Comparison of Positive End-Expiratory Pressure with Reverse Trendelenburg Position in Morbidly Obese Patients Undergoing Bariatric Surgery: Effects on Hemodynamics and Pulmonary Gas Exchange

Perilli, Valter; Sollazzi, Liliana; Modesti, Cristina; Annetta, Maria Giuseppina; Sacco, Teresa; Bocci, Maria Grazia; Tacchino, Roberto M.; Proietti, R.

doi:10.1381/096089203322190826

Cited by 63 publications

(49 citation statements)

References 20 publications

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“…Boyce et al (32) have shown a significant extension of a "safe apnea period" in these patients by employing the 30°reverse Trendelenburg position during induction of anesthesia. Perilli et al (33) have shown benefits of this position for oxygenation during anesthesia. Juvin et al (6) have reported a higher rate of difficult intubation in obese patients compared with lean ones, and a high risk of desaturation in obese patients with difficult intubation.…”

Section: Intraoperative Patient Managementmentioning

confidence: 98%

Best Practice Recommendations for Anesthetic Perioperative Care and Pain Management in Weight Loss Surgery

et al. 2005

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Best practice recommendations for anesthetic perioperative care and pain management in weight loss surgery. Obes Res. 2005;13:254 -266. Objective: To develop evidence-based recommendations that optimize the safety and efficacy of perioperative anesthetic care and pain management in weight loss surgery (WLS) patients. Research Methods and Procedures:This Task Group examined the scientific literature on anesthetic perioperative care and pain management published in MEDLINE from January 1994 to March 2004. We also reviewed additional data from other sources (e.g., book chapters). The search yielded 195 abstracts, of which 35 references were reviewed in detail. Task Group consensus was used to provide recommendations when evidence in the literature was insufficient. Results: We developed anesthesia practice and patient safety advisory recommendations for preoperative evaluation, intraoperative management, and postoperative care and pain management of WLS patients. We also provided suggestions related to medical error reduction and systems improvements, credentialing, and future research. Discussion: Obesity-related comorbidities including obstructive sleep apnea place WLS patients at increased risk for complications perioperatively. Regarding perioperative safety and outcomes, conclusive evidence beyond the accepted standard of care in the reviewed literature is limited. Few reports specifically address the perioperative needs of severely obese patients. In this advisory, we synthesize current knowledge and make best practice recommendations for perioperative care and pain management in WLS patients. These recommendations require periodic review as further medical knowledge and evidence evolve.

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Section: Intraoperative Patient Managementmentioning

confidence: 98%

Best Practice Recommendations for Anesthetic Perioperative Care and Pain Management in Weight Loss Surgery

et al. 2005

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“…1,6,7,[12][13][14] Several ventilatory strategies aiming at improving arterial oxygenation and respiratory mechanics during laparoscopic surgery have been investigated: the application of positive end-expiratory pressure (PEEP) has been shown to counterbalance the diaphragm cranial shift increasing functional residual capacity and decreasing respiratory system elastance (E RS ). 12,13,[15][16][17] Recently, translating the concept of lung-protective ventilatory strategy from the adult respiratory distress syndrome context, 9,14,[18][19][20] the application of an "open lung" strategy consisting in a recruiting maneuver (RM) followed by the subsequent application of PEEP has been suggested to effectively reexpand pneumoperitoneum-induced atelectasis and improve oxygenation during laparoscopic surgery. [21][22][23][24][25] However, to our knowledge, the effects of the open lung strategy on respiratory mechanics partitioned between its chest wall and lung components (i.e., the relative effect exerted by the open lung strategy on lung and chest wall mechanics) have not been thoroughly investigated.…”

Section: Effects Of Recruitment Maneuver and Positive End-expiratory mentioning

confidence: 99%

Effects of Recruitment Maneuver and Positive End-expiratory Pressure on Respiratory Mechanics and Transpulmonary Pressure during Laparoscopic Surgery

