Cuidado respiratorio perioperatorio del obeso / Perioperative respiratory care of obesity

Diciembre 18, 2017. No. 2936

Manejo respiratorio perioperatorio de los pacientes obesos Respiratory Management of Perioperative Obese Patients. Imber DA1,2, Pirrone M1,3, Zhang C1,4, Fisher DF5, Kacmarek RM6, Berra L7,8. Author information Respir Care. 2016 Dec;61(12):1681-1692. Epub 2016 Sep 13. Abstract With a rising incidence of obesity in the United States, anesthesiologists are faced with a larger volume of obese patients coming to the operating room as well as obese patients with ever-larger body mass indices (BMIs). While there are many cardiovascular and endocrine issues that clinicians must take into account when caring for the obese patient, one of the most prominent concerns of the anesthesiologist in the perioperative setting should be the status of the lung. Because the pathophysiology of reduced lung volumes in the obese patient differs from that of the ARDS patient, the best approach to keeping the obese patient's lung open and adequately ventilated during mechanical ventilation is unique. Although strong evidence and research are lacking regarding how to best ventilate the obese surgical patient, we aim with this review to provide an assessment of the small amount of research that has been conducted and the pathophysiology we believe influences the apparent results. We will provide a basic overview of the anatomy and pathophysiology of the obese respiratory system and review studies concerning pre-, intra-, and postoperative respiratory care. Our focus in this review centers on the best approach to keeping the lung recruited through the prevention of compression atelectasis and the maintaining of physiological lung volumes. We recommend the use of PEEP via noninvasive ventilation (NIV) before induction and endotracheal intubation, the use of both PEEP and periodic recruitment maneuvers during mechanical ventilation, and the use of PEEP via NIV after extubation. It is our hope that by studying the underlying mechanisms that make ventilating obese patients so difficult, future research can be better tailored to address this increasingly important challenge to the field of anesthesia. KEYWORDS: PEEP; atelectasis; mechanical ventilation; noninvasive ventilation; obesity; recruitment maneuver PDF International Anesthesia Research Society Annuals Meetings USA Informes / Information

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org

Más de ventilación perioperatoria / More on perioperative ventilation

Septiembre 7, 2017. No. 2804

Efectos de la ventilación mecánica intraoperatoria y de la ventilación de protección pulmonar en el paciente quirúrgico adulto Peris-Montalt R, Cruz-García-Dihinx I, Errando C, Granell M. MÉD.UIS. 2015;28(1):65-78. PDF Conceptos actuales de ventilación protectora durante la anestesia general. Current concepts of protective ventilation during general anaesthesia. Serpa Neto A1, Schultz MJ2, Slutsky AS3. Author information Swiss Med Wkly. 2015 Nov 12;145:w14211. doi: 10.4414/smw.2015.14211. eCollection 2015. Abstract Mechanical ventilation with high tidal volumes (VT) has been common practice in operating theatres because this strategy recruits collapsed lung tissue and improves ventilation-perfusion mismatch, thus decreasing the need for high inspired oxygen concentrations. Positive end-expiratory pressure (PEEP) was not used routinely because it was thought to impair cardiovascular function. Over the past two decades there have been advances in our understanding of the causes and importance of ventilation-induced lung injury based on studies in animals with healthy lungs, and trials in critically ill patients with and without acute respiratory distress syndrome. Recent data from randomised controlled trials in patients receiving ventilation during general anaesthesia for surgery have demonstrated that lung-protective strategies (use of low VT, use of PEEP if indicated, and avoidance of excessive oxygen concentrations) are also of importance during intraoperative ventilation. PDF XIV Congreso Virtual Mexicano de Anestesiología 2017 Octubre 1-Diciembre 31, 2017 Información / Information Video informativo Convocatoria para el Curso de Posgrado en Medicina del Dolor y Paliativa 2018 para Mexicanos y extranjeros. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán Informes (52) 55 5487 0900 ext. 5011 de lunes a viernes de 9.00 a 14 h (hora de Ciudad de México).  Informes / Information California Society of Anesthesiologists Reuniones / Events Informacion / Information

