Abstract
Indirect measurement of the respiratory exchange ratio (RER) has been shown to predict the occurrence of postoperative complications after major open non-cardiac surgery. Our main objective was to demonstrate the ability of the RER, indirectly measured by the anaesthesia respirator, to predict the occurrence of postoperative complications following laparoscopic surgery. We performed an observational, prospective and monocentric study. Haemodynamic and respiratory parameters were collected at several timepoints to calculate the RER by a non-volumetric method: RER = (FetCO2–FiCO2)/(FiO2–FetO2). Fifty patients were prospectively included. Nine patients (18%) had at least one postoperative complication. The mean RER was significantly higher for the subgroup of patients with complications than the subgroup without (1.04 ± 0.27 vs 0.88 ± 0.13, p < 0.05). The RER could predict the occurrence of post-operative complications with an area under the ROC curve of 0.73 (95% CI 0.59–0.85, p = 0.021). The best cut off was 0.98, with a sensitivity of 56% and a specificity of 88%. One hour after insufflation, the FiO2–FetO2 difference was significantly lower and the RER was significantly higher in the complications subgroup than in the subgroup without complications (4.4/− 1.6% vs 5.8/− 1.2%, p = 0.001 and 0.95 [0.85–1.04] vs 0.83 [0.75–0.92], p = 0.04, respectively). The RER measured during laparoscopic surgery can predict the occurrence of postoperative complications.
Trial registration The objectives and procedures of the study was registered at Clinicaltrials.gov (NCT03751579); date: November 23, 2018.
Similar content being viewed by others
Abbreviations
- ADH:
-
Antidiuretic hormone
- AKI:
-
Acute kidney injury
- ASA-PS:
-
American Society of Anesthesiologists physical status
- BIS:
-
Bispectral index
- CERAR:
-
Comité d’Éthique de la Recherche en Anesthésie-Réanimation
- CI:
-
Cardiac index
- CV:
-
Coefficient of variation
- DavO2 :
-
Arterio-venous difference in oxygen
- DO2 :
-
Oxygen delivery
- GDT:
-
Goal-directed therapy
- KDIGO:
-
Kidney disease improving global outcomes
- FiCO2 :
-
Inspired fraction in CO2
- FetCO2 :
-
End tidal fraction in CO2
- FiO2 :
-
Inspired fraction in O2
- FetO2 :
-
End tidal fraction in O2
- HR:
-
Heart rate
- LSC:
-
Least significant change
- MAP:
-
Mean arterial pressure
- PaO2/FiO2 :
-
Arterial oxygen partial pressure to fractional inspired oxygen ratio
- PEEP:
-
Positive end-expiratory pressure
- RER:
-
Respiratory exchange ratio
- ROC:
-
Receiver operating characteristic
- ScVO2 :
-
Central venous saturation in oxygen
- STROBE:
-
Strengthening the reporting of observational studies in epidemiology
- VCO2 :
-
CO2 production
- VO2 :
-
O2 consumption
References
Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee T-S. Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest. 1988;94:1176–86.
Donati A, Loggi S, Preiser J-C, Orsetti G, Münch C, Gabbanelli V, et al. Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients. Chest. 2007;132:1817–24.
Grocott MPW, Dushianthan A, Hamilton MA, Mythen MG, Harrison D, Rowan K. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a cochrane systematic review. Br J Anaesth. 2013;111:535–48.
Solberg G, Robstad B, Skjønsberg OH, Borchsenius F. Respiratory gas exchange indices for estimating the anaerobic threshold. J Sports Sci Med. 2005;4:29–36.
Cohen IL, Sheikh FM, Perkins RJ, Feustel PJ, Foster ED. Effect of hemorrhagic shock and reperfusion on the respiratory quotient in swine. Crit Care Med. 1995;23:545–52.
Piot J, Hébrard A, Durand M, Payen JF, Albaladejo P. An elevated respiratory quotient predicts complications after cardiac surgery under extracorporeal circulation: an observational pilot study. J Clin Monit Comput. 2018;33:145–53.
Bar S, Grenez C, Nguyen M, de Broca B, Bernard E, Abou-Arab O, et al. Predicting postoperative complications with the respiratory exchange ratio after high-risk noncardiac surgery: a prospective cohort study. Eur J Anaesthesiol. 2020. https://doi.org/10.1097/EJA.0000000000001111.
Gustafsson UO, Tiefenthal M, Thorell A, Ljungqvist O, Nygrens J. Laparoscopic-assisted and open high anterior resection within an ERAS protocol. World J Surg. 2012;36:1154–61.
Pascual M, Alonso S, Parés D, Courtier R, Gil MJ, Grande L, et al. Randomized clinical trial comparing inflammatory and angiogenic response after open versus laparoscopic curative resection for colonic cancer. Br J Surg. 2011;98:50–9.
Toulouse E, Masseguin C, Lafont B, McGurk G, Harbonn A, A Roberts J, et al. French legal approach to clinical research. Anaesthesia Critical Care & Pain Medicine. 2018;37:607–14.
Langeron O, Bourgain J-L, Francon D, Amour J, Baillard C, Bouroche G, et al. Difficult intubation and extubation in adult anaesthesia. Anaesth Critic Care Pain Med. 2018;37:639–51.
Spadaro S, Karbing DS, Mauri T, Marangoni E, Mojoli F, Valpiani G, et al. Effect of positive end-expiratory pressure on pulmonary shunt and dynamic compliance during abdominal surgery. Br J Anaesth. 2016;116:855–61.
