mechanical ventilation for robotic surgery · 2020-03-26 · • during robotic surgery elastance...
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Mechanical ventilation for robotic surgery
Dr. Nurdan BedirliGazi University Anesthesiology Department
Agenda • Respiratory challenges• Pneumoperitoneum• Steep Trendelenburg position
• Optimizing mechanical ventilation setting
Minimal invasivesurgery
Maximum invasive respiratory physiology
Respiratory problems related to robotic surgery
Learning curve
Need for multiple breathing circuits
Positioning• Trendelenburg• Reverse Trendelenburg
Pneumoperitoneum
• ↑CO2
• ↑IAP
Reverse Trendelenburg position
• FRC↑• Respiratory work↓• Thromboembolism
Respiratory System
Steep‐Trendelenburg position
• Endobronchial intubation• Atelectasis• FRC ↓• TLC↓• Compliance↓• Breathing work increases• Hypoxia
Respiratory system
Compression
Airway Chest Wall Pleura LungsAirwayresistance↑
Pleural pressure > alveolar pressureCOMPRESSION ATELECTASIA
Vena Cava
IAP↑Steep Trendelenburg
Blood shift tothorax
80 Patients 60 without COPD
20 with COPD
TV 6‐8 ml/IBW
PEEP 5‐7cmH2O
The day before the surgery, postoperative 40 min. 120 min, 24 h, 5 d
VC
FEV1
MEF50/MIF50
What is the effect of intraoperative Trendelenburg position andpneumoperitoneum on postoperative lung function in healty lungs?
Prolonged use of steep Trendelenburg position combined with pneumoperitoneumduring surgery• Effects lung function in the postoperative period• In heathy lungs• Recovery may need 5 days• MV• low TV• constant PEEP (5‐7)• no RM
General anesthesia +Pneumoperitonium + Position
Conventional MV
Prevent hipoxia‐Improve SpO2
Low TV / PEEP<5
Alveolar injury
Postoperative complication
Lung protective ventilation prevents PPC
LPMV=Individualized mechanical ventilation
Individualizing mechanical ventilation‐key points• Preoperative risk assessment • Starts with induction of anesthesia• Optimal ventilatory setting• Low tidal volume• PEEP titration• Alveolar recruitment
• Intraoperative monitoring of lung mechanics• Crs• Pplat• Pdriving• Ptp
Preoperative evaluation
Anamnesis Airwayevaluation
Pulmonary risk
Cardiac risk
Glaucoma anamnesis
Central nervous system diseases
Tromboemboli anamnesis
Patient constent: orbital/facial edemaprolonged intubation
Induction of anesthesia• Patient positioning at the induction• Avoid supine position• 30 degree head up and reverse Trendelenburg position• NIPPV or CPAP
Intraoperative ventilatory settings
Tidal volume
Serpa Neto A, Schultz MJ, Gama de Abreu M. Intraoperative ventilation strategies toprevent postoperative pulmonary complications: Systematic review, meta‐analysis, and trial sequential analysis. Best Pract Res Clin Anaesthesiol. 2015 Sep;29(3):331‐40
Hemmes SN, Gama de Abreu M, Pelosi P, et al. on behalf oft he PROVE Network Investigators forthe Clinical Trial Network of the European Society of Anaesthesiology. High versus low positive end‐expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre randomised controlled trial. Lancet. 2014 Aug 9;384(9942):495‐50
Futier E, Constantin JM, Paugam‐Burtz C, et al; IMPROVE Study Group. A trial of intraoperative low‐tidal‐volume ventilation in abdominal surgery. N Engl J Med. 2013 Aug 1;369(5):428‐37.
Tidal volume
Serpa Neto A, Schultz MJ, Gama de Abreu M. Intraoperative ventilation strategies toprevent postoperative pulmonary complications: Systematic review, meta‐analysis, and trial sequential analysis. Best Pract Res Clin Anaesthesiol. 2015 Sep;29(3):331‐40
Hemmes SN, Gama de Abreu M, Pelosi P, et al. on behalf oft he PROVE Network Investigators forthe Clinical Trial Network of the European Society of Anaesthesiology. High versus low positive end‐expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre randomised controlled trial. Lancet. 2014 Aug 9;384(9942):495‐50
Futier E, Constantin JM, Paugam‐Burtz C, et al; IMPROVE Study Group. A trial of intraoperative low‐tidal‐volume ventilation in abdominal surgery. N Engl J Med. 2013 Aug 1;369(5):428‐37.
Don’t forget !
Low TV
IBW
• NIH/NHLBI ARDSNet• Women: 45.5 + 0.905 x ([boy‐cm] – 152.4)• Men: 50.0 + 0,905 x ([boy‐cm] – 152.4)
29.343 patient / Postop 30 day mortality / Hospital stay lenght
Low TV (IBW) + PEEP < 5
Low tidal volume alone may be insufficient or even harm the lungs
Low TV is effective only combined with PEEP
PEEP does not open collapsed alveolusPrevents the alveolus from collapse
Individualize PEEP‐How?
