Açık Kalp Cerrahisinde Düşük Tidal Volüm Ventilasyon: 8 ml/kg ve 6 ml/kg Tidal volümden Hangisi Daha İyi?

Öz

Amaç: Koroner arter baypas greftleme operasyonunda düşük tidal hacim stratejisi ile akciğer koruyucu ventilasyonda 6ml/kg ile 8 ml/kg tidal hacim sonuçlarını karşılaştırması amaçlanmıştır. Yöntem: Randomize, tek merkezli, prospektif çalışmaya alınan ardışık 32 hasta, iki eşit gruba ayrıldı. 6ml/kg ve 8ml/kg tidal volüm ile ventilasyonun sonuçları karşılaştırıldı. Arterial kan basınçları, kalp hızı, santral venöz basınç, ekspirasyon tidal hacimi, solunum frekansı, alveolar dakika ventilasyonu, inspirasyon süresi, statik kompliyans, pik hava yolu basıncı, plato basıncı, sürüm basıncı, arter kan gazı verileri ve PaCO2-EtCO2 farkı T1 (CPB'den 15 dak. önce), T2 (kardiyopulmoner baypasın sonlandırılmasından 15 dak. sonra) ve T3 (ameliyatın sonunda) zamanlarında kaydedildi. PaO2/FiO2 oranı ekstübasyon sonrası T1, T2 ve T3 ile 6. (T4) ve 12. saatte (T5) kaydedildi. Bulgular: Grup 6 ml/kg'da ekstübasyon süresi ve yoğun bakımda kalış süresi anlamlı olarak daha uzundu (sırasıyla p<0,001, p=0,001). Taburculuk süreleri her iki grupta benzerdi. Grup 6ml/kg'da PaCO2 daha yüksekti (sırasıyla T1, T2, T3; p=0,002, p=0,004, p=0,001). Hemodinamik değişiklikler her iki grupta da benzer seyretti. PaO2 / FiO2 oranı Grup 8 ml/kg'da T2'de anlamlı olarak daha yüksek (p=0,009) ve diğer zamanlarda benzerdi. Sonuç: 8 ml/kg düşük tidal hacim stratejisi ile mekanik ventilasyon, 6 ml/kg ile karşılaştırıldığında daha kısa ekstübasyon süresi ve yoğun bakımda kalış süresi dikkate alındığında daha olumlu sonuçlara sahiptir.

Anahtar Kelimeler

• Açık kalp cerrahisi
• Kardiyak Anestezi
• Düşük Tidal Volum Ventilasyon

Low Tidal Volume Ventilation in Open Heart Surgery: Which Tidal Volume is Better 8 ml/kg or 6 ml/kg?

Öz

Objective: To compare the outcomes of 6m/kg vs. 8 ml/kg tidal volume in the lung protective ventilation - low tidal volume strategy in coronary artery bypass grafting operation. Methods: Thirty-two patients enrolled in a randomized, single-center, prospective study were divided into two groups. The outcomes of 6m/kg vs. 8 ml/kg were compared. Arterial blood pressures, heart rate, central venous pressure, expired tidal volume, respiratory frequency, the alveolar minute ventilation, the inspiratory time, static compliance, peak airway pressure, plateau pressure, driving pressure, arterial blood gas data and PaCO2-EtCO2 difference were recorded at T1 (15 min. prior to CPB), T2 (15 min. following the termination of cardio pulmonary bypass), and T3 times (at the end of the surgery). PaO2/FiO2 ratio was recorded at T1, T2 and T3 and 6th (T4) and 12th hours (T5) after extubation. Results: In Group 6ml/kg, extubation time and length of stay in the intensive care unit were significantly longer (p<0.001, p=0.001, respectively). Discharge times were similar in both groups. In group 6ml/kg, PaCO2 was high at all times (T1, T2, T3; p=0.002, p=0.004, p=0.001, respectively), Hemodynamic changes had a similar course in both groups, in Group 6ml/kg. The PaO2/FiO2 ratio was significantly higher in Group 8ml/kg at T2 (p=0.009) and similar at other times. Conclusion: Mechanical ventilation with a low tidal volume strategy with 8 ml/kg has more favorable outcomes by considering the shorter extubation time and length of stay in the intensive care unit comparing with 6 ml/kg.

