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Monothematic meeting of Sfar

Mechanical ventilation in abdominal surgery§,§§ Ventilation me´canique pour chirurgie abdominale E. Futier a,*, T. Godet a, A. Millot b, J.-M. Constantin a, S. Jaber b a

Department of anesthesiology and critical care medicine, Estaing hospital, university teaching hospital of Clermont-Ferrand, retinoids, reproduction and developmental diseases (R2D2) unit, EA 7281, 1, place Lucie-Aubrac, 63003 Clermont-Ferrand cedex 1, France Department of anaesthesiology and critical care medicine B (DAR B), Saint-E´loi teaching hospital, university hospital of Montpellier, institut national de la sante´ et de la recherche me´dicale (Inserm U-1046), 34295 Montpellier, France b

A R T I C L E I N F O

A B S T R A C T

Keywords: Mechanical ventilation Postoperative pulmonary complications Abdominal surgery Positive end-expiratory pressure

One of the key challenges in perioperative care is to reduce postoperative morbidity and mortality. Patients who develop postoperative morbidity but survive to leave hospital have often reduced functional independence and long-term survival. Mechanical ventilation provides a specific example that may help us to shift thinking from treatment to prevention of postoperative complications. Mechanical ventilation in patients undergoing surgery has long been considered only as a modality to ensure gas exchange while allowing maintenance of anesthesia with delivery of inhaled anesthetics. Evidence is accumulating, however, suggesting an association between intraoperative mechanical ventilation strategy and postoperative pulmonary function and clinical outcome in patients undergoing abdominal surgery. Non-protective ventilator settings, especially high tidal volume (VT) (> 10–12 mL/ kg) and the use of very low level of positive end-expiratory pressure (PEEP) (PEEP < 5 cmH2O) or no PEEP, may cause alveolar overdistension and repetitive tidal recruitment leading to ventilatorassociated lung injury in patients with healthy lungs. Stimulated by previous findings in patients with acute respiratory distress syndrome, the use of lower tidal volume ventilation is becoming increasingly more common in the operating room. However, lowering tidal volume, though important, is only part of the overall multifaceted approach of lung protective mechanical ventilation. In this review, we aimed at providing the most recent and relevant clinical evidence regarding the use of mechanical ventilation in patients undergoing abdominal surgery. ß 2014 Socie´te´ franc¸aise d’anesthe´sie et de re´animation (Sfar). Published by Elsevier Masson SAS. All rights reserved. R E´ S U M E´

Mots cle´s : Ventilation me´canique Complications pulmonaires postope´ratoires Chirurgie abdominale Pression expiratoire positive

L’un des objectifs essentiels en me´decine pe´riope´ratoire est une re´duction de la morbidite´ et, ide´alement, de la mortalite´ postope´ratoire. Les complications postope´ratoires sont responsables d’une alte´ration du pronostic du patient chirurgical, notamment fonctionnel, mais e´galement d’une augmentation de la mortalite´ a` longs termes. La ventilation me´canique est un exemple spe´cifique nous donnant l’opportunite´ de changer de paradigme en passant d’une approche curative a` une approche pre´ventive des complications postope´ratoires. La ventilation me´canique chez les patients ope´re´s d’une chirurgie a longtemps e´te´ conside´re´e comme une simple modalite´ permettant d’assurer les e´changes gazeux tout en assurant l’entretien d’une anesthe´sie ge´ne´rale par l’administration d’agents haloge´ne´s. Toutefois, un certain nombre d’arguments plaident pour l’existence d’une association entre les modalite´s de la ventilation me´canique perope´ratoire et le pronostic clinique postope´ratoire chez les patients subissant une chirurgie abdominale. L’application d’une strate´gie de ventilation non protective, particulie`rement

§

Article presented at Monothematic meeting of Sfar (Socie´te´ franc¸aise d’anesthe´sie et de reanimation): ‘‘Perioperative ventilation’’, Paris, May 21, 2014. This article is published under the responsibility of the Scientific Committee of the ‘‘Journe´e Monothe´matique 2014’’ de la Sfar. The editorial board of the Annales franc¸aises d’anesthe´sie et de re´animation was not involved in the conception and validation of its content. * Corresponding author. E-mail address: [email protected] (E. Futier). §§

http://dx.doi.org/10.1016/j.annfar.2014.07.007 0750-7658/ß 2014 Socie´te´ franc¸aise d’anesthe´sie et de re´animation (Sfar). Published by Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Futier E, et al. Mechanical ventilation in abdominal surgery. Ann Fr Anesth Reanim (2014), http:// dx.doi.org/10.1016/j.annfar.2014.07.007

