Ventilación / Ventilation

Diciembre 9, 2017. No. 2927

Ventilación protectora y maniobras de reclutamiento pulmonar en cirugía mayor María Camila Arango-Granados, Fredy Ariza Rev Argent Anestesiol 2016;74:1-9 - DOI: 10.1016/j.raa.2016.05.002 Resumen La ventilación mecánica es una intervención frecuente en el escenario quirúrgico, especialmente para procedimientos de alta complejidad y en pacientes críticamente enfermos, pero no está exenta de complicaciones. Los estudios durante los últimos años han estado encaminados a definir cuál es la estrategia ventilatoria que ofrece el mejor perfil de seguridad durante cirugía mayor. Esta revisión busca exponer cuál es la evidencia disponible sobre estrategias ventilatorias y maniobras de reclutamiento pulmonar en el paciente llevado a cirugía mayor. Para esto se realizó una búsqueda estructurada de la literatura incluida en las bases de datos MEDLINE y SciELO. Las publicaciones disponibles parecen coincidir en que el uso de volúmenes corrientes bajos reduce las complicaciones pulmonares postoperatorias en pacientes que serán sometidos a cirugía mayor. Sin embargo, existe evidencia contradictoria sobre este beneficio en cirugía de tórax. Los hallazgos sobre el uso de presión positiva al final de la espiración aún son heterogéneos. La literatura disponible indica que en cirugía de tórax, cirugía cardiovascular y cirugía traumatológica esta estrategia parece tener potenciales beneficios. En cambio, en cirugía abdominal mayor y neurocirugía existen datos contradictorios que indican la necesidad de futuras investigaciones. Aun es necesario estudiar si las maniobras de reclutamiento ofrecen reales beneficios para los pacientes que se llevan a cirugía mayor, independiente del tipo de cirugía. Finalmente, aún no es posible establecer si tanto la ventilación protectora como las maniobras de reclutamiento pulmonar realizadas en el intraoperatorio impactan en los desenlaces a largo plazo o la mortalidad. PDF Posición prona en pacientes con síndrome de dificultad respiratoria aguda Prone positioning acute respiratory distress syndrome patients. Guérin C1,2,3. Author information Ann Transl Med. 2017 Jul;5(14):289. doi: 10.21037/atm.2017.06.63. Abstract Prone position has been used in acute respiratory distress syndrome (ARDS) patients for more than 40 years in ICU. After having demonstrated its capability to significantly improve oxygenation in a large number of patients, sometimes dramatically, this procedure has been found to prevent ventilator-induced lung injury, the primary concern for the intensivists managing ARDS patients. Over the time, several trials have been done, which regularly improved and refined from each other. At the end, significant improvement in survival has been demonstrated in the most severe ARDS patients, at a threshold of 100-150 mmHg PaO2/FiO2 ratio. The effect of proning on survival cannot be predicted and seems unrelated with both severity of oxygenation impairment and oxygenation response to proning. The rate of complication is declining with the increase in centers expertise. The pressure sores are more frequent in prone and require a special attention. Prone position is a key component of lung protective mechanical ventilation and should be used as a first line therapy in association with low tidal volume and neuromuscular blocking agents in patients with severe ARDS. KEYWORDS: Acute respiratory distress syndrome (ARDS); hypoxemia; mechanical ventilation; prone position; ventilator induced lung injury PDF Volumen corriente en síndrome de falla respiratoria aguda. Como mejor seleccionarlo Tidal volume in acute respiratory distress syndrome: how best to select it. Umbrello M1, Marino A2, Chiumello D1,2. Author information Ann Transl Med. 2017 Jul;5(14):287. doi: 10.21037/atm.2017.06.51. Abstract Mechanical ventilation is the type of organ support most widely provided in the intensive care unit. However, this form of support does not constitute a cure for acute respiratory distress syndrome (ARDS), as it mainly works by buying time for the lungs to heal while contributing to the maintenance of vital gas exchange. Moreover, it can further damage the lung, leading to the development of a particular form of lunginjury named ventilator-induced lung injury (VILI). Experimental evidence accumulated over the last 30 years highlighted the factors associated with an injurious form of mechanical ventilation. The present paper illustrates the physiological effects of delivering a tidal volume to the lungs of patients with ARDS, and suggests an approach to tidal volume selection. The relationship between tidal volume and the development of VILI, the so called volotrauma, will be reviewed. The still actual suggestion of a lung-protective ventilatory strategy based on the use of low tidal volumes scaled to the predicted body weight (PBW) will be presented, together with newer strategies such as the use of airway driving pressure as a surrogate for the amount of ventilatable lung tissue or the concept of strain, i.e., the ratio between the tidal volume delivered relative to the resting condition, that is the functional residual capacity (FRC). An ultra-low tidal volume strategy with the use of extracorporeal carbon dioxide removal (ECCO2R) will be presented and discussed. Eventually, the role of other ventilator-related parameters in the generation of VILI will be considered (namely, plateau pressure, airway driving pressure, respiratory rate (RR), inspiratory flow), and the promising unifying framework of mechanical power will be presented. KEYWORDS: Acute respiratory distress syndrome (ARDS); mechanical ventilation; tidal volume; ventilator-induced lung injury (VILI) 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