Background: Intraoperative lung-protective ventilation has been recommended to reduce postoperative pulmonary complications after abdominal surgery. Although the protective role of a more physiologic tidal volume has been established, the added protection afforded by positive end-expiratory pressure (PEEP) remains uncertain. The authors hypothesized that a low fixed PEEP might not fit all patients and that an individually titrated PEEP during anesthesia might improve lung function during and after surgery.
Methods: Forty patients were studied in the operating room (20 laparoscopic and 20 open-abdominal). They underwent elective abdominal surgery and were randomized to institutional PEEP (4cm H2O) or electrical impedance tomography–guided PEEP (applied after recruitment maneuvers and targeted at minimizing lung collapse and hyperdistension, simultaneously). Patients were extubated without changing selected PEEP or fractional inspired oxygen tension while under anesthesia and submitted to chest computed tomography after extubation. Our primary goal was to individually identify the electrical impedance tomography–guided PEEP value producing the best compromise of lung collapse and hyperdistention.
Results: Electrical impedance tomography–guided PEEP varied markedly across individuals (median, 12cm H2O; range, 6 to 16cm H2O; 95% CI, 10–14). Compared with PEEP of 4cm H2O, patients randomized to the electrical impedance tomography– guided strategy had less postoperative atelectasis (6.2±4.1 vs. 10.8±7.1% of lung tissue mass; P = 0.017) and lower intraoperative driving pressures (mean values during surgery of 8.0±1.7 vs. 11.6±3.8cm H2O; P < 0.001). The electrical impedance tomography–guided PEEP arm had higher intraoperative oxygenation (435±62 vs. 266±76 mmHg for laparoscopic group; P < 0.001), while presenting equivalent hemodynamics (mean arterial pressure during surgery of 80±14 vs. 78±15 mmHg; P = 0.821).
Conclusions: PEEP requirements vary widely among patients receiving protective tidal volumes during anesthesia for abdominal surgery. Individualized PEEP settings could reduce postoperative atelectasis (measured by computed tomography) while improving intraoperative oxygenation and driving pressures, causing minimum side effects. (Anesthesiology 2018; 129:1070-81)
CME Credit: 1.00 AMA PRA Category 1 Credit™
Required Hardware / Software:Adobe Acrobat Reader, Internet connection. Web browser version must have been released within the last three years.
Activity Release Date:11/13/2018
Activity Expiration Date:11/12/2021
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Anesthesiology’s Journal CME is open to all readers. To take part in Anesthesiology Journal-based CME, complete the following steps:1. Read the accreditation information presented on this page.2. Read this month’s article designated for credit (listed below) ineither the print or online edition.3....
Anesthesiology’s Journal CME is open to all readers. To take part in Anesthesiology Journal-based CME, complete the following steps:1. Read the accreditation information presented on this page.2. Read this month’s article designated for credit (listed below) ineither the print or online edition.3. Register at http://www.asahq.org/shop-asa/journal-cme. Nonmembers will be asked to provide payment.4. Achieve a score of at least 50% correct on the six-question online journal quiz and complete the evaluation.5. Claim credit in 15-minute increments, for a maximum of 1 AMA PRA Category 1 Credit™ per journal article.
Purpose: The focus of Anesthesiology Journal-based CME is to educate readers on current developments in the science and clinical practice of anesthesiology.
Target Audience: Anesthesiology Journal-based CME is intended for anesthesiologists. Researchers and other health care professionals with an interest in anesthesiology may also participate.
Accreditation and Designation Statements: The American Society of Anesthesiologists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The American Society of Anesthesiologists designates this journalbased activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
This Month’s Anesthesiology Journal-based CME ArticleRead the article by Pereira et al. entitled “Individual Positive Endexpiratory Pressure Settings Optimize Intraoperative Mechanical Ventilation and Reduce Postoperative Atelectasis” on page 1070, and the corresponding editorial by Kacmarek and Villar entitled “Lung-protective Ventilation in the Operating Room: Individualized Positive End-expiratory Pressure Is Needed!” on page 1057.
Learning ObjectivesAfter successfully completing this activity, the learner will be able to describe the components of lung protective ventilation and their intended benefits; recognize potential effects of positive endexpiratory pressure (PEEP) application; and recognize the effects of PEEP in changing lung mechanics during open and laparoscopic procedures.
DisclosuresThis journal article has been selected for and planned as a journal activity, which is designated for AMA PRA Category 1 Credit. The authors disclosed relationships in keeping with Anesthesiology’s requirements for all journal submissions. All relationships journal authors disclosed to Anesthesiology are disclosed to learners, even those relationships that are not relevant financial relationships, per the ACCME’s requirements foractivities.
Editor-in-Chief: Evan D. Kharasch, M.D., Ph.D., has reported receiving consulting fees from TEN Healthcare.
CME Editors: Leslie C. Jameson, M.D., has reported no relevantfinancial relationships with commercial interests. Dan J. Kopacz, M.D., has reported holding an equity position with SoloDex, LLC.
Authors: Sérgio M. Pereira, M.D., Mauro R. Tucci, M.D., Ph.D., Caio C. A. Morais, P.T., M.Sc., Claudia M. Simões, M.D., Ph.D., Bruno F. F. Tonelotto, M.D., Michel S. Pompeo, M.D., Fernando U. Kay, M.D., Ph.D., Paolo Pelosi, M.D., F.E.R.S., Joaquim E. Vieira, M.D., Ph.D., Marcelo B. P. Amato, M.D., Ph.D., Robert M. Kacmarek, Ph.D., R.R.T., and Jesús Villar, M.D., Ph.D., have disclosed no relevant financial relationships with commercial interests.
Resolution of Conflicts of InterestIn accordance with the ACCME Standards for Commercial Support, the American Society of Anesthesiologists has implemented mechanisms, prior to the planning and implementation of this Journal-based activity, to identify and resolve conflicts of interest for all individuals in a position to control content of this activity.
DisclaimerThe information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a health care provider relative to diagnostic and treatment options of a specific patient’s medical condition.
The American Society of Anesthesiologists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The American Society of Anesthesiologists designates this journal-based CME activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should
claim only the credit commensurate with the extent of their participation in the activity.
1.00 Non-physician Credit Non-physicians may receive a Certificate of Completion stating that this activity was designated for 1.00 AMA PRA Category 1 Credit(s)™.
Activity Release Date: 11/13/2018 Activity Expiration Date: 11/12/2021