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l’application d’un volume courant (VT) e´leve´ (> 10–12 mL/kg de poids ide´al the´orique) et/ou d’une pression de fin d’expiration positive faible (< 5 cmH2O) ou nulle, peut eˆtre responsable d’une surdistension alve´olaire et de phe´nome`nes d’ouverture-fermeture cycliques des alve´oles a` l’origine de le´sions pulmonaires induites par la ventilation chez des patients ayant des poumons sains a` l’initiation de la ventilation. Sous l’impulsion de travaux publie´s chez les patients pre´sentant un syndrome de de´tresse respiratoire aigu, l’utilisation d’une strate´gie de ventilation protective en utilisant un VT re´duit devient plus commune en re´animation comme au bloc ope´ratoire. L’objectif de cette revue est de pre´senter les modalite´s de re´alisation d’une strate´gie protective de ventilation me´canique en chirurgie abdominale. ß 2014 Socie´te´ franc¸aise d’anesthe´sie et de re´animation (Sfar). Publie´ par Elsevier Masson SAS. Tous droits re´serve´s.

1. Introduction One of the key challenges in perioperative care is to reduce postoperative morbidity. Patients who develop postoperative complications but survive to leave hospital often have reduced functional independence and long-term survival [1]. Postoperative pulmonary complications (PPCs) account for a substantial proportion of risks related to the surgical procedure and general anesthesia, are a major cause of postoperative morbidity and mortality, and are associated with considerable costs in hospital care [2]. Recent findings from the Massachusetts General Hospital offered us particularly striking evidence of the harmful effect of PPCs [3]. By analyzing data from a cohort of 33,769 surgical cases, the authors found that unplanned reintubation for respiratory failure within the first three days after surgery was associated with a 72-fold increased risk for in-hospital mortality. Mechanical ventilation provides a specific example that can encourage clinicians to consider a paradigm shift from treatment to prevention of postoperative complications. While surgical complications are a major cause of postoperative morbidity, evidence is accumulating suggesting an association between intraoperative mechanical ventilation strategy and postoperative pulmonary morbidity. Mechanical ventilation is an essential supportive therapy to maintain gas exchange during general anesthesia, but inadequate ventilator settings can aggravate and even initiate lung damage in patients with healthy lungs at the onset of ventilation [4–7]. Stimulated by previous findings in patients with acute respiratory distress syndrome, the use of lower tidal volume (VT) ventilation is increasingly being used in the operating room [8–10]. There is however compelling evidence that lower VT ventilation, albeit important to protect the lung from cyclic overstretching of aerated lung areas, is not sufficient and that concomitant application of positive end-expiratory pressure (PEEP) and recruitment maneuvers are inseparable parts of a lung-protective mechanical ventilation strategy in patients undergoing abdominal surgery.

This review addresses current knowledge of the multifaceted determinants of lung protection during mechanical ventilation and will highlight recent studies relevant for the use of prophylactic lung-protective ventilation in abdominal surgery. 2. Why should anesthesiologists protect the lungs during abdominal surgery? It has been reported that 5 to 10% of all surgical patients and 9 to 40% of those undergoing abdominal surgery develop PPCs following surgery [1,11,12], with the highest incidence between day 1 and day 3 after surgery [12]. Major surgical trauma is the main determinant of postoperative modifications in the respiratory function, and successful surgery is an obvious sine qua none condition for satisfactory postoperative outcomes. Nevertheless, several additional causative mechanisms are encountered during abdominal surgery, including blood losses, sepsis, excessive fluid administration and ischemia-reperfusion organ injury (Table 1), which can all create the conditions for PPCs. Mechanical ventilation is a more insidious mechanism that may be responsible for additional lung aggression, especially in the context of major surgery. Ventilator-associated lung injury can result from cyclic overstretching of aerated alveolar areas with high VT ventilation, from repeated closing (at end expiration) and opening (at the next inspiration) of peripheral airways leading to damage at the alveolar-bronchiolar junctions, from low lung volume associated with recruitment and de-recruitment of unstable lung units, and from the application of excessive airway pressures [13]. Each mechanism may trigger an inflammatory reaction in the lungs but it has also been suggested that the physical forces generated during mechanical ventilation may initiate and propagate a systemic release of inflammatory mediators [14]. Whether a short-term period of mechanical ventilation using injurious ventilator settings may be sufficient to initiate lung damage is subjected to controversy. A short-term non-protective mechanical ventilation

