Effects of individualized high positive end-expiratory pressure and crystalloid administration on postoperative pulmonary function in patients undergoing robotic-assisted radical prostatectomy: a prospective randomized single-blinded pilot study

Background Robotic-assisted laparoscopic prostatectomy (RALP) using a combination of capnoperitoneum and steep Trendelenburg positioning (STP) results in important pathophysiological pulmonary changes. The aim of the study was to evaluate if restrictive crystalloid administration and individual management of positive end-expiratory pressure (PEEP) improve peri- and postoperative pulmonary function in patients undergoing RALP in permanent 45 degree STP.Methods 98 patients undergoing RALP under standardized anesthesia were either allocated to a standard PEEP (5 mmHg) group or an individualized high PEEP group. Furthermore, each group was divided into a liberal vs restrictive crystalloid group (30 ml vs 15 ml per kg predicted body weight). Individualized PEEP levels were determined by means of preoperative PEEP titration in STP. In each of the four study groups following intraoperative parameters were analyzed: ventilation setting (PIP, driving pressure [Pdriv], lung compliance [LC], mechanical power [MP]), and postoperative pulmonary function (bed-side spirometry). The following spirometric parameters were measured pre- and postoperatively: the Tiffeneau index (FEV1/FVC ratio) and mean forced expiratory flow (FEF25 − 75). Data are shown as mean ± standard deviation (SD), and groups were compared with ANOVA. A P-value of < 0.05 was considered significant.Results The two individualized high PEEP groups (mean PEEP 15.5 [± 1.71 cmH2O]) showed significantly higher PIP and MP levels but significantly decreased Pdriv and increased LC. On the first and second postoperative day, patients with individualized higher PEEP levels had a significantly higher mean Tiffeneau index (day 1: 77.6% (± 6.6) vs 73.6% (± 8.8), P = 0.014; day 2: 76.5% (± 6.1) vs 72.7% (± 9.3), P = 0.021) and FEF25 − 75 (day 1: 2.41 liter/sec (± 0.9) vs 1.95 liter/sec (± 0.8), P = 0.009; day 2: 2.45 liter/sec (± 0.9) vs 2.07 liter/sec (± 0.8), P = 0.033). Perioperative oxygenation and postoperative spirometric parameters were not influenced by restrictive or liberal crystalloid infusion in either of the two PEEP groups.Conclusions Higher individualized PEEP levels during RALP improved blood oxygenation, lung-protective ventilation, and postoperative pulmonary function up to 48 hours after surgery. Restrictive crystalloid infusion during RALP seemed to have no effect on peri- and postoperative oxygenation and pulmonary function.

Postoperative Vomiting Following Laparoscopic Cholecystectomy Is Associated with Intraoperative Fluid Administration: A Retrospective Cohort Study

Potential risk factors for postoperative vomiting (POV) are important for daily anesthesia practice. To identify the risk factors associated with POV we retrospectively reviewed 553 adult patients who underwent scheduled simple laparoscopic cholecystectomy under sevoflurane-based general anesthesia between January and December 2018. Patients who experienced POV were predominantly women, had lower body weight, and higher ASA (American Society of Anesthesiologists) physical status. The POV group showed female sex predominance, lower body weight, and higher ASA physical status, with a significant difference when compared with the non-POV group. In univariate analysis, female sex and Apfel scores of 2, 3, and 4 were associated with a higher POV incidence. Age > 70 years, higher body weight, and ASA physical status III were associated with a lower POV incidence. In multivariate logistic regression, sex, age, Apfel score, and intraoperative crystalloid infusion rate were POV predictive factors. Receiver operating characteristic analysis showed a negative association between the intraoperative crystalloid infusion rate and POV occurrence with an area under the curve of 0.73 (p = 0.001). The cutoff intraoperative crystalloid infusion rate was 2 mL/kg/h with 82% sensitivity and 49% specificity (≥2 mL/kg/h was associated with a lower POV incidence vs. <2 mL/kg/h (OR, 95% CI; 0.52 [0.33–0.83])). To decrease POV in these patients, identifying high-risk factors and an intraoperative crystalloid administration of ≥2 mL/kg/h should be considered in patients undergoing LC under sevoflurane-based general anesthesia.

