REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
OfficialPublicationoftheBrazilianSocietyofAnesthesiologywww.sba.com.br
SCIENTIFIC
ARTICLE
Use
of
positive
pressure
in
pre
and
intraoperative
of
bariatric
surgery
and
its
effect
on
the
time
of
extubation
Letícia
Baltieri,
Laisa
Antonela
dos
Santos,
Irineu
Rasera-Junior,
Maria
Imaculada
de
Lima
Montebelo,
Eli
Maria
Pazzianotto-Forti
∗MastersPrograminPhysicalTherapy,UniversidadeMetodistadePiracicaba(UNIMEP),Piracicaba,SãoPaulo,Brazil
Received23August2013;accepted31October2013 Availableonline8January2015
KEYWORDS Diseases; Obesity;
Bariatricsurgery; Ventilation:positive pressure
Abstract
Backgroundandobjective: Toinvestigatetheinfluenceofintraoperativeandpreoperative
pos-itivepressureinthetimeofextubationinpatientsundergoingbariatricsurgery.
Method: Randomizedclinicaltrial,inwhich40 individualswithabodymassindexbetween
40and55kg/m2,agebetween25and55years,nonsmokers,underwentbariatricsurgerytype
Roux-en-Ygastricbypassbylaparotomyandwithnormalpreoperativepulmonaryfunctionwere randomizedintothefollowinggroups:G-pre(n=10):individualswhoreceivedtreatmentwith noninvasivepositivepressurebeforesurgeryfor1h;G-intra(n=10):individualswhoreceived positiveend-expiratorypressureof10cmH2Othroughoutthesurgicalprocedure;andG-control
(n=20):notreceivedanypreorintraoperativeintervention.Followingwererecorded:time betweeninductionofanesthesiaandextubation,betweentheendofanesthesiaandextubation, durationofmechanicalventilation,andtimebetweenextubationanddischargefromthe post-anestheticrecovery.
Results:Therewas nostatisticaldifferencebetween groups.However,when appliedtothe
Cohen coefficient,the useofpositive end-expiratory pressure of10cmH2Oduringsurgery
showedalargeeffectonthetimebetweentheendofanesthesiaandextubation.Aboutthis sametime,thetreatmentperformedpreoperativelyshowedmoderateeffect.
Conclusion:The use ofpositive end-expiratory pressureof10cmH2Ointhe intraoperative
andpositivepressurepreoperatively,influencedthetimeofextubationofpatientsundergoing bariatricsurgery.
©2014SociedadeBrasileiradeAnestesiologia.PublishedbyElsevier EditoraLtda.Allrights reserved.
∗Correspondingauthor.
E-mail:[email protected](E.M.Pazzianotto-Forti). http://dx.doi.org/10.1016/j.bjane.2013.10.021
PALAVRAS-CHAVE Doenc¸as;
Obesidade; Cirurgiabariátrica; Ventilac¸ãomecânica: pressãopositiva
Utilizac¸ãodapressãopositivanopréenointraoperatóriodecirurgiabariátricae seusefeitossobreotempodeextubac¸ão
Resumo
Justificativaeobjetivo: Investigar ainfluênciado usoda pressãopositiva intraoperatóriae
pré-operatórianotempodeextubac¸ãodepacientessubmetidosàcirurgiabariátrica.
Método: Trata-sedeensaioclínicorandomizado,noqual40indivíduoscomíndicedemassa
corporal entre40e55kg/m2,idadeentre25e55anos,nãotabagistas,submetidosà
cirur-gia bariátrica do tipo derivac¸ão gástrica em Y de Roux por laparotomia e com prova de func¸ão pulmonar pré-operatória dentro da normalidade foram randomizados nos seguintes grupos:G-pré (n=10):indivíduosquereceberamtratamentocompressãopositiva não inva-sivaantesdacirurgia,duranteumahora,G-intra(n=10):indivíduosquereceberamPositive End-expiratory Pressure de10cm H2O durantetodo oprocedimento cirúrgico e G-controle
(n=20):nãoreceberamqualquertipodeintervenc¸ãopréouintraoperatória.Foramanotados osseguintestempos:tempodecorridoentreainduc¸ãoanestésicaeaextubac¸ão,entreo tér-minodaanestesiaeextubac¸ão,tempodeventilac¸ãomecânica,etempoentreaextubac¸ãoe aaltadaRecuperac¸ãoPós-Anestésica.