Table 1 Perioperative risk factors for postoperative pulmonary complications. Risk factors Surgical-related factors

Anesthesia-related factors

Patient-related factors

Type of surgery Vascular Intra-thoracic Upper abdominal Neurosurgery Head and neck Emergent surgery Reintervention Duration of surgery  2 hours Non-laparoscopic > laparoscopic

Excessive fluid loading Blood transfusion Neuromuscular blocking agent Hypothermia Postoperative nasogastric tube Need for postoperative ventilator assist

Age > 65 years ASA score  3 Chronic obstructive pulmonary disease Obstructive sleep apnea Preoperative SpO2 < 96% Cardiac insufficiency Recent respiratory infection (< 1 month) Dependent functional status Active smoking Chronic alcoholic consumption Preoperative denutrition Preoperative anemia (Hb value < 10 g/dL) BMI >27 kg/m2

Adapted from Arozullah et al. [31], Smetana [32] and Canet et al. [33]. ASA: American Society of Anesthesiology; BMI: body mass index; SpO2: peripheral oxygen saturation.

Please cite this article in press as: Futier E, et al. Mechanical ventilation in abdominal surgery. Ann Fr Anesth Reanim (2014), http:// dx.doi.org/10.1016/j.annfar.2014.07.007

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(VT of 12 mL/kg ideal body weight and zero PEEP during  5 hours) has been shown to promote bronchoalveolar procoagulant and inflammatory changes in patients without pre-existing lung injury undergoing elective abdominal procedures, suggesting that mechanical ventilation per se could exert a proinflammatory stimulus and could trigger apoptotic cell death in non-injured lungs in the context of major surgery [15,16]. Conversely, a recent prospective randomized experimental study found that 60-min of non-protective ventilation (VT of 10 mL/kg ideal body weight) did not promote significant changes in the exhaled breath condensate levels of nitrite and nitrate of patients with low risk for PPCs undergoing elective peripheral orthopedic surgery, as compared with lower VT ventilation [17]. A possible interpretation is that of a multiple-hits mechanism whereby aggressive ventilator settings may result in lung injury in previously healthy lungs when combined with another aggression. Interesting experimental data have shown that overstretching the lungs with high VT (and no PEEP) did not result in significant production and release of lung and systemic proinflammatory cytokines in intact animals, but promoted the release of systemic inflammatory mediators in the presence of preexisting inflammatory state induced by mesenteric ischemiareperfusion [18]. This has been confirmed in another study in which the authors evidenced that different insults may interact to bring about greater production and release of inflammatory mediators than either alone, and in a way that depends on their sequence [19]. These data give substance to the hypothesis according to which previous injury may sensitize lungs to inadequate mechanical ventilation, but also that injurious mechanical ventilation may sensitize lungs to postoperative pulmonary complications in the context of major surgery. 3. Low tidal volume ventilation in patients with healthy lungs The use of lung-protective ventilation, which refers to the application of lower VT (calculated on the predicted body weight rather than the actual body weight) and PEEP, is now considered standard care in patients with acute respiratory distress syndrome (ARDS) [20,21]. A recent meta-analysis has suggested that lower VT ventilation might also be associated with better clinical outcomes in a broader population of patients than only ARDS [4]. Stimulated by these findings, low VT ventilation is also becoming more popular in the operating room environment. A recent observational study reported that the use of VT > 10 mL/kg in the operating room decreased from 28.5% in 2006 to 16.3% in 2010 [9]. These data were confirmed in a recent retrospective analysis of 29,343 mechanically ventilated patients between 2008 and 2011 [10]. Unfortunately, and in contrast with their primary hypothesis, the authors found that mechanical ventilation with VT of 6 to 8 mL/kg predicted body weight (whose incidence has increased from 22.7% to 37.7% between 2008 and 2011) was associated during the same period with an increased risk of 30day mortality (adjusted hazard ratio, 1.61; 95% confidence interval, 1.20 to 2.15; P = 0.001). It must be emphasized that only a minimal level of PEEP (median PEEP = 4 cmH2O [interquartile range 2.2–5]) was applied in patients receiving low VT ventilation. This study provides a striking example of possible misinterpretation of the lung-protective concept in clinical practice. Indeed, while most clinicians have appropriated the concept of lowering the VT to prevent overdistension, PEEP still remains not commonly applied in the operating room [8]. In an observational study involving 2960 patients from 49 university and non-university French hospitals, our group reported that more than 80% of patients still received mechanical ventilation with zero PEEP, while 90% received PEEP levels lower than 4 cmH2O [8]. Why anesthesiologists are reluctant to use PEEP in

