Individualised, perioperative open-lung ventilation strategy during one-lung ventilation (iPROVE-OLV): a multicentre, randomised, controlled clinical trial.

BACKGROUND: It is uncertain whether individualisation of the perioperative open-lung approach (OLA) to ventilation reduces postoperative pulmonary complications in patients undergoing lung resection. We compared a perioperative individualised OLA (iOLA) ventilation strategy with standard lung-protective ventilation in patients undergoing thoracic surgery with one-lung ventilation. METHODS: This multicentre, randomised controlled trial enrolled patients scheduled for open or video-assisted thoracic surgery using one-lung ventilation in 25 participating hospitals in Spain, Italy, Turkey, Egypt, and Ecuador. Eligible adult patients (age ≥18 years) were randomly assigned to receive iOLA or standard lung-protective ventilation. Eligible patients (stratified by centre) were randomly assigned online by local principal investigators, with an allocation ratio of 1:1. Treatment with iOLA included an alveolar recruitment manoeuvre to 40 cm H2O of end-inspiratory pressure followed by individualised positive end-expiratory pressure (PEEP) titrated to best respiratory system compliance, and individualised postoperative respiratory support with high-flow oxygen therapy. Participants allocated to standard lung-protective ventilation received combined intraoperative 4 cm H2O of PEEP and postoperative conventional oxygen therapy. The primary outcome was a composite of severe postoperative pulmonary complications within the first 7 postoperative days, including atelectasis requiring bronchoscopy, severe respiratory failure, contralateral pneumothorax, early extubation failure (rescue with continuous positive airway pressure, non-invasive ventilation, invasive mechanical ventilation, or reintubation), acute respiratory distress syndrome, pulmonary infection, bronchopleural fistula, and pleural empyema. Due to trial setting, data obtained in the operating and postoperative rooms for routine monitoring were not blinded. At 24 h, data were acquired by an investigator blinded to group allocation. All analyses were performed on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov, NCT03182062, and is complete. FINDINGS: Between Sept 11, 2018, and June 14, 2022, we enrolled 1380 patients, of whom 1308 eligible patients (670 [434 male, 233 female, and three with missing data] assigned to iOLA and 638 [395 male, 237 female, and six with missing data] to standard lung-protective ventilation) were included in the final analysis. The proportion of patients with the composite outcome of severe postoperative pulmonary complications within the first 7 postoperative days was lower in the iOLA group compared with the standard lung-protective ventilation group (40 [6%] vs 97 [15%], relative risk 0·39 [95% CI 0·28 to 0·56]), with an absolute risk difference of -9·23 (95% CI -12·55 to -5·92). Recruitment manoeuvre-related adverse events were reported in five patients. INTERPRETATION: Among patients subjected to lung resection under one-lung ventilation, iOLA was associated with a reduced risk of severe postoperative pulmonary complications when compared with conventional lung-protective ventilation. FUNDING: Instituto de Salud Carlos III and the European Regional Development Funds.

Encuesta sobre la anestesiología en cirugía vascular e impacto de la pandemia por la COVID-19 / Survey on anesthesiology in vascular surgery and COVID-19 pandemic impact

Los pacientes sometidos a cirugía vascular son pluripatológicos y complejos. En los últimos años ha habido un incremento importante en el número de pacientes intervenidos por vía endovascular. La Sección de Anestesiología Cardíaca, Vascular y Torácica de la Sociedad Española de Anestesiología y Reanimación (SEDAR) diseñó una encuesta telemática basada en 29 preguntas mediante Google Forms® que envió a todos sus miembros. Un total de 204 anestesiólogos contestaron una serie de preguntas estructuradas en bloques: 1. Cirugía de la endarterectomía carotídea; 2. Reparación de aneurisma de aorta abdominal y torácica; 3. Cirugía arterial y venosa de miembros inferiores; 4. Impacto de la pandemia por la COVID-19 sobre la programación quirúrgica en cirugía vascular; 5. Programas de recuperación intensificada en cirugía vascular, y 6. Otras preguntas. A pesar de determinadas diferencias en cuanto al manejo anestésico, la anestesia locorregional es una técnica ampliamente utilizada. Los tres determinantes para la actuación del anestesiólogo son el paciente, su patología y la idiosincrasia de cada centro. Actualmente, los programas de recuperación acelerada en cirugía vascular no están ampliamente implementados en España. Finalmente, los resultados ponen de manifiesto que, durante la primera ola de la pandemia por la COVID-19, la cirugía vascular quedó prácticamente reducida a la cirugía urgente y emergente, según las recomendaciones anestésicas y quirúrgicas de las diferentes sociedades científicas, incluidas la SEDAR y la SEACV.(AU)