Resultados: Nãohouvediferenc¸aestatísticaentreosgrupos,porémquandoaplicadoao
Coe-ficientedeCohen,ousodaPositiveEnd-expiratoryPressurede10cmH2Onointraoperatório
mostrouumefeitograndesobreotempoentreotérminodaanestesiaeaextubac¸ão.Sobre estemesmotempo,otratamentorealizadonopré-operatórioapresentouefeitomoderado.
Conclusão:Ouso daPositiveEnd-expiratoryPressure de 10cmH2Onointraoperatórioe da
pressãopositivanopré-operatório,podeinfluenciarotempodeextubac¸ãodepacientes sub-metidosàcirurgiabariátrica.
©2014SociedadeBrasileira deAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.
Introduction
Obesityiscurrentlyconsideredapublichealthproblemthat is reaching epidemic proportions.1 In 2008, over 1.4 bil-lionadultswereoverweightand,ofthese,over200million men and nearly300 million women were obese.1 Consid-eredtobeofmultifactorialorigin,theprobablecausesof obesityincludeacombinationofgenetic,endocrine, behav-ioral, socioeconomic, psychological, and environmental imbalances and,consequently,the emergence ofmultiple comorbidities.2Conservativetreatmentinvolvesnutritional therapy,drugtherapy,andphysicalactivity.When conserva-tivetreatmentisunsuccessfulandobesitybecomesmorbid, thebariatricsurgeryisindicated.3
Most surgical procedures requiring general anesthesia maytriggertheonsetofpostoperativecomplications,such as atelectasis, due to a decrease in functional residual capacity (FRC).4 Moreover, the loss of abdominal muscle integrity due tothe incisionand the need for neuromus-cularblockers,sedatives,andanalgesicsalsointerferewith musclecontractility,whichinturntriggerstheinadequate respiratorymuscleperformanceaftersurgery.5
Theseeffectsofgeneralanesthesiawhenassociatedwith morbid obesity may further worsen the development of intraoperativeandpostoperativecomplications.6Thus,the longerthedurationofsurgery,andconsequentlythe anes-theticprocedure,thegreaterthechancesofpostoperative pulmonarycomplications.7
Respiratoryphysiotherapywithre-expansiontechniques has proven benefits in reducing complications after
abdominalsurgery,8 but there are nowell-designed clini-caltrialsintheliteraturetoprovethatthereissuperiority betweenthe proposedtreatment formsfor the preopera-tive,intraoperativeandpost-operativeperiodsofabdominal surgery.
Literatureontheuseofnoninvasivemechanical ventila-tionpostoperativelyisvastandshowsgoodresults.9---11Some ventilatorystrategieshavebeenusedpostoperativelyinan attempttoimprovegasexchangethroughtheuseofpositive pressuremaneuversaimingatalveolarrecruitmentandeven reducingthesurgical time.12,13 However,theliterature on theuseofpositivepressurepreoperativelyasaprophylactic mannerisstillscarce.
Thus,thehypothesisofthestudywasthatpositive pres-sure applied during both pre- and intraoperative periods mayinfluencethe extubationtimeof patients undergoing bariatricsurgery.
Therefore, the aim of this study was to investi-gate the influence of intraoperative 10cm H2O positive
end-expiratory pressure (PEEP) and preoperative positive pressureonextubation timeof patientsundergoing Roux-en-Ygastricbypassbariatricsurgery.
Method
Studydesign
under protocol 54/11, and all patients provided written informedconsent.
Participants
Individuals with body mass index (BMI) between 40 and 55kgm−2,agedbetween25and55years,undergoing
Roux-en-Y gastric bypass bariatric surgery by laparotomy, and with normal preoperative pulmonary function tests were included.Smokersorthosewithhemodynamicinstabilityor surgicalcomplicationswereexcluded.
Samplesizecalculation
The sample size calculation was based on a pilot study, consideringthedifferenceoftheexpiratoryreservevolume (ERV)valuesobtainedbetweenthepreoperativeand postop-erativeperiods.Theleastsignificantdifference(0.18L)and theerrorstandarddeviation(0.11L)wereusedforthe cal-culation.ANOVAtestwasused,adoptingastatisticalpower of80%andan alphaof 0.05.Thus,anumberof 10 volun-teerspergroupwasdetermined.Samplesizecalculationwas performedusingtheBioEstatsoftwareversion5.3(Belém, Brazil).