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the operating room is only speculative, but the fact that most patients demonstrate normal oxygenation during surgery is a plausible explanation. There is, however, no physiological data to support applying zero PEEP during abdominal surgery. Indeed, there is widespread acceptance that general anesthesia, with or without muscle paralysis, markedly modifies lung structure and diaphragm position, and promotes a reduction in lung volume, which is a key determinant of atelectasis formation [22]. Although the initial injury is simple collapse of alveoli, the pathophysiological changes associated with atelectasis formation can result from repeated reopening of collapsed alveoli during mechanical ventilation leading to stretch-induced ultrastructural damage with both epithelial and endothelial disruption and from local production and systemic release of inflammatory mediators [22]. Finally, although large VT ventilation can cause adjacent nonatelectatic lung regions to overstretch, the use of low VT ventilation without PEEP (or very low levels of PEEP) promotes loss of lung aeration and atelectasis formation [23]. It must be highlighted, however, that PEEP alone is ineffective to reopen a collapsed lung. The use of recruitment maneuvers (RMs) is required to obtain a complete reopening, while PEEP is needed to keep the lung open in both obese and non-obese patients [24,25]. Moreover, because the beneficial effect of recruitment is transient, a single RM may not be sufficient and repeated RM should be considered especially during prolonged laparoscopic abdominal surgery [26]. 4. Recent findings in lung protective ventilation during abdominal surgery Two recent randomized controlled trials explicitly exploring differences between lung-protective and non-protective ventilation strategies in patients undergoing abdominal surgery have been published in the last few months [27,28]. Of particular relevance was the use, in these two studies, of a multifaceted strategy combining low VT, PEEP and RMs. In a study of 56 patients undergoing open abdominal surgery, Severgnini et al. [27] found that, compared with non-protective ventilation (VT of 9 mL/kg PBW and zero PEEP), the use of lower VT (7 mL/kg PBW), 10 cmH2O of PEEP and RMs (applied after intubation, before extubation and in case of disconnection from the ventilator) improves several aspects of postoperative pulmonary function during the first three on postoperative days. Unfortunately, the study was not powered enough to explore more robust clinical outcomes. In the multicenter IMPROVE trial involving 400 patients with an intermediateto-high risk of PPCs undergoing laparoscopic and non-laparoscopic surgery, our study group recently found that use of a prophylactic lung-protective approach composed of VT of 6 to 8 mL/kg PBW, PEEP of 6 to 8 cmH2O and repeated RMs was associated with a significant reduction in major pulmonary and extra-pulmonary complications (10.5% versus 27.5% in the lung-protective and nonprotective groups, respectively; relative risk, 0.40; 95% confidence interval, 0.24–0.68; P = 0.001) within the first 7 days following surgery [28]. Of note was the 69% reduction of patients requiring intubation or non-invasive ventilation for postoperative respiratory failure (relative risk, 0.29; 95% confidence interval, 0.14–0.61; P = 0.001). To better investigate the effect of higher versus lower levels of PEEP in patients mechanically ventilated with low VT (8 mL/kg PBW) ventilation, a large international multicenter study (PROVHILO) involving 900 patients has recently been completed [29]. The authors found that the incidence of PPCs was comparable (38% versus 39%; relative risk, 1.01; 95% confidence interval, 0.85–1.20; P = 0.84) between patients receiving a low PEEP strategy (PEEP  2 cmH2O without RM) and those receiving the higher PEEP strategy (12 cmH2O of PEEP and RMs applied after intubation and before extubation). Compared with the low PEEP

