Obez hastalarda koruyucu ventilasyon uygulamasında düşük ve yüksek peep uygulamasının karşılaştırılması
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Date
2017
Authors
Akca, Sevgi
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Publisher
Uludağ Üniversitesi
Abstract
Giriş: Obez hastalarda ideal intraoperatif koruyucu ventilasyon stratejisi tartışmalıdır. Çalışmamızda, laparoskopik cerrahi uygulanacak obez hastalarda, vital kapasite manevrasını (VKM) takiben farklı tidal volüm (TV) ve pozitif ekspirasyon sonu basıncı (PEEP) kombinasyonlarının hemodinami, ventilasyon ve oksijenasyon parametreleri ve spirometrik ölçümler üzerine etkilerini araştırmayı amaçladık. Gereç-yöntem: Etik komite ve hasta onamı alındıktan sonra, genel anestezi altında laparoskopik abdominal cerrahi uygulanacak, ASA II-III sınıfı, vücut kitle indeksi 30-50 kg/m² olan 50 hasta çalışmaya dahil edildi. Anestezi ve analjezi standardize edildi. Hastalar randomize 2 gruba ayrıldı. Vital kapasite manevrası (8 sn süre ile 40 cm H₂O havayolu basıncı) sonrası Grup 1'e (n=25) TV 8 ml/kg [ideal vücut ağırlığı (İVA)] ve PEEP 5 cm H₂O, Grup 2'ye (n=25) TV 6 ml/İVA ve PEEP 10 cm H₂O uygulandı. Hemodinami ve ventilasyon parametreleri, preoperatif, intraoperatif 10.dk, 20.dk, 40.dk ve 60.dk, ekstübasyon öncesi (EÖ) ve ekstübasyon sonrası (ES) dönemlerde kaydedildi. Arterial kan gazı örnekleri, indüksiyon öncesi, indüksiyon sonrası, EÖ ve derlenme sonu (DS) dönemlerde alındı. Spirometrik değerlendirme; preoperatif, postoperatif 24.sa (PO) ve taburculuk öncesi dönemlerde yapıldı. Ayrıca perioperatif özellikler kaydedildi. Bulgular: Hastaların demografik verileri benzerdi. Ortalama arter basıncı, Grup 1'de EÖ ve ES dönemlerinde daha yüksek izlendi (p<0.05, p<0.05). Kompliyans, Grup 1'de EÖ dönemde daha yüksekti (p<0.05). Grup 1'de plato basıncı 60.dk'da yüksek bulundu (p<0.05). PaO₂ değeri, Grup 2'de DS döneminde daha yüksek bulundu (p<0.05). Zorlu vital kapasite, Grup 1'de PO dönemde daha düşük saptandı (p<0.01). Grup 2'de intraoperatif dönemde 2 hastada vazoaktif ajan gereksinimi oldu. Grup 1'de hastane taburculuk süresinin daha kısa olduğu görüldü (p<0.05). Sonuç: TV 6 ml/İVA ve PEEP 10 cm H₂O kombinasyonu, TV 8 ml/İVA ve PEEP 5 cm H₂O uygulaması ile karşılaştırıldığında intraoperatif hipotansiyon riski artabilir, fakat solunumsal parametreler daha iyi korunabilir. Bunun yanı sıra, her iki koruyucu ventilasyon modelinde klinik olarak minimal farklılıklar olması nedeni ile uygulama hasta ve cerrahi riske özgü seçilmelidir.