Investigators
Thestudy included threeresearchers:oneresponsible for the patient initial evaluation and inclusion, one blind to initial data of volunteers and responsible for randomiza-tion,andone responsiblefortreatment application.After patient eligibility, randomization was performed and a sealedenvelopewashandedtotheinvestigatorresponsible fortreatmentapplication.
Screeningofvolunteers
Theinitialscreeningofvolunteerswasperformedby search-ingthepatientregistrationformforpossibleinclusioninthe study.Volunteersweredividedintothreedifferentgroups afterrandomizationinblocksoffiveusingMicrosoftExcel®
software.
Treatmentapplication
Subjectsinpreoperative group (PO)group received treat-mentwithbilevelpositiveairwaypressure(BiPAPSynchrony II---Respironics®)viafacialmaskforonehourbeforesurgery.
Theinspiratorypositiveairwaypressure(IPAP)wasstarted at12cmH2Oandadjustedaccordingtotheindividual
tol-erance, maintaining a respiratory rate below 30 breaths perminuteandatidalvolumeabout8---10mLkg−1ofideal
weight.Positiveend-expiratorypressure(PEEP)wassetat 8cmH2O.
Subjects in intraoperative group (IO) group received 10cmH2OPEEPthroughoutthesurgicalprocedure.
Subjects in control group received no preoperative or intraoperativeintervention.
All patients underwent bariatric surgery performed by the same surgical team under general anesthesia and
standard ventilation withtheDräger FabiusGS ventilator, involumecontrolmode,withtidalvolumeof6---8mLkg−1,
PEEP of 5cm H0O (except for IO group), and fraction of
inspiredoxygenbetween0.4and0.6.
Procedures
Respiratory evaluation consisted of anthropometric data collectionandpulmonaryfunctiontestbyspirometer micro-QuarkPony-FC(Cosmed,Rome,Italy).
Spirometrywasperformedinaccordancewithstandards oftheAmericanThoracicSociety(ATS)andEuropean Respi-ratory Society (ERS).14 Volunteers withnormal pulmonary functionwereincludedinthestudy.
Patientswerefollowed-upbytheinvestigatorinthe oper-ating room,and thesurgical procedure wasperformed as follows:thepatientpositionedonthesurgicaltablewas sub-jectedtoinductionofanesthesiawithinhaled sevoflurane andintravenouspropofol,andanesthesiamaintenancewith remifentanilby continuousinfusion pump.Afterinduction ofanesthesia,thepatientunderwentorotrachealintubation andwasplacedonmechanicalventilation.Bariatricsurgery began with a midline incision in the upper abdomen and duringthesurgicalprocedurethepatientwastreatedwith neuromuscularblockers andanalgesics,accordingtoneed evaluated by the surgeon and the anesthesiologist. After surgery, remifentanil was discontinuedand considered as theend ofanesthesia. Subsequently,thepatientcouldbe extubatedandtransferredtothepost-anesthesiacareunit (PACU)usingoxygenmask.Ascoreof10ontheAldreteand Kroulikscale,15 usedashospitalprotocol,wasrequiredfor patientdischargefromPACU.
Outcomemeasurements
The following outcomes were recorded during surgical procedure:timebetweeninductionofanesthesiaand extu-bation,timebetweentheendofanesthesiaandextubation, timeofmechanicalventilation,andtimebetween extuba-tionandPACUdischarge.
Statisticalanalysis
The SPSS version 17.0 was used for statistical analysis. Quantitative data are presented as mean and standard deviation(SD)andqualitativedataasfrequencies.Not sat-isfiedtheassumptionofnormalityandhomoscedasticityby Shapiro---WilkandLevene’stests,theKruskal---Wallistestwas performed.A5%levelofsignificancewasconsidered.
Treatment influence on variables was tested using an effectsizetocomparetreatmentgroupswithcontrolgroup. Forthis,theCohen’sdpooledorweightedwasused.
