Lung protective properties of the volatile anesthetics

O’Gara, Brian; Talmor, Daniel

doi:10.1007/s00134-016-4429-x

Cited by 42 publications

(20 citation statements)

References 15 publications

(15 reference statements)

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“…Although a 2013 Cochrane review concluded “ that no evidence indicated that the drug used to maintain anaesthesia during one‐lung ventilation affected participant outcomes ” there is a significant body of randomised controlled trial data suggesting a reduced incidence of pulmonary inflammation and/or pulmonary complications in thoracic patients receiving volatile anaesthesia . This is perceived to stem from an immunomodulatory effect of volatile anaesthesia . Conversely, propofol is well recognised to have anti‐oxidant properties both in vitro and in vivo, and there is a substantial animal literature supporting a protective effect of propofol in preventing lung injury via inhibition of oxidative stress‐mediated cellular dam .…”

Section: Discussionmentioning

confidence: 99%

Association between anaesthetic technique and unplanned admission to intensive care after thoracic lung resection surgery: the second Association of Cardiothoracic Anaesthesia and Critical Care (ACTACC) National Audit

et al. 2019

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Unplanned intensive care admission is a devastating complication of lung resection and is associated with significantly increased mortality. We carried out a two-year retrospective national multicentre cohort study to investigate the influence of anaesthetic and analgesic technique on the need for unplanned postoperative intensive care admission. All patients undergoing lung resection surgery in 16 thoracic surgical centres in the UK in the calendar years 2013 and 2014 were included. We defined critical care admission as the unplanned need for either tracheal intubation and mechanical ventilation or renal replacement therapy, and sought an association between mode of anaesthesia (total intravenous anaesthesia vs. volatile) and analgesic technique (epidural vs. paravertebral) and need for intensive care admission. A total of 253 out of 11,208 patients undergoing lung resection in the study period had an unplanned admission to intensive care in the postoperative period, giving an incidence of intensive care unit admission of 2.3% (95%CI 2.0-2.6%). Patients who had an unplanned admission to intensive care unit had a higher mortality (29.00% vs. 0.03%, p < 0.001), and hospital length of stay was increased (26 vs. 6 days, p < 0.001). Across univariate, complete case and multiple imputation (multivariate) models, there was a strong and significant effect of both anaesthetic and analgesic technique on the need for intensive care admission. Patients receiving total intravenous anaesthesia (OR 0.50 (95%CI 0.34-0.70)), and patients receiving epidural analgesia (OR 0.56 (95%CI 0.41-0.78)) were less likely to have an unplanned admission to intensive care after thoracic surgery. This large retrospective study suggests a significant effect of both anaesthetic and analgesic technique on outcome in patients undergoing lung resection. We must emphasise that the observed association does not directly imply causation, and suggest that well-conducted, large-scale randomised controlled trials are required to address these fundamental questions.

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Section: Discussionmentioning

confidence: 99%

Association between anaesthetic technique and unplanned admission to intensive care after thoracic lung resection surgery: the second Association of Cardiothoracic Anaesthesia and Critical Care (ACTACC) National Audit

et al. 2019

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“…For example, pulmonary inflammation has been shown to occur in nearly all mechanically ventilated patients, although the degree of inflammation can be influenced by ventilator settings and anesthetic type 192021. Atelectasis is also common, occurring in up to 90% of patients 22.…”

Section: Perioperative Lung Injurymentioning

confidence: 99%

Perioperative lung protective ventilation

O’Gara

Talmor

2018

BMJ

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Perioperative lung injury is a major source of postoperative morbidity, excess healthcare use, and avoidable mortality. Many potential inciting factors can lead to this condition, including intraoperative ventilator induced lung injury. Questions exist as to whether protective ventilation strategies used in the intensive care unit for patients with acute respiratory distress syndrome are equally beneficial for surgical patients, most of whom do not present with any pre-existing lung pathology. Studied both individually and in combination as a package of intraoperative lung protective ventilation, the use of low tidal volumes, moderate positive end expiratory pressure, and recruitment maneuvers have been shown to improve oxygenation and pulmonary physiology and to reduce postoperative pulmonary complications in at risk patient groups. Further work is needed to define the potential contributions of alternative ventilator strategies, limiting excessive intraoperative oxygen supplementation, use of non-invasive techniques in the postoperative period, and personalized mechanical ventilation. Although the weight of evidence strongly suggests a role for lung protective ventilation in moderate risk patient groups, definitive evidence of its benefit for the general surgical population does not exist. However, given the shift in understanding of what is needed for adequate oxygenation and ventilation under anesthesia, the largely historical arguments against the use of intraoperative lung protective ventilation may soon be outdated, on the basis of its expanding track record of safety and efficacy in multiple settings.

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“…Possible mechanisms for this effect include purposeful activity of the diaphragm and improved lung compliance due to anti-inflammatory properties of volatile agents. 8,23 Although some recommend muscular paralysis during the first 48 h in patients with severe ARDS, 24 we did not use muscular relaxants because they interfere with monitoring the depth of sedation clinically and preclude spontaneous breathing.…”

Section: Discussionmentioning

confidence: 99%

“…Current German and Spanish sedation guidelines recommend sedation using an inhaled anesthetic such as isoflurane as an alternative to intravenous sedation, especially when deep sedation is indicated. 4,5 In addition, isoflurane has bronchodilatory effects 6,7 and lung-protective properties, 8 which may be of benefit in patients with ARDS undergoing continuous lateral rotational therapy. 9 The AnaConDa system (Sedana Medical, Uppsala, Sweden), commercially available in Europe and Canada, can be used to deliver inhaled anesthetics via common intensive care ventilators.…”

Section: Introductionmentioning

confidence: 99%