et al. 2013

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Background: The authors tested the hypothesis that during laparoscopic surgery, Trendelenburg position and pneumoperitoneum may worsen chest wall elastance, concomitantly decreasing transpulmonary pressure, and that a protective ventilator strategy applied after pneumoperitoneum induction, by increasing transpulmonary pressure, would result in alveolar recruitment and improvement in respiratory mechanics and gas exchange. Methods: In 29 consecutive patients, a recruiting maneuver followed by positive end-expiratory pressure 5 cm H 2 O maintained until the end of surgery was applied after pneumoperitoneum induction. Respiratory mechanics, gas exchange, blood pressure, and cardiac index were measured before (T BSL ) and after pneumoperitoneum with zero positive end-expiratory pressure (T preOLS ), after recruitment with positive end-expiratory pressure (T postOLS ), and after peritoneum desufflation with positive end-expiratory pressure (T end ). Results: Esophageal pressure was used for partitioning respiratory mechanics between lung and chest wall (data are mean ± SD): on T preOLS , chest wall elastance (E cw ) and elastance of the lung (E L ) increased (8.2 ± 0.9 vs. 6.2 ± 1.2 cm H 2 O/L, respectively, on T BSL ; P = 0.00016; and 11.69 ± 1.68 vs. 9.61 ± 1.52 cm H 2 O/L on T BSL ; P = 0.0007). On T postOLS , both chest wall elastance and E L decreased (5.2 ± 1.2 and 8.62 ± 1.03 cm H 2 O/L, respectively; P = 0.00015 vs. T preOLS ), and PaO 2 /inspiratory oxygen fraction improved (491 ± 107 vs. 425 ± 97 on T preOLS; P = 0.008) remaining stable thereafter. Recruited volume (the difference in lung volume for the same static airway pressure) was 194 ± 80 ml. Pplat RS remained stable while inspiratory transpulmonary pressure increased (11.65 + 1.37 cm H 2 O vs. 9.21 + 2.03 on T preOLS ; P = 0.007). All respiratory mechanics parameters remained stable after abdominal desufflation. Hemodynamic parameters remained stable throughout the study. Conclusions:In patients submitted to laparoscopic surgery in Trendelenburg position, an open lung strategy applied after pneumoperitoneum induction increased transpulmonary pressure and led to alveolar recruitment and improvement of E cw and gas exchange. LAPAROSCOPY is a well-established procedure for pelvic gynecologic surgery often performed in Trendelenburg position.1,2 To facilitate laparoscopic surgical manipulation, a pneumoperitoneum is usually induced through carbon dioxide inflation. Both the increase in abdominal pressure as a result of carbon dioxide inflation and the head down body position have been shown to impair the respiratory function during the procedure, mainly inducing atelectasis formation in the dependent lung regions. 1,[3][4][5][6] The resulting decrease in functional residual capacity poses Address correspondence to Dr. Cinnella: Departmentt of Anesthesia and Intensive Care, Policlinico 'Riuniti' -University of Foggia, Viale Pinto 1 -71100 Foggia, Italy. g.cinnella@unifg.it. Information on purchasing reprints may be found at www.anesthesiology.org...

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“…In severely obese patients, the 30°r everse Trendelenburg position, with the use of a ramp to elevate the head, neck, and shoulders, or configuration of the operating room table provides the safest apnea period for tracheal intubation compared with the supine horizontal or 30°backup Fowler position. [47][48][49] Atelectasis formation is largely prevented by positive end-expiratory pressure applied during the anesthetic induction and is associated with more favorable oxygenation. 50 Evidence regarding the difficulty of intubation through direct laryngoscopy is conflicting.…”

Section: Induction and Intubationmentioning

confidence: 99%

Cardiovascular Evaluation and Management of Severely Obese Patients Undergoing Surgery

Poirier¹,

Alpert²,

Fleisher³

et al. 2009

Circulation

243

114

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Abstract-Obesity is associated with comorbidities that may lead to disability and death. During the past 20 years, the number of individuals with a body mass index Ͼ30, 40, and 50 kg/m 2 , respectively, has doubled, quadrupled, and quintupled in the United States. The risk of developing comorbid conditions rises with increasing body mass index. Possible cardiac symptoms such as exertional dyspnea and lower-extremity edema occur commonly and are nonspecific in obesity. The physical examination and electrocardiogram often underestimate cardiac dysfunction in obese patients. The risk of an adverse perioperative cardiac event in obese patients is related to the nature and severity of their underlying heart disease, associated comorbidities, and the type of surgery. Severe obesity has not been associated with increased mortality in patients undergoing cardiac surgery but has been associated with an increased length of hospital stay and with a greater likelihood of renal failure and prolonged assisted ventilation. Comorbidities that influence the preoperative cardiac risk assessment of severely obese patients include the presence of atherosclerotic cardiovascular disease, heart failure, systemic hypertension, pulmonary hypertension related to sleep apnea and hypoventilation, cardiac arrhythmias (primarily atrial fibrillation), and deep vein thrombosis. When preoperatively evaluating risk for surgery, the clinician should consider age, gender, cardiorespiratory fitness, electrolyte disorders, and heart failure as independent predictors for surgical morbidity and mortality. An obesity surgery mortality score for gastric bypass has also been proposed. Given the high prevalence of severely obese patients, this scientific advisory was developed to provide cardiologists, surgeons, anesthesiologists, and other healthcare professionals with recommendations for the preoperative cardiovascular evaluation, intraoperative and perioperative management, and postoperative cardiovascular care of this increasingly prevalent patient population. (Circulation. 2009;120:86-95.)

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Comparison of Positive End-Expiratory Pressure with Reverse Trendelenburg Position in Morbidly Obese Patients Undergoing Bariatric Surgery: Effects on Hemodynamics and Pulmonary Gas Exchange

Abstract: RTP and PEEP can be considered adequate ventilatory settings for morbidly obese patients, without any significant difference with regard to gas exchange improvement. However, the decrease in CO may partially counteract the beneficial effects on oxygenation of these ventilatory settings.

Cited by 63 publications

References 20 publications

Best Practice Recommendations for Anesthetic Perioperative Care and Pain Management in Weight Loss Surgery

Best Practice Recommendations for Anesthetic Perioperative Care and Pain Management in Weight Loss Surgery

Effects of Recruitment Maneuver and Positive End-expiratory Pressure on Respiratory Mechanics and Transpulmonary Pressure during Laparoscopic Surgery

Cardiovascular Evaluation and Management of Severely Obese Patients Undergoing Surgery

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