• Complians• Respiratory pressure• Plato pressure• Driving pressure• Transpulmonary pressure
• IAP Robotic Surgery
• Adjust PEEP that provides• maximum complians• within safe driving pressureslimits
Monitoring
Always with RM
Robotic surgery‐ Problems relating interpretation of the pressure• Elevation of intra‐abdominal pressure• Position‐related lung volume changes• Obesity
Crit Care Med. 2013 Aug;41(8):1870‐7.
PigInfluence of IAP
FRCPlateau and driving pressuresCL and CCWEnd expiratory and end inspiratory transpulmonary pressures
GroupsPEEP 1 cm H2O PEEP 10 cm H2O + RM (PCV‐ PIP= 40 and PEEP =20)
• FRC reduce as IAP increase• Capacity of PEEP to preventreduce FRC is limited when IAP exceed PEEP
• TV and PEEP is constant• increased IAP result in increased Pplat and Pdriving• changes in transpulmonary driving pressure withrespect to IAP increase is negligible
• Conclusion• FRC reduced as IAP increases
• Capacity of PEEP 10 to prevent reduction of FRC is limited when IAP exceed the PEEP level
• In the presence of raised IAP• Ptp may be helpful for setting mechanical ventilator parameters
What fraction of increased driving pressure icrease Ptp and risk for VILI during robotic surgery?
• 35 ASA II patients Robotic surgery pneumoperitoneum andtrendelenburg position• Surgery stages: Pneumoperitoneum/Pneumoperitoneum + Trendelenburg• Respiratory mechanics calculated• Esophageal baloon pressures• Respiratory flows
• Regional lung ventilation assessed• Electrical impedance tomography
• Pn + Trendelenburg• 82% increse in driving pressure (A)• 38 % increse in Ptp (B)• 198% increase in chest Wall component of driving pressure (C)
Comparion baseline withPneumoperitoneum+Trendelenburg• Ecw increased 223%• EL incresed 48%
• During robotic surgery elastance CW is the primary contributor to total respiratory system elastance in contrast to laparoscopy• Mechanism• Not clear• Diaphragm and abdominal wall stretch• Reduced area of lung apposed to the rib cage because of Trendelenburg position• Rigid framework that the robot arms docked to the ports
Moderate‐High PEEP needed to resist IAP for robotic surgery
Recruitment + PEEP
Robotic surgery ventilationdependent on RM + PEEP
Contradications RM
Emphysema
Hemodynamic instability
Right heart failure
Increased ICP
During RM
• Arrhythmia• Newly emerged• Resistant
• SAP<90 mmHg• >3 minutes• Resistant fluid replasment and medication
Hemodynamic instabilty
• SpO2<92%• SpO2<92% before RM –5% decrease
Decreased in oxygen saturation
strategy for ventilation
FiO2 0.4
VCV ‐ tidal volume 6 to 8 mL/kg IBW
PEEP 5‐7 cmH2O
Respiratuary rate ‐ETCO2 40‐45 mmHg
I:E 1:2
Monitor P plato and P driving
Initial
• Just after intubation• After Pneumoperitoneum
• Afterpneumoperitoneum+Trendelenburgposition• Before docking
RM‐automated
strategy for ventilation problems
Driving pressure>15cm
H2O
Hipoksia SpO2<92
Rule out bronchospasm andendobronchial intubation
FiO2 ↑ (not more than 50)
I:E= 1:1
Perform recruitment maneuvers
Reduce insuflation pressure
strategy for ventilation problems
Hypercarbia
Hyperventilation
Subcutaneous emphysema
Hipoxia andhypercarbia
persistDiscuss conversion to open surgery
Summary
FiO2< 70% induction/extubation
Semi fowler‐intubation/extubation
NIMV‐induction/extubation
TV↓, Frequency↑
Minimal FiO2
Recruitment +PEEP
Reverse (sugammadeks)
Emergence from anaesthesiaand postoperative care
Avoide condition that negate theintraoperative efforts to recruit and
maintain an open lung
Emergence‐Optimize position
• Avoid supine position• 30 degree head up and reverse Trendelenburg position
Emergence‐Avoid ZEEP
• Avoid tracheal tube suctioning immediately before trachealextubation• NIPPV or CPAP• Don’t turn off the ventilator allowing carbon dioxide to accumulate tostimulate spontaneous ventilation• Other interventions likely beneficial• prevention of coughing and bucking on the tracheal tube
Emergence‐FiO2
• In the appropriate clinical conditions, the use of low FIO2 (<0.4)
Postoperative
• When high FiO2 (>0.8) is used during emergence• use of low FiO2 (<0.3) CPAP immediately after tracheal extubation may reducethe risk of resorption atelectasis
• Administration of postoperative supplemental oxygen is recommended when room air SpO2 decreases below 94% • Avoid routine application of supplemental oxygen withoutinvestigating and treating the underlying cause
CPAP/NIMW
• During the transition between mechanical ventilation andspontaneous breathing• Postoperative prophylactic CPAP/NIMW for patients who use thesebefore surgery• Think for patients with high risk • Obese• Robotic surgery
CPAP administered after a major surgery may reduce atelectasis, thefrequency PPC• Postoperative• CPAP of 7.5 cm H2O vs 6 L min flow of 50% oxygen by the Venturi mask mayreduce reintubation rate, PPC• CPAP of 10 cmH2O