Effects of Individualised High Positive End-Expiratory Pressure and Crystalloid Administration on Postoperative Pulmonary Function in Patients Undergoing Robotic-Assisted Radical Prostatectomy: A Prospective Randomised Single-Blinded Pilot Study

Abstract

Objectives: Robotic-assisted laparoscopic prostatectomy (RALP) is typically conducted in steep Trendelenburg position (STP). The aim of the study was to evaluate whether crystalloid administration and individual management of positive end-expiratory pressure (PEEP) improve peri- and post-operative pulmonary function in patients undergoing RALP. Design: Prospective randomised single-centre single-blinded explorative study. Setting: Patients were either allocated to a standard PEEP (5 cmH2O) group or an individualised high PEEP group. Furthermore, each group was divided into a liberal and a restrictive crystalloid group (8 vs. 4 mL/kg/h predicted body weight). Individualised PEEP levels were determined by means of preoperative recruitment manoeuvre and PEEP titration in STP. Participants: Informed consent was obtained from 98 patients scheduled for elective RALP. Interventions: The following intraoperative parameters were analysed in each of the four study groups: ventilation setting (peak inspiratory pressure [PIP], plateau pressure, driving pressure [Pdriv], lung compliance [LC] and mechanical power [MP]) and postoperative pulmonary function (bed-side spirometry). The spirometric parameters Tiffeneau index (FEV1/FVC ratio) and mean forced expiratory flow (FEF25–75) were measured pre- and post-operatively. Data are shown as mean ± standard deviation (SD), and groups were compared with ANOVA. A p-value of <0.05 was considered significant. Results: The two individualised high PEEP groups (mean PEEP 15.5 [±1.71 cmH2O]) showed intraoperative significantly higher PIP, plateau pressure and MP levels but significantly decreased Pdriv and increased LC. On the first and second postoperative day, patients with individualised high PEEP levels had a significantly higher mean Tiffeneau index and FEF25–75. Perioperative oxygenation and ventilation and postoperative spirometric parameters were not influenced by restrictive or liberal crystalloid infusion in either of the two respective PEEP groups. Conclusions: Individualised high PEEP levels (≥14 cmH2O) during RALP improved intraoperative blood oxygenation and resulted in more lung-protective ventilation. Furthermore, postoperative pulmonary function was improved for up to 48 h after surgery in the sum of the two individualised high PEEP groups. Restrictive crystalloid infusion during RALP seemed to have no effect on peri- and post-operative oxygenation and pulmonary function.

Mechanical power during robotic-assisted laparoscopic prostatectomy: an observational study

“…When PEEP was individualized, resulting in levels between 12-14 cmH 2 O, arterial oxygenation and respiratory system compliance were higher compared to a lower fixed level (i.e. 5 cmH 2 O) [22,31,33,34]. However, in the same position, increasing PEEP to 10 cmH 2 O raised total mechanical power compared to 5 cmH 2 O of PEEP, although respiratory system elastance did not change.…”

“…During mechanical ventilation, PEEP levels usually do not exceed 5 cmH 2 O, which can be not sufficient to avoid lung atelectasis and prevent VILI [22]. Previous studies suggested to select PEEP achieving the maximal respiratory system compliance, the lower driving pressure or according to the intrabdominal pressure [9,22,[30][31][32]. When PEEP was individualized, resulting in levels between 12-14 cmH 2 O, arterial oxygenation and respiratory system compliance were higher compared to a lower fixed level (i.e.…”