Cohen’s d pooled is calculated as follows: Cohen’s
d=mean 1−mean 2weighted SD−1, with weighted
SD=(SD1+SD2)2−1.
Surgical patients (n=271) Excluded (n=228)
Excluded (n=3)
Inability to evaluate: hospital routine (n=147)
Laparoscopic surgery (n=40)
Asthma (n=11) Smoking (n=9)
COPD (n=1) Age <25 years (n=1)
Age >55 years (n=1)
Another surgical type (intragastric balloon, revision, etc.) (n=4) BMI <40 kg.m–2 (n=12)
BMI >55 kg.m–2 (n=2)
Evaluated and randomized (n=43)
PO group (n=10) IO group (n=13)
PO group (n=10) IO group (n=10)
BMI: Body Mass Index; COPD: chronic obstructive pulmonary disease; OTI: orotracheal intubation; BE: bronchospasm.
Control group (n=20) Control group
(n=20)
Difficult TI + BE (n=1)
Surgical
complications (n=2)
Figure1 Flowchartofpatientsincluded.
Results
Within 20 weeks of the study, 271 patients under-went surgery, and of these, 228 were excluded for not meeting the criteria previously established. Forty-three patients were evaluatedand, of these, three were excluded during the study, leaving 40 patients: 20 in control group, 10 in IO group, and 10 in PO group (Fig.1).
Table1showstheanthropometriccharacteristicsof vol-unteers,withnostatisticaldifference,indicatingthesample homogeneity.
Table 2 summarizes the findings regarding intraopera-tivemeasurements,withnostatisticaldifferencesbetween groups.
Table3summarizesthevaluesobtainedfromthe treat-menteffectsizeanalysisusingCohen’scoefficient applied to the duration of surgery variables, revealing that the
Table1 Age,gender,andanthropometricdataofgroups,presentedasmeanandstandarddeviation.
Control IO PO p
n 20 10 10
Sex(F/M) 16/4 9/1 8/2 0.773
Age(years) 40.7±10.6 37.3±11.4 42±11.2 0.622
Weight(kg) 120.8±20.26 119.7±17.8 120.9±17.0 0.894
Height(cm) 162±27.7 163.1±8.2 163.9±9.07 0.973
BMI(kgm−2) 45.72
±4.08 44.8±4.7 44.8±2.8 0.534
Idealbodyweight(kg)a 60.59±4.52 60.6±4.9 60.9±6.1 0.980
F,female;M,male;BMI,bodymassindex;IO,intraoperativegroup;PO,preoperativegroup.
Table2 Timepointspresentedinminutes.
Timepoint Mean±SD
Control IO PO p
n 20 10 10
Inductionofanesthesia---extubation 132.2±12.71 128.5±14.3 131±14.2 0.58
Endofanesthesia---extubation 23.8±7.85 17±6.74 19.3±6.2 0.07
MVtime 128.4±12.03 126.2±13.9 127.3±14.2 0.65
Extubation---PACUdischarge 213.5±65.7 249.5±77.8 218.4±83.1 0.52
SD,standarddeviation;MV,mechanicalventilation;PACU,post-anesthesiacareunit;IO,intraoperativegroup;PO,postoperativegroup.
intraoperativePEEPapplicationshowedgreateffectonthe timebetweentheendofanesthesiaandextubation,aswell asthepreoperative application of positivepressure, with moderateeffect.
Discussion
Results show that there was no statistical difference betweengroupswhentherespectivetimeswereevaluated. However, when applied to the Cohen coefficient, which evaluates the treatment effect, the preoperative use of 10cmH2O PEEP showedalarge effectonpatient
extuba-tiontimefromtheend of anesthesia. Thus,patients who haveundergone thistreatment reducedthe timespentin trachealintubation.Regardingthissametime,the preoper-ativetreatmentshowedmoderateeffect.
Among the respiratory changes resulting from obesity, theobeseindividualpresentschangesinbreathing mechan-ics,decreased respiratorymuscle strength,decreased gas exchange,anddecreasedlungvolumeandcapacity(mainly ERV and FRC) due to fat deposition on the thorax and abdomen.17 Thus, when undergoing a surgical procedure, theyareexposedtohigherrisksofcomplications.