Excessive intravenous crystalloid infusion after video-assisted thoracoscopic surgery lobectomy is associated with postoperative pneumonia

Background Video-assisted thoracoscopic surgery has been widely used in thoracic surgery worldwide. Our goal was to identify the risk factors for postoperative pneumonia in patients undergoing video-assisted thoracoscopic surgery lobectomy. Methods A retrospective analysis of adult patients undergoing video-assisted thoracoscopic surgery lobectomy between 2016 and 05 and 2017–04 was performed. We used univariate analyses and multivariate analyses to examine risk factors for postoperative pneumonia after lobectomy. Results The incidence of postoperative pneumonia was 19.7% (n = 143/727). Patients with postoperative pneumonia had a higher postoperative length of stay and total hospital care costs when compared to those without postoperative pneumonia. Multivariate analysis showed that body mass index grading ≥24.0 kg/m2 (vs. <24.0 kg/m2: odds ratio 1.904, 95% confidence interval 1.294–2.802, P = 0.001) and right lung lobe surgery (vs. left lung lobe surgery: odds ratio 1.836, 95% confidence interval 1.216–2.771, P = 0.004) were independent risk factors of postoperative pneumonia. Total intravenous crystalloid infusion grading in the postoperative 24 h ≥ 1500 mL was also identified as the risk factors (vs. 1000 to < 1500 mL: odds ratio 2.060, 95% confidence interval 1.302–3.260, P = 0.002). Conclusions Major risk factors for postoperative pneumonia following video-assisted thoracoscopic surgery lobectomy are body mass index grading ≥24.0 kg/m2, right lung lobe surgery and total intravenous crystalloid infusion grading in the postoperative 24 h ≥ 1500 mL.

Abstract 190: Hybrid Strategy of Damage Control IR (DCIR) and REBOA Would be Feasible for Traumatic Hemorrhagic Shock Patients Suffering From Severe Pelvic Injuries

Introduction: Massive hemorrhage with pelvic injury is sometimes lethal. So, success or failure of hemostatic intervention in the hyperacute phase leads to survival of patients directly. Recently, a hybrid strategy with Operative Management (OM) and Interventional Radiology (IR) and/or Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for torso or pelvic severe trauma has been recognized world-widely. But, awareness of Damage control IR (DCIR) which is conscious of time and coagulopathy as Damage control surgery (DCS) is still not enough. So, we studied the possibility of the hybrid strategy with DCIR and REBOA for traumatic hemorrhagic shock patients with pelvic fracture. Methods: This study included patients who underwent traditional IR or DCIR with REBOA, if it were needed, for a traumatic shock state mainly due to pelvic fracture, at our emergency and trauma center. They were sorted into traditional IR group (group IR) and DCIR group (group DCIR). The primary endpoint was a survival rate in the first 30 days after injured. Secondary endpoints were fluid factors such as total amount of crystalloid infusion and blood transfusion within the first 24 hours, and for the duration of the recovery from shock state. Results: 64 trauma shock patients were sorted into group IR (n=38) and group DCIR (n=26). All REBOA patients (n=18) were in group DCIR. Initial systolic BP (group IR vs DCIR; 75mmHg vs. 54), RTS (5.66 vs. 4.12) and Ps (0.61 vs. 0.39) were significantly lower in group DCIR. ISS (32.8 vs. 41.5) and initial Shock Index (1.9 vs. 2.4) were higher in group DCIR significantly. There were no significant differences in the amount of total crystalloid infusion (7353+/-3152ml vs. 7140+/-5342ml) and blood transfusion (4183+/-3485ml vs. 3972+/-3188ml), and the survival rate (30/38 (79%) vs. 16/28 (62%)). But the required time to recovery from shock state was significantly shorter in group DCIR (65min vs. 43min). Conclusion: The hybrid strategy with DCIR and REBOA did not increase any amount of blood transfusion or crystalloid infusion or the mortality rate. But it could shorten the duration of shock state compared with traditional IR treatment. Thus, this hybrid strategy would be feasible for hemorrhage shock patients suffering from pelvic severe trauma.