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org

Ventilación perioperatoria / Perioperative ventilation

Septiembre 6, 2017. No. 2803

Epidemiología, práctica de ventilación y resultado en pacientes con mayor riesgo de complicaciones pulmonares postoperatorias: LAS VEGAS - un estudio observacional en 29 países. Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications: LAS VEGAS - an observational study in 29 countries. LAS VEGAS investigators. Collaborators (492) Eur J Anaesthesiol. 2017 Aug;34(8):492-507. doi: 10.1097/EJA.0000000000000646. Abstract BACKGROUND: Limited information exists about the epidemiology and outcome of surgical patients at increased risk of postoperative pulmonary complications (PPCs), and how intraoperative ventilation was managed in these patients. OBJECTIVES: To determine the incidence of surgical patients at increased risk of PPCs, and to compare the intraoperative ventilation management and postoperative outcomes with patients at low risk of PPCs.  CONCLUSION: The incidence of patients with a predicted increased risk of PPCs is high. A large proportion of patients receive high VT and low PEEP levels. PPCs occur frequently in patients at increased risk, with worse clinical outcome. TRIAL REGISTRATION: The study was registered at Clinicaltrials.gov, number NCT01601223. PDF Ventilación intraoperatoria protectora con niveles más altos o más bajos de presión positiva de expiración final en pacientes obesos (PROBESE): protocolo de estudio para un ensayo controlado aleatorio. Protective intraoperative ventilation with higher versus lower levels of positive end-expiratory pressure in obese patients (PROBESE): study protocol for a randomized controlled trial. Bluth T1, Teichmann R1, Kiss T1, Bobek I2, Canet J3, Cinnella G4, De Baerdemaeker L5, Gregoretti C6, Hedenstierna G7, Hemmes SN8,9, Hiesmayr M10,11,12,13, Hollmann MW8,9, Jaber S14, Laffey JG15,16,17,18, Licker MJ19, Markstaller K13, Matot I20, Müller G21, Mills GH22, Mulier JP23, Putensen C24, Rossaint R25, Schmitt J21, Senturk M26, Serpa Neto A27,28, Severgnini P29, Sprung J30, Vidal Melo MF31, Wrigge H32, Schultz MJ9,33, Pelosi P34, Gama de Abreu M35; PROBESE investigators; and the PROtective VEntilation Network (PROVEnet); Clinical Trial Network of the European Society of Anaesthesiology (ESA). Collaborators (157) Author information Trials. 2017 Apr 28;18(1):202. doi: 10.1186/s13063-017-1929-0. Erratum to Protective intraoperative ventilation with higher versus lower levels of positive end-expiratory pressure in obese patients (PROBESE): study protocol for a randomized controlled trial. [Trials. 2017] Abstract BACKGROUND: Postoperative pulmonary complications (PPCs) increase the morbidity and mortality of surgery in obese patients. High levels of positive end-expiratory pressure (PEEP) with lung recruitment maneuvers may improve intraoperative respiratory function, but they can also compromise hemodynamics, and the effects on PPCs are uncertain. We hypothesized that intraoperative mechanical ventilation using high PEEP with periodic recruitment maneuvers, as compared with low PEEP without recruitment maneuvers, prevents PPCs in obese patients. METHODS/DESIGN: The PRotective Ventilation with Higher versus Lower PEEP during General Anesthesia for Surgery in OBESE Patients (PROBESE) study is a multicenter, two-arm, international randomized controlled trial. In total, 2013 obese patients with body mass index ≥35 kg/m2 scheduled for at least 2 h of surgery under general anesthesia and at intermediate to high risk for PPCs will be included. Patients are ventilated intraoperatively with a low tidal volume of 7 ml/kg (predicted body weight) and randomly assigned to PEEP of 12 cmH2O with lung recruitment maneuvers (high PEEP) or PEEP of 4 cmH2O without recruitment maneuvers (low PEEP). The occurrence of PPCs will be recorded as collapsed composite of single adverse pulmonary events and represents the primary endpoint. DISCUSSION: To our knowledge, the PROBESE trial is the first multicenter, international randomized controlled trial to compare the effects of two different levels of intraoperative PEEP during protective low tidal volume ventilation on PPCs in obese patients. The results of the PROBESE trial will support anesthesiologists in their decision to choose a certain PEEP level during general anesthesia for surgery in obese patients in an attempt to prevent PPCs. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02148692. Registered on 23 May 2014; last updated 7 June 2016. KEYWORDS: Mechanical ventilation; Obesity; Positive end-expiratory pressure; Postoperative pulmonary complication; Recruitment maneuver PDF XIV Congreso Virtual Mexicano de Anestesiología 2017 Octubre 1-Diciembre 31, 2017 Información / Information Video informativo Convocatoria para el Curso de Posgrado en Medicina del Dolor y Paliativa 2018 para Mexicanos y extranjeros. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán Informes (52) 55 5487 0900 ext. 5011 de lunes a viernes de 9.00 a 14 h (hora de Ciudad de México).  Informes / Information California Society of Anesthesiologists Reuniones / Events Informacion / Information

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org