Eichler Lars, Truskowska Katarzyna, Dupree A, Busch P, Goetz Alwin E, Zöllner Christian
Department of Anesthesiology and Critical Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany.
Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
Obes Surg. 2018 Jan;28(1):122-129. doi: 10.1007/s11695-017-2794-3.
Bariatric surgery has proven a successful approach in the treatment of morbid obesity and its concomitant diseases such as diabetes mellitus and arterial hypertension. Aiming for optimal management of this challenging patient cohort, tailored concepts directly guided by individual patient physiology may outperform standardized care. Implying esophageal pressure measurement and electrical impedance tomography-increasingly applied monitoring approaches to individually adjust mechanical ventilation in challenging circumstances like acute respiratory distress syndrome (ARDS) and intraabdominal hypertension-we compared our institutions standard ventilator regimen with an individually adjusted positive end expiratory pressure (PEEP) level aiming for a positive transpulmonary pressure (P ) throughout the respiratory cycle.
After obtaining written informed consent, 37 patients scheduled for elective bariatric surgery were studied during mechanical ventilation in reverse Trendelenburg position. Before and after installation of capnoperitoneum, PEEP levels were gradually raised from a standard value of 10 cm HO until a P of 0 +/- 1 cm HO was reached. Changes in ventilation were monitored by electrical impedance tomography (EIT) and arterial blood gases (ABGs) were obtained at the end of surgery and 5 and 60 min after extubation, respectively.
To achieve the goal of a transpulmonary pressure (P ) of 0 cm HO at end expiration, PEEP levels of 16.7 cm HO (95% KI 15.6-18.1) before and 23.8 cm HO (95% KI 19.6-40.4) during capnoperitoneum were necessary. EIT measurements confirmed an optimal PEEP level between 10 and 15 cm HO before and 20 and 25 cm HO during capnoperitoneum, respectively. Intra- and postoperative oxygenation did not change significantly.
Patients during laparoscopic bariatric surgery require high levels of PEEP to maintain a positive transpulmonary pressure throughout the respiratory cycle. EIT monitoring allows for non-invasive monitoring of increasing PEEP demand during capnoperitoneum. Individually adjusted PEEP levels did not result in improved postoperative oxygenation.
减肥手术已被证明是治疗病态肥胖及其伴随疾病（如糖尿病和动脉高血压）的一种成功方法。为了对这一具有挑战性的患者群体进行最佳管理，由个体患者生理状况直接指导的定制概念可能优于标准化护理。鉴于食管压力测量和电阻抗断层扫描——在急性呼吸窘迫综合征（ARDS）和腹腔内高压等具有挑战性的情况下越来越多地应用于单独调整机械通气的监测方法——我们将我们机构的标准通气方案与旨在在整个呼吸周期中实现正跨肺压（P）的单独调整的呼气末正压（PEEP）水平进行了比较。
在获得书面知情同意后，对37例计划进行择期减肥手术的患者在头高脚底位机械通气期间进行了研究。在建立气腹前后，PEEP水平从10 cmH₂O的标准值逐渐升高，直到达到P为0±1 cmH₂O。通过电阻抗断层扫描（EIT）监测通气变化，并分别在手术结束时以及拔管后5分钟和60分钟采集动脉血气（ABG）。
为了在呼气末实现跨肺压（P）为0 cmH₂O的目标，气腹前PEEP水平为16.7 cmH₂O（95%可信区间15.6 - 18.1），气腹期间为23.8 cmH₂O（95%可信区间19.6 - 40.4）。EIT测量分别证实气腹前最佳PEEP水平在10至15 cmH₂O之间，气腹期间在20至25 cmH₂O之间。术中和术后氧合没有显著变化。
腹腔镜减肥手术期间的患者需要高水平的PEEP以在整个呼吸周期中维持正跨肺压。EIT监测允许在气腹期间对不断增加的PEEP需求进行无创监测。单独调整的PEEP水平并未导致术后氧合改善。