InthestudybyBlouwetal.,18 anincreasedpercentage ofrespiratoryfailurewasfoundinpatientswithBMIabove 43kgm−2afterbariatricsurgery.Similarworkshighlightthe
need for prophylactic interventions, in order to prevent respiratory complications in patients undergoing bariatric surgery.
Regarding postoperativepulmonary complications, it is knownthatmanyofthemarerelatedtothetypeofsurgery, incisionsite,typeandduration ofanesthetic andsurgical procedure,whichinterfereswiththepatient’srecovery.7
Table3 Treatmenteffectsizeofbothgroupscomparedto controlgroup.
Timepoint Cohen’sd
IOgroup POgroup
Inductionofanesthesia---extubation 0.27 0.08
Endofanesthesia---extubation 0.93 0.64
MVtime 0.16 0.08
Extubation---PACUdischarge 0.50 0.06
VM,mechanicalventilation;PACU,post-anesthesiacareunit;IO, intraoperativegroup;PO, postoperativegroup. Cohen coeffi-cientoflessthan0.3isconsideredasmalleffect,of0.4---0.7 asmoderate,andhigherthan0.8aslarge.
Thesearchforphysicaltherapyresourcesthatcanhelp toreducethetimeoftrachealintubationisofgreatvalue, as prolonged duration of surgery or anesthesia may lead tomorepronouncedpulmonarycomplications.19 Asurgical timelastingmorethan210minisan independentrisk fac-tor for the onset of pulmonary complications after upper abdominalsurgeryandis alsoassociatedwithhigher mor-tality rate.7 In the present study, the mean duration of surgery was significantly lower, but they were morbidly obesepatientswhoalreadyhavepreviouspulmonary alter-ations associated with obesity and, in fact, it is very importanttorecognizeresourcesthatmayminimize post-operativecomplicationsforthesepatients.
As for duration of surgery (anesthesia induction---extubation), there was similarity between groups. In the presentstudy,thedurationofsurgeryshowednosignificant differencebetweengroupsbecauseallstudysubjects under-wentthesamesurgicalprocedure,anestheticprotocol,and mechanicalventilation,aswellassurgeryperformedbythe same team. However, even with the proposed treatment showing a weak effect, the intubation time and conse-quently the MV time were higher in the control group. Althoughasignificanteffectofthetreatmentsproposedin thisstudycannotbeshown,thestudybyRemísticoetal.13 showedshorter durationof surgeryin thegroup receiving alveolarrecruitmentwith30cmH2OPEEP.
Perhapstheresultsofthisstudyregardingintraoperative treatmentdidnotshowastrongeffectonextubationtime reductionduetothelowerPEEPvaluesused.Thisfactmay alsobecorroboratedbyastudythatevaluatedtheeffectsof thealveolarrecruitmentmaneuverinbariatricsurgeryusing intraoperative PEEPvaluesof 5,20 and30cmH2O,
show-ingbetterbloodoxygenationwithhighervaluesofarterial oxygenpressurein subjectswhounderwentthemaneuver with 30cm H2O PEEP.12 However, in Schuman20 literature
review,theuseof10cmH2OPEEPisrecommendedforthese
patients.
Asforextubationtime,consideredfromthemaintenance anesthetic drugs discontinuation topatient extubation, it was shorter in subjects ventilated with 10cm H2O PEEP,
and subsequently in subjects who usedthe positive pres-surepreoperatively.Anotherstudyevaluatedtheeffectsof analveolarrecruitmentmaneuverwithdifferentPEEP val-uesduringbariatricsurgeryandconcludedthatthesubjects usingthemaneuverwith10cmH2OPEEPnotonlyhavelower
pulmonarycomplications,butspentlesstimeinPACU.21 Thus,withtheextubationtimereduction,the intraoper-ativeuseof10cmH2OPEEP,besidesbenefitingthepatient,
concern for hospital administration, as intensive care accountforupto25%to30%ofallhospitalresources.22
InthestudybyErlandssonetal.,23itwasdemonstrated thatobesepatientswhoareventilatedwithhigherPEEP dur-ingbariatricsurgerytendtopreventlungcollapseandhave bettergasexchangeduringsurgery.
Therefore,itisconcludedthattheintraoperativeuseof 10cm H2O PEEP and preoperative positive pressure
influ-encedtheextubationtimeofpatientsundergoingbariatric surgery.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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