Anahtar Kelimeler

• Open heart surgery
• cardiac anesthesia
• low tidal volume ventilation

Kaynakça

1. Szelkowski LA, Puri NK, Singh R, Massimiano PS. Current trends in preoperative, intraoperative, and postoperative care of the adult cardiac surgery patient. Curr Probl Surg. 2015;52(1):531-569. doi:10.1067/j.cpsurg.2014.10.001
2. Rong LQ, Di Franco A, Gaudino M. Acute respiratory distress syndrome after cardiac surgery. J Thorac Dis. 2016;8(10):E1177-e1186. doi:10.21037/jtd.2016.10.74
3. Badenes R, Lozano A, Belda FJ. Postoperative pulmonary dysfunction and mechanical ventilation in cardiac surgery. Crit Care Res Pract. 2015;420513. doi:10.1155/2015/420513
4. Duggan M, Kavanagh BP. Pulmonary atelectasis: a pathogenic perioperative entity. Anesthesiology. 2005;102(4):838-854. doi:10.1097/00000542-200504000-00021
5. Cereda M, Kavanagh BP. Compartmentalization of lung injury--atelectasis versus overstretch. Crit Care Med. 2014;42(1):223-224. doi:10.1097/CCM.0b013e3182a264ed
6. Zupancich E, Paparella D, Turani F, et al. Mechanical ventilation affects inflammatory mediators in patients undergoing cardiopulmonary bypass for cardiac surgery: a randomized clinical trial. J Thorac Cardiovasc Surg. 2005;130(2):378-383. doi:10.1016/j.jtcvs.2004.11.061
7. Bignami E, Di Lullo A, Saglietti F, et al. Routine practice in mechanical ventilation in cardiac surgery in Italy. J Thorac Dis. 2019;11(4):1571-1579. doi:10.21037/jtd.2019.03.04
8. Zochios V, Klein AA, Gao F. Protective Invasive Ventilation in Cardiac Surgery: A Systematic Review With a Focus on Acute Lung Injury in Adult Cardiac Surgical Patients. J Cardiothorac Vasc Anesth. 2018;32(4):1922-1936. doi:10.1053/j.jvca.2017.10.031