Please cite this article in press as: Futier E, et al. Mechanical ventilation in abdominal surgery. Ann Fr Anesth Reanim (2014), http:// dx.doi.org/10.1016/j.annfar.2014.07.007

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strategy, the higher PEEP strategy resulted in more frequent hemodynamic instability (defined as systolic arterial blood pressure < 90 mmHg for more than 3 minutes), higher need for vasoactive drugs and larger volume of fluid infused. Nevertheless, the use of a fixed PEEP level of 12 cmH2O in all patients is somewhat surprising and could explain some of the results of this study since there is widespread recognition that applying high levels of PEEP can compromise hemodynamic. It has also been showed that the level of PEEP after RM was applied, rather than RM itself, is the main determinant of the lasting effects of the procedure on cardiac output and arterial pressure [30]. 5. Conclusion PPCs adversely affect clinical outcomes and healthcare utilization, so that prevention as a measure of the quality of care. Mechanical ventilation with the use of apparently non-injurious ventilator settings may sensitize lungs to PPCs in the context of major abdominal surgery. The existing data strongly suggest that, even in patients with healthy lungs, the use of a prophylactic multifaceted strategy of mechanical ventilation composed of low VT ventilation, moderate PEEP and repeated recruitment maneuvers can markedly help at improving postoperative outcome after laparoscopic and non-laparoscopic abdominal surgery. Disclosure of interest Dr Futier reports receiving consulting fees form General Electric Medical System. Dr Jaber reports receiving consulting fees form Dra¨ger Medical, Maquet, Hamilton and Fisher & Paykel Healthcare. The other authors declare that they have no conflicts of interest concerning this article. References [1] Khuri SF, Henderson WG, DePalma RG, Mosca C, Healey NA, Kumbhani DJ. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg 2005;242:326–41. [2] Shander A, Fleisher LA, Barie PS, Bigatello LM, Sladen RN, Watson CB. Clinical and economic burden of postoperative pulmonary complications: patient safety summit on definition, risk-reducing interventions, and preventive strategies. Crit Care Med 2011;39:2163–72. [3] Brueckmann B, Villa-Uribe JL, Bateman BT, Grosse-Sundrup M, Hess DR, Schlett CL, et al. Development and validation of a score for prediction of postoperative respiratory complications. Anesthesiology 2013;118:1276–85. [4] Serpa Neto A, Cardoso SO, Manetta JA, Pereira VG, Esposito DC, Pasqualucci Mde O, et al. Association between use of lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis. JAMA 2012;308:1651–9. [5] Determann RM, Royakkers A, Wolthuis EK, Vlaar AP, Choi G, Paulus F, et al. Ventilation with lower tidal volumes as compared with conventional tidal volumes for patients without acute lung injury: a preventive randomized controlled trial. Crit Care 2010;14:R1. [6] Wolthuis EK, Vlaar AP, Choi G, Roelofs JJ, Juffermans NP, Schultz MJ. Mechanical ventilation using non-injurious ventilation settings causes lung injury in the absence of pre-existing lung injury in healthy mice. Crit Care 2009;13:R1. [7] Gajic O, Dara SI, Mendez JL, Adesanya AO, Festic E, Caples SM, et al. Ventilatorassociated lung injury in patients without acute lung injury at the onset of mechanical ventilation. Crit Care Med 2004;32:1817–24. [8] Jaber S, Coisel Y, Chanques G, Futier E, Constantin JM, Michelet P, et al. A multicentre observational study of intra-operative ventilatory management during general anaesthesia: tidal volumes and relation to body weight. Anaesthesia 2012;67:999–1008.

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Please cite this article in press as: Futier E, et al. Mechanical ventilation in abdominal surgery. Ann Fr Anesth Reanim (2014), http:// dx.doi.org/10.1016/j.annfar.2014.07.007

Mechanical ventilation in abdominal surgery.

One of the key challenges in perioperative care is to reduce postoperative morbidity and mortality. Patients who develop postoperative morbidity but s...
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