusions

The incidence of postoperative hypoxemia was not reduced by an open-lung approach with protective ventilation strategy in obese patients undergoing LBS. A pragmatic application of a PEEP level of 10 cm H2O was comparable to individual PEEP titration in these patients.

Trial Registration

Clinicaltrials.gov identifier, NCT02579798; https://clinicaltrials.gov/ct2/show/NCT02579798

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Data Availability

Data are available upon reasonable request to the corresponding author.

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Acknowledgements

Assistance with the study: The authors would like to thank the following persons from the Department of Anaesthesiology, CHU Brugmann-HUDERF, Brussels, Belgium, who kindly performed the protocol study in the operating room: Ida Stany M.D., Robert Tircoveanu M.D., Yannick Ciccarella M.D., Jean-Louis Majcher M.D., Christiane Dzechi M.D., and Muj Mulaj M.D.

Funding

This work was supported only by CHU Brugmann-HUDERF departmental sources and the Brugmann foundation.

Author information

Authors and Affiliations

  1. Department of Anaesthesiology, CUB Erasme, Université Libre de Bruxelles, 1070, Brussels, Belgium

    Delphine Van Hecke

  2. Department of Anaesthesiology, CHU Brugmann-HUDERF, Université Libre de Bruxelles, 1090, Brussels, Belgium

    Javad S. Bidgoli

  3. Department of Anaesthesiology, CHU Brugmann-HUDERF, Université Libre de Bruxelles, 1090, Brussels, Belgium

    Philippe Van der Linden

Authors
  1. Delphine Van Hecke
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  2. Javad S. Bidgoli
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  3. Philippe Van der Linden
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Corresponding author

Correspondence to Delphine Van Hecke.

Ethics declarations

Our study was a prospective, randomized controlled study, approved by the Institutional Ethics Committee. Written informed consent was obtained from all participating subjects. This manuscript adheres to the applicable Enhancing the Quality and Transparency of Health Research (EQUATOR) guidelines.

Conflicts of Interest

The authors declare that they have no conflict of interest.

Ethical and Consent Statement

Ethical and consent statement provided by the Institutional Ethics Committee. Written informed consent was obtained from all participating subjects.

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Annex 1: anesthetic protocol

Annex 1: anesthetic protocol

All subjects stopped consuming solid food from 6 h and clear liquids from 2 h before the elective surgery, and received 0.5–1 mg alprazolam and 150 mg ranitidine perorally, 1 h before the procedure as premedication.

Before induction, each patient was placed in ‘Ramp’ position. Basic monitoring was undertaken, including: electrocardiogram, non-invasive blood pressure (NIBP), and pulse oximetry oxygen saturation (SpO2).

An 18-gauge catheter was placed in a vein and a 20-gauge catheter in a radial artery. Further monitoring included entropy, thumb’s adductor neuromuscular monitor, nasopharyngeal temperature probe, and urinary catheter.

Anesthesia was induced by intravenous administration of propofol (2–3 mg/kg IBW) and sufentanil (GEPS model with target concentration of 0.3 ng/mL based on IBW: discontinued 1 h before the end of surgery). The intubation (tube size 8 for women and 8.5 for men) was facilitated by the administration of intravenous rocuronium (0.6 mg/kg corrected IBW). Antibiotic prophylaxis (cefazolin 2 g and metronidazole 500 mg) was also given at the induction.

Anesthesia was maintained with desflurane (6–8%) to keep entropy values between 40 and 60. Every 30 min, a train of 4 (TOF 50 Hz) was performed and a rocuronium bolus (0.15 mg/kg IBW) was administered as needed to maintain a TOF ratio of 0:4.

At the end of surgery, all patients received paracetamol (1 g). Neuromuscular blockade was checked at the thumb’s adductor. The neuromuscular blockade was reversed with 4 mg/kg (corrected IBW) sugammadex when the train-of-four (TOF) ratio reached 2:4.

After attaining a TOF ratio of 4:4 with a sustained tetanic stimulation at 100 Hz over 5 s, patients were placed in ‘Ramp’ position and the administration of desflurane and mechanical ventilation with volume control mode was discontinued in order to switch to mechanical ventilation with pressure support [PEEP of 5 cm H2O and 100% inspired fraction of oxygen (FiO2)].

Anti-emetic prophylaxis was administered to all patients as follows: 40 mg methylprednisolone at the induction and 4 mg ondansetron at the end of the intervention.

Thromboprophylaxis included intermittent pneumatic compression device beginning before surgery and low molecular weight heparin (80 mg/day) beginning 6 h after the procedure.

In the postoperative period, each patient received paracetamol 1 g every 6 h and patient-controlled intravenous analgesia with piritramide was started at the post-anesthesia care unit (PACU) (2-mg bolus every 7 min with a maximum of 30 mg in 4 h).

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Van Hecke, D., Bidgoli, J.S. & Van der Linden, P. Does Lung Compliance Optimization Through PEEP Manipulations Reduce the Incidence of Postoperative Hypoxemia in Laparoscopic Bariatric Surgery? A Randomized Trial. OBES SURG 29, 1268–1275 (2019). https://doi.org/10.1007/s11695-018-03662-x

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  • DOI: https://doi.org/10.1007/s11695-018-03662-x

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