Effect of different mechanical ventilation modes on cerebral blood flow during thoracoscopic surgery in neonates: A randomised controlled trial

Abstract

Background and Aims: Infants exposed to major surgery are at risk of injuries to the immature brain because of reduced arterial oxygen saturation. This study compared the effect of volume-controlled ventilation (VCV) versus pressure-controlled ventilation (PCV) on cerebral oxygenation in neonates subjected to repair of tracheoesophageal fistula (TEF) under video-assisted thoracoscopic surgery (VATS). Methods: This randomised controlled study included 30 full-term neonates scheduled for VATS for managing TEF under general anaesthesia. They were randomised to either VC group (n = 15), who received VCV, or PC group (n = 15), who received PCV. Cerebral oxygenation (rScO 2 ) was monitored throughout the surgery with documentation of episodes of cerebral desaturation. Peripheral oxygen saturation, partial pressure of carbon dioxide (PaCO 2 ), and end-tidal carbon dioxide were recorded at baseline, after induction of anaesthesia, and every 30 min till the end of the surgery. Results: rScO 2 was significantly higher in the PC group than the VC group at baseline and was significantly higher in the VC group after 15 min (P = 0.041). Later, it was comparable in both the groups up to 60 min after starting the surgery. Cerebral desaturation was significantly more common in the PC group (80%) compared to VC group (33.3%) (P = 0.010). PC group required higher fraction of inspired oxygen and positive end-expiratory pressure to prevent cerebral desaturation. PaCO 2 was significantly higher in the PC group than the VC group at 30 and 60 min (P = 0.005 and 0.029). Conclusion: VCV is safer than PCV for cerebral oxygenation during VATS in neonates.

Risk of bias in published randomised controlled trials

“…The demographic data of the 27 included articles are given in Table 1 . [ 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 ] Overall, 13 out of 27 were judged as having a low risk of bias. [ 5 6 9 10 12 15 16 20 21 22 23 24 27 ] In contrast, 6 out of 27 had a high risk of bias,[ 4 13 14 25 28 30 ] and 8 out of 27 had some concerns regarding biases.…”

“…[ 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 ] Overall, 13 out of 27 were judged as having a low risk of bias. [ 5 6 9 10 12 15 16 20 21 22 23 24 27 ] In contrast, 6 out of 27 had a high risk of bias,[ 4 13 14 25 28 30 ] and 8 out of 27 had some concerns regarding biases. [ 7 8 11 17 18 19 26 29 ] In domain 1, that is, bias arising from the randomisation process, 3 out of 27 had some concerns regarding biases.…”

“…[ 25 28 30 ] Rest of the trials were judged as having a low risk of bias. [ 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 26 27 29 ] In domain 2, that is, bias due to deviations from intended interventions, 7 out of 27 had some concerns regarding biases. [ 5 8 11 13 14 18 29 ] and the remaining trials were judged as having a low risk of bias.…”

Paediatric anaesthesia practice: Has it really changed over the times?

“…This is largely evident in the seven articles pertaining to paediatric anaesthesia being published in this issue of the Indian Journal of Anaesthesia (IJA). [ 1 2 3 4 5 6 7 ]…”

“…have reported a study in this issue of the IJA wherein, the regional cerebral oxygen saturation (rScO2) was measured by near-infrared spectroscopy (NIRS) in 30 full-term neonates weighing more than 2,500 g and undergoing either VCV or PCV through uncuffed tubes during thoracoscopic surgery. [ 2 ] They reported more episodes of cerebral desaturation, higher fractional inspired concentration of oxygen (FIO 2 ), positive end-expiratory pressure (PEEP) requirement, and higher partial pressure of carbon dioxide (PaCO 2 ) levels with PCV mode compared with the VCV mode. The exact cause for this cannot be determined from the article.…”