Patients undergoing vascular surgery are multi-pathological and complex. In recent years there has been a significant increase in the number of patients undergoing endovascular surgery. The Cardiac, Vascular and Thoracic section of the Spanish Society of Anesthesiology and Resuscitation (SEDAR) designed a telematic survey based on 29 questions using Google Forms® that was sent to all members of this society. A total of 204 anesthesiologists answered questions structured in blocks: 1. Carotid endarterectomy; 2. Abdominal and thoracic aortic aneurysm repair; 3. Lower limb arterial and venous surgery; 4. Impact of the COVID-19 pandemic on vascular surgical scheduling; 5. Enhanced recovery after vascular surgery; 6. Other questions. Despite certain differences in anesthetic management, locoregional anesthesia is a widely used technique. The three determinants for the anesthesiologist’s performance are the patient, his or her pathology and the idiosyncrasy of each center. Currently, accelerated recovery programs in vascular surgery are not widely implemented in Spain. Finally, the results show that during the first wave of the COVID-19 pandemic, vascular surgery was practically reduced to urgent and emergent surgery, following the anesthetic and surgical recommendations of the different scientific societies, including SEDAR and SEACV.(AU)

Effects of oxygen on post-surgical infections during an individualised perioperative open-lung ventilatory strategy: a randomised controlled trial.

BACKGROUND: We aimed to examine whether using a high fraction of inspired oxygen (FIO2) in the context of an individualised intra- and postoperative open-lung ventilation approach could decrease surgical site infection (SSI) in patients scheduled for abdominal surgery. METHODS: We performed a multicentre, randomised controlled clinical trial in a network of 21 university hospitals from June 6, 2017 to July 19, 2018. Patients undergoing abdominal surgery were randomly assigned to receive a high (0.80) or conventional (0.3) FIO2 during the intraoperative period and during the first 3 postoperative hours. All patients were mechanically ventilated with an open-lung strategy, which included recruitment manoeuvres and individualised positive end-expiratory pressure for the best respiratory-system compliance, and individualised continuous postoperative airway pressure for adequate peripheral oxyhaemoglobin saturation. The primary outcome was the prevalence of SSI within the first 7 postoperative days. The secondary outcomes were composites of systemic complications, length of intensive care and hospital stay, and 6-month mortality. RESULTS: We enrolled 740 subjects: 371 in the high FIO2 group and 369 in the low FIO2 group. Data from 717 subjects were available for final analysis. The rate of SSI during the first postoperative week did not differ between high (8.9%) and low (9.4%) FIO2 groups (relative risk [RR]: 0.94; 95% confidence interval [CI]: 0.59-1.50; P=0.90]). Secondary outcomes, such as atelectasis (7.7% vs 9.8%; RR: 0.77; 95% CI: 0.48-1.25; P=0.38) and myocardial ischaemia (0.6% [n=2] vs 0% [n=0]; P=0.47) did not differ between groups. CONCLUSIONS: An oxygenation strategy using high FIO2 compared with conventional FIO2 did not reduce postoperative SSIs in abdominal surgery. No differences in secondary outcomes or adverse events were found. CLINICAL TRIAL REGISTRATION: NCT02776046.

Use of Dexmedetomidine in Cardiothoracic and Vascular Anesthesia.

Dexmedetomidine is a highly selective α2-adrenergic agonist with analgesic and sedative properties. In the United States, the Food and Drug Administration approved the use of the drug for short-lasting sedation (24 h) in intensive care units (ICUs) in patients undergoing mechanical ventilation and endotracheal intubation. In October 2008, the Food and Drug Administration extended use of the drug for the sedation of nonintubated patients before and during surgical and nonsurgical procedures. In the European Union, the European Medicine Agency approved the use of dexmedetomidine in September 2011 with a single recognized indication: ICU adult patients requiring mild sedation and awakening in response to verbal stimulus. At present, the use of dexmedetomidine for sedation outside the ICU remains an off-label indication. The benefits of dexmedetomidine in critically ill patients and in cardiac, electrophysiology-related, vascular, and thoracic procedures are discussed.

The accuracy of the anesthetic conserving device (AnaConDa©) as an alternative to the classical vaporizer in anesthesia.

BACKGROUND: The Anesthetic Conserving Device--AnaConDa® (ACD)--has been compared with a conventional vaporizer. However, the accuracy of the administered concentration of volatile anesthetics was not examined. In the present study we measured the accuracy of the ACD when used as a portable vaporizer. METHODS: This prospective study included 30 ASA I-III patients scheduled for elective surgery under general anesthesia. The patients were randomly organized into 3 groups of 10 patients per group. In each group, the sevoflurane infusion rate was adjusted to deliver 1.0 vol%, 1.5 vol%, and 2.0 vol% alveolar concentration. Hemodynamic data, bispectral index, and end-tidal sevoflurane concentrations were recorded every 2 minutes. RESULTS: We analyzed 801 data points from 30 patients. The mean difference between the end-tidal sevoflurane concentration and the target concentration was -11.0 ± 9.3% of the target when the target was 1.0 vol%, -5.4 ± 6.4% when the target was 1.5 vol%, and -4.0 ± 7.4% when the target was 2.0 vol%. No significant differences were found in the error at the different target concentrations. CONCLUSIONS: We found that the ACD may be a valid alternative to the conventional vaporizer. The ACD is very simple to use, delivery rate needs to be adjusted only once per hour, and the anesthetic savings are independent of the circuit characteristics and fresh gas flow rate.