Introduction: The ideal intraoperative protective ventilation strategy in obese patients remains controversial. We aimed to investigate the effects of different combinations of positive end-expiratory pressure (PEEP) and tidal volume (TV) following vital capacity maneuvers (VCM) on haemodynamic, ventilatory and arterial oxygenation parameters and spirometric measurements in obese patients with undergoing abdominal laparoscopic surgery. Method: After the approval of ethics committee and patient, 50 patients with BMİ 30-50 kg/m² of ASA II-III class undergoing abdominal laparoscopic surgery with general anesthesia were included to the study. Anaesthesia and analgesia were standardized. Patients were randomly allocated into two groups. After the vital capacity maneuver (a positive airway pressure of 40 cm H₂O for 8 sec), Group 1 (n=25) was ventilated with TV 8 ml kg-1 IBW plus PEEP 5 cm H₂O, Group 2 (n=25) was ventilated with TV 6 ml kg-1 IBW plus PEEP 10 cm H₂O. Parameters of haemodynamic and ventilatory were recorded before operation, 10. min, 20. min, 40. min and 60. min during operation, before extubation (BE) and after extubation (AE). Arterial blood gas samples were taken after induction, BE and after recovery (AR). Spirometry was assessed at the following times: before operation, 24 h after operation (PO) and before discharge. Perioperative characteristics were also recorded. Results: The demographic data of the patients were similar. Mean arterial pressure was higher in Group 1 at the BE and AE periods (p <0.05, p <0.05). Compliance was higher in Group 1 at the BE period (p <0.05). In Group 1, plateau pressure was higher in 60. min (p <0.05). In Group 2, PaO₂ value was higher at the AR period (p<0.05). The forced vital capacity was lower in the PO period in Group 1 (p <0.01). In Group 2, two patients needed vasoactive agent intraoperatively. In Group 1, the duration of hospital discharge was shorter (p <0.05). Conclusion: The TV 6 ml / IVA and PEEP 10 cm H 2 O combination may increase the risk of intraoperative hypotension, but the respiratory parameters may be better preserved compared to TV 8 ml / IVA and PEEP 5 cm H 2 O administration. Hoewever, the application should be chosen for patient and surgical risk because there were minimal clinical differences in both protective ventilation model.
Introduction: The ideal intraoperative protective ventilation strategy in obese patients remains controversial. We aimed to investigate the effects of different combinations of positive end-expiratory pressure (PEEP) and tidal volume (TV) following vital capacity maneuvers (VCM) on haemodynamic, ventilatory and arterial oxygenation parameters and spirometric measurements in obese patients with undergoing abdominal laparoscopic surgery. Method: After the approval of ethics committee and patient, 50 patients with BMİ 30-50 kg/m² of ASA II-III class undergoing abdominal laparoscopic surgery with general anesthesia were included to the study. Anaesthesia and analgesia were standardized. Patients were randomly allocated into two groups. After the vital capacity maneuver (a positive airway pressure of 40 cm H₂O for 8 sec), Group 1 (n=25) was ventilated with TV 8 ml kg-1 IBW plus PEEP 5 cm H₂O, Group 2 (n=25) was ventilated with TV 6 ml kg-1 IBW plus PEEP 10 cm H₂O. Parameters of haemodynamic and ventilatory were recorded before operation, 10. min, 20. min, 40. min and 60. min during operation, before extubation (BE) and after extubation (AE). Arterial blood gas samples were taken after induction, BE and after recovery (AR). Spirometry was assessed at the following times: before operation, 24 h after operation (PO) and before discharge. Perioperative characteristics were also recorded. Results: The demographic data of the patients were similar. Mean arterial pressure was higher in Group 1 at the BE and AE periods (p <0.05, p <0.05). Compliance was higher in Group 1 at the BE period (p <0.05). In Group 1, plateau pressure was higher in 60. min (p <0.05). In Group 2, PaO₂ value was higher at the AR period (p<0.05). The forced vital capacity was lower in the PO period in Group 1 (p <0.01). In Group 2, two patients needed vasoactive agent intraoperatively. In Group 1, the duration of hospital discharge was shorter (p <0.05). Conclusion: The TV 6 ml / IVA and PEEP 10 cm H 2 O combination may increase the risk of intraoperative hypotension, but the respiratory parameters may be better preserved compared to TV 8 ml / IVA and PEEP 5 cm H 2 O administration. Hoewever, the application should be chosen for patient and surgical risk because there were minimal clinical differences in both protective ventilation model.
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Keywords
PEEP, Tidal volüm, Obezite, Vital kapasite, Laparoskopik cerrahi, Tidal volume, Obesity, Vital capasity, Laparoscopic surgery
Citation
Akca, S. (2017). Obez hastalarda koruyucu ventilasyon uygulamasında düşük ve yüksek peep uygulamasının karşılaştırılması. Yayınlanmamış uzmanlık tezi. Uludağ Üniversitesi Tıp Fakültesi.