Vallet B, Blanloeil Y, Cholley B, Orliaguet G, Pierre S, Tavernier B. Guidelines for perioperative haemodynamic optimization. Ann Franç Anesth Réanim. 2013;32:e151–e158158.
Hoffman GM, Torres A, Forster HV. Validation of a volumeless breath-by-breath method for measurement of respiratory quotient. J Appl Physiol. 1993;75:1903–10.
Waldau T, Larsen VH, Parbst H, Bonde J. Assessment of the respiratory exchange ratio in mechanically ventilated patients by a standard anaesthetic gas analyser: respiratory exchange ratio. Acta Anaesthesiol Scand. 2002;46:1242–50.
Buehler S, Lozano-Zahonero S, Wirth S, Runck H, Gamerdinger K, Förster K, et al. The equilibration of PCO2 in pigs is independent of lung injury and hemodynamics. Crit Care Med. 2016;44:e502.
Jammer I, Wickboldt N, Sander M, Smith A, Schultz MJ, Pelosi P, et al. Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (epco) definitions. Eur J Anaesthesiol. 2015;32:88–105.
Hayes M, Timmins A, Yau E, Palazzo M, Watston D. Elevation of systemic oxygen delivery in the treatment of critically ill patients. N Engl J Med. 1994;330:1717–22.
Laparoscopic physiologic perturbations: implications for at-risk patients. The 3rd edition: Prevention & management. https://laparoscopy.blogs.com/prevention_management_3/2010/07/laparoscopic-physiologic-perturbations-implications-for-atrisk-patients.html
Mullett CE, Viale JP, Sagnard PE, Miellet CC, Ruynat LG, Counioux HC, et al. Pulmonary CO2 elimination during surgical procedures using intra- or extraperitoneal CO2 insufflation. Anesth Analg. 1993;76:622–6.
Lind L. Metabolic gas exchange during gynaecological laparotomy and laparoscopy. Can J Anaesth. 1994;41:19–22.
McHoney MC, Corizia L, Eaton S, Wade A, Spitz L, Drake DP, et al. Laparoscopic surgery in children is associated with an intraoperative hypermetabolic response. Surg Endosc. 2006;20:452–7.
Safran D, Sgambati S, Orlando R. Laparoscopy in high-risk cardiac patients. Surg Gynecol Obstet. 1993;176:548–54.
Koivusalo A-M, Lindgren L. Effects of carbon dioxide pneumoperitoneum for laparoscopic cholecystectomy. Acta Anaesthesiol Scand. 2000;44:834–41.
Guinot P-G, de Broca B, Bernard E, Abou Arab O, Lorne E, Dupont H. Respiratory stroke volume variation assessed by oesophageal Doppler monitoring predicts fluid responsiveness during laparoscopy. Br J Anaesth. 2014;112:660–4.
Glaser R, Sannwald GA, Buhr HJ, Kuntz C, Mayer H, Klee F, et al. General stress response to conventional and laparoscopic cholecystectomy. Ann Surg. 1995;221:372–80.
Bellani G, Foti G, Spagnolli E, Milan M, Zanella A, Greco M, et al. Increase of oxygen consumption during a progressive decrease of ventilatory support is lower in patients failing the trial in comparison with those who succeed. Anesthesiology. 2010;113:378–85.
Taskin O, Buhur A, Birincioglu M, Burak F, Atmaca R, Yilmaz I, et al. The effects of duration of CO2 insufflation and irrigation on peritoneal microcirculation assessed by free radical scavengers and total glutathion levels during operative laparoscopy. J Am Assoc Gynecol Laparosc. 1998;5:129–33.
Friesenecker B, Tsai AG, Dünser MW, Mayr AJ, Martini J, Knotzer H, et al. Oxygen distribution in microcirculation after arginine vasopressin-induced arteriolar vasoconstriction. Am J Physiol Heart Circ Physiol. 2004;287:H1792–H18001800.
Hatipoglu S. Effect of laparoscopic abdominal surgery on splanchnic circulation: historical developments. WJG. 2014;20:18165.
Tan W, Qian D, Zheng M, Lu X, Han Y, Qi D. Effects of different doses of magnesium sulfate on pneumoperitoneum-related hemodynamic changes in patients undergoing gastrointestinal laparoscopy: a randomized, double-blind, controlled trial. BMC Anesthesiol. 2019;19:237.
Kazama T, Ikeda K, Kato T, Kikura M. Carbon dioxide output in laparoscopic cholecystectomy. Br J Anaesth. 1996;76:530–5.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Author information
Authors and Affiliations
Contributions
SB and PGG contributed to the study concept and design. SB, DS, BdB, OAA, MM, FL, HD, PGG, and EL contributed to the acquisition, analysis, or interpretation of the data. SB and PGG performed the statistical analysis. SB, PGG, HD, MM, and EL drafted the manuscript. All authors read and approved the final manuscript.
Corresponding author
Ethics declarations
Conflict of interest
The authors have no financial conflicts of interest.
Statement of human rights
This research involving Human Participants was approved by an independent ethics committee (Comité d’Éthique de la Recherche en Anesthésie-Réanimation (CERAR); Ref: IRB 00010254-2018-156).
Informed consent
All patients provided their informed consent prior to inclusion in the study.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Bar, S., Santarelli, D., de Broca, B. et al. Predictive value of the respiratory exchange ratio for the occurrence of postoperative complications in laparoscopic surgery: a prospective and observational study. J Clin Monit Comput 35, 849–858 (2021). https://doi.org/10.1007/s10877-020-00544-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10877-020-00544-5