Vanamail Prasanna V, Balakrishnan Kalpana, Prahlad Sarojini, Chockalingam Punitha, Dash Radhika, Soundararajan Dinesh K
Department of Anaesthesiology, Cancer Institute (WIA), Chennai, Tamil Nadu, India.
Department of Anaesthesiology, Pain and Palliative Care, Cancer Institute (WIA), Chennai, Tamil Nadu, India.
Indian J Crit Care Med. 2021 Sep;25(9):1031-1039. doi: 10.5005/jp-journals-10071-23962.
Diaphragmatic dysfunction following upper abdominal surgery is less recognized due to a lack of diagnostic modality for bedside evaluation. We used point-of-care ultrasound to evaluate the diaphragmatic inspiratory amplitude (DIA) in upper abdominal surgery for cancer. Our primary hypothesis was DIA would be reduced in the immediate postoperative period in patients with postoperative pulmonary complications (PPCs). Our aim was to identify an optimal cutoff of DIA for the diagnosis of PPCs.
We conducted a prospective, observational study in patients aged 18-75 years undergoing elective, upper abdominal oncological surgeries under combined general and epidural anesthesia. Ultrasound evaluation of the diaphragm was done by measuring the DIA in the right and left hemidiaphragms during quiet and deep breathing on the day before surgery and postoperative days (PODs) 1, 2, and 3. Patients were followed up for PPCs until POD 7. The linear mixed-effects model examined the association between DIA and PPCs and other perioperative factors. Receiver-operating characteristics analysis was done to determine the optimal cutoff of DIA in diagnosing PPCs.
DIA measured in the 162 patients showed a significant decrease in their absolute values postoperatively from its preoperative baseline measurement. This decrease in DIA was significantly associated with PPC [right hemidiaphragm, = -0.17, 95% confidence interval (CI) -0.31 to -0.02, = 0.001 during quiet breathing; left hemidiaphragm, = -0.24, 95% CI = -0.44 to -0.04, = 0.018 and = -0.40, 95% CI = -0.71 to -0.09, = 0.012 during quiet and deep breathing, respectively]. A cutoff value of DIA of left hemidiaphragm at 1.3 cm during quiet breathing and 1.6 cm during deep breathing had a sensitivity of 77 and 75%, respectively, in their ability to diagnose PPCs [left hemidiaphragm quiet breathing, area under the curve (AUC): 0.653, 95% CI 0.539-0.768, = 0.015; left hemidiaphragm deep breathing, AUC: 0.675, 95% CI 0.577-0.773, = 0.007].
Following upper abdominal surgery, the DIA is decreased and associated with PPCs. DIA of left hemidiaphragm less than 1.3 cm during quiet breathing and 1.6 cm during deep breathing has a sensitivity of 77 and 75%, respectively, in diagnosing PPCs following upper abdominal surgery.
Vanamail PV, Balakrishnan K, Prahlad S, Chockalingam P, Dash R, Soundararajan DK. Ultrasonographic Assessment of Diaphragmatic Inspiratory Amplitude and Its Association with Postoperative Pulmonary Complications in Upper Abdominal Surgery: A Prospective, Longitudinal, Observational Study. Indian J Crit Care Med 2021;25(9):1031-1039.
由于缺乏床旁评估的诊断方法，上腹部手术后膈肌功能障碍较少被认识到。我们使用床旁超声评估上腹部癌症手术患者的膈肌吸气幅度（DIA）。我们的主要假设是，术后肺部并发症（PPCs）患者术后即刻DIA会降低。我们的目的是确定用于诊断PPCs的DIA最佳临界值。
我们对年龄在18 - 75岁、在全身麻醉联合硬膜外麻醉下接受择期上腹部肿瘤手术的患者进行了一项前瞻性观察研究。在手术前一天以及术后第1、2和3天，通过测量左右半膈肌在安静呼吸和深呼吸时的DIA来进行膈肌超声评估。对患者进行PPCs随访至术后第7天。线性混合效应模型检验了DIA与PPCs及其他围手术期因素之间的关联。进行受试者工作特征分析以确定诊断PPCs时DIA的最佳临界值。
162例患者测量的DIA术后绝对值较术前基线测量值显著降低。DIA的这种降低与PPCs显著相关[安静呼吸时，右侧半膈肌，β = -0.17，95%置信区间（CI）-0.31至-0.02，P = 0.001；左侧半膈肌，β = -0.24，95% CI = -0.44至-0.04，P = 0.018，安静呼吸和深呼吸时β = -0.40，95% CI = -0.71至-0.09，P = 0.012]。安静呼吸时左侧半膈肌DIA临界值为1.3 cm，深呼吸时为1.6 cm，其诊断PPCs的敏感度分别为77%和75%[左侧半膈肌安静呼吸时，曲线下面积（AUC）：0.653，95% CI 0.539 - 0.768，P = 0.015；左侧半膈肌深呼吸时，AUC：0.675，95% CI 0.577 - 0.773，P = 0.007]。
上腹部手术后，DIA降低且与PPCs相关。安静呼吸时左侧半膈肌DIA小于1.3 cm，深呼吸时小于1.6 cm，对上腹部手术后PPCs的诊断敏感度分别为77%和75%。
Vanamail PV, Balakrishnan K, Prahlad S, Chockalingam P, Dash R, Soundararajan DK. 上腹部手术中膈肌吸气幅度超声评估及其与术后肺部并发症的关联：一项前瞻性、纵向、观察性研究。《印度重症监护医学杂志》2021；25(9):1031 - 1039。
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