9. Davies JD, Senussi MH, Mireles-Cabodevila E. Should A Tidal Volume of 6 mL/kg Be Used in All Patients? Respir Care. 2016;61(6):774-790. doi:10.4187/respcare.04651
10. Tenney SM, Remmers JE. Comparative quantitative morphology of the mammalian lung: diffusing area. Nature. 1963;197:54-56. doi:10.1038/197054a0
11. Vieillard-Baron A, Prin S, Augarde R, et al. Increasing respiratory rate to improve CO2 clearance during mechanical ventilation is not a panacea in acute respiratory failure. Crit Care Med. Jul 2002;30(7):1407-1412. doi:10.1097/00003246-200207000-00001
12. Kallet RH, Campbell AR, Dicker RA, Katz JA, Mackersie RC. Effects of tidal volume on work of breathing during lung-protective ventilation in patients with acute lung injury and acute respiratory distress syndrome. Crit Care Med. 2006;34(1):8-14. doi:10.1097/01.ccm.0000194538.32158.af
13. Patroniti N, Pesenti A. Low tidal volume, high respiratory rate and auto-PEEP: the importance of the basics. Crit Care. 2003;7(2):105-6. doi:10.1186/cc1883
14. Contreras M, Ansari B, Curley G, et al. Hypercapnic acidosis attenuates ventilation-induced lung injury by a nuclear factor-κB-dependent mechanism. Crit Care Med. 2012;40(9):2622-2630. doi:10.1097/CCM.0b013e318258f8b4
15. Kregenow DA, Swenson ER. The lung and carbon dioxide: implications for permissive and therapeutic hypercapnia. Eur Respir J. 2002;20(1):6-11. doi:10.1183/09031936.02.00400802
16. http://www.ardsnet.org/tools.shtml (Erişim tarihi: 10.08.2020)
17. Doig GS, Simpson F. Randomization and allocation concealment: a practical guide for researchers. J Crit Care. 2005;20(2):187-191; doi:10.1016/j.jcrc.2005.04.005
18. Hoşten T, Kuş A, Gümüş E, Yavuz Ş, İrkil S, Solak M. Comparison of intraoperative volume and pressure-controlled ventilation modes in patients who undergo open heart surgery. J Clin Monit Comput. 2017;31(1):75-84. doi:10.1007/s10877-016-9824-x
19. Chaney MA, Nikolov MP, Blakeman BP, Bakhos M. Protective ventilation attenuates postoperative pulmonary dysfunction in patients undergoing cardiopulmonary bypass. J Cardiothorac Vasc Anesth. 2000;14(5):514-518. doi:10.1053/jcan.2000.9487
20. Lellouche F, Dionne S, Simard S, Bussières J, Dagenais F. High tidal volumes in mechanically ventilated patients increase organ dysfunction after cardiac surgery. Anesthesiology. 2012;116(5):1072-1082. doi:10.1097/ALN.0b013e3182522df5
21. García-Delgado M, Navarrete-Sánchez I, Colmenero M. Preventing and managing perioperative pulmonary complications following cardiac surgery. Curr Opin Anaesthesiol. 2014;27(2):146-152. doi:10.1097/aco.0000000000000059
22. Reis Miranda D, Gommers D, Struijs A, et al. Ventilation according to the open lung concept attenuates pulmonary inflammatory response in cardiac surgery. Eur J Cardiothorac Surg. 2005;28(6):889-895. doi:10.1016/j.ejcts.2005.10.007
23. Zamani MM, Najafi A, Sehat S, et al. The effect of intraoperative lung protective ventilation vs conventional ventilation, on postoperative pulmonary complications after cardiopulmonary bypass. J Cardiovasc Thorac Res. 2017;9(4):221-228. doi:10.15171/jcvtr.2017.38
24. Wrigge H, Uhlig U, Baumgarten G, et al. Mechanical ventilation strategies and inflammatory responses to cardiac surgery: a prospective randomized clinical trial. Intensive Care Med. 2005;31(10):1379-1387.
25. Koner O, Celebi S, Balci H, Cetin G, Karaoglu K, Cakar N. Effects of protective and conventional mechanical ventilation on pulmonary function and systemic cytokine release after cardiopulmonary bypass. Intensive Care Med. 2004;30(4):620-626. doi:10.1007/s00134-003-2104-5
26. Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, Wheeler A. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301-8. doi:10.1056/nejm200005043421801
27. Lutfi MF. The physiological basis and clinical significance of lung volume measurements. Multidisciplinary respiratory medicine. 2017;12(1):1-12.
28. Young CC, Harris EM, Vacchiano C, et al. Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations. Br J Anaesth. 2019;123(6):898-913.
29. Van der Zee P, Gommers D. Recruitment maneuvers and higher PEEP, the so-called open lung concept, in patients with ARDS. Critical Care. 2019;23(1):1-7.
30. Satoh K, Ohashi A, Kumagai M, Sato M, Kuji A, Joh S. Evaluation of differences between PaCO2 and ETCO2 by Age as measured during general anesthesia with patients in a supine position. Journal of Anesthesiology. 2015;doi.org/10.1155/2015/710537
31. Futier E, Constantin JM, Paugam-Burtz C, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med.2013;369(5):428-437. doi:10.1056/NEJMoa1301082
32. Bugedo G, Retamal J, Bruhn A. Driving pressure: a marker of severity, a safety limit, or a goal for mechanical ventilation? Crit Care. 4 2017;21(1):199. doi:10.1186/s13054-017-1779-x
33. Puzio J, Kucewicz E, Sioła M, et al. Atypical and opportunistic pulmonary infections after cardiac surgery. Anestezjologia intensywna terapia. 2009;41(1):41.
34. Topal A, Eren M. Risk factors for the development of pneumonia post cardiac surgery. Cardiovasc J Afr. 2012;23(4):212.
35. Bicer Y, Simsek S, Yapici N, Aydin O, Sogut F, Aykac Z. Risk factor analysis of pneumonias developing after open heart surgery. Critical Care. 2005;9(1):1-2.