Intraoperative ventilatory strategies for prevention of pulmonary atelectasis in obese patients undergoing laparoscopic bariatric surgery.
BACKGROUND
Atelectasis occurs regularly after induction of general anesthesia, persists postoperatively, and may contribute to significant postoperative morbidity and additional health care costs. Laparoscopic surgery has been reported to be associated with an increased incidence of postoperative atelectasis. It has been shown that during general anesthesia, obese patients have a greater risk of atelectasis than nonobese patients. Preventing atelectasis is important for all patients but is especially important when caring for obese patients.


METHODS
We randomly allocated 66 adult obese patients with a body mass index between 30 and 50 kg/m(2) scheduled to undergo laparoscopic bariatric surgery into 3 groups. According to the recruitment maneuver used, the zero end-expiratory pressure (ZEEP) group (n = 22) received the vital capacity maneuver (VCM) maintained for 7-8 s applied immediately after intubation plus ZEEP; the positive end-expiratory pressure (PEEP) 5 group (n = 22) received the VCM maintained for 7-8 s applied immediately after intubation plus 5 cm H(2)O of PEEP; and the PEEP 10 group (n = 22) received the VCM maintained for 7-8 s applied immediately after intubation plus 10 cm H(2)O of PEEP. All other variables (e.g., anesthetic and surgical techniques) were the same for all patients. Heart rate, noninvasive mean arterial blood pressure, arterial oxygen saturation, and alveolar-arterial Pao(2) gradient (A-a Pao(2)) were measured intraoperatively and postoperatively in the postanesthesia care unit (PACU). Length of stay in the PACU and the use of a nonrebreathing O(2) mask (100% Fio(2)) or reintubation were also recorded. A computed tomographic scan of the chest was performed preoperatively and postoperatively after discharge from the PACU to evaluate lung atelectasis.


RESULTS
Patients in the PEEP 10 group had better oxygenation both intraoperatively and postoperatively in the PACU, lower atelectasis score on chest computed tomographic scan, and less postoperative pulmonary complications than the ZEEP and PEEP 5 groups. There was no evidence of barotrauma in any patient in the 3 study groups.


CONCLUSIONS
Intraoperative alveolar recruitment with a VCM followed by PEEP 10 cm H(2)O is effective at preventing lung atelectasis and is associated with better oxygenation, shorter PACU stay, and fewer pulmonary complications in the postoperative period in obese patients undergoing laparoscopic bariatric surgery.
Department of Anesthesiology, King Faisal Specialist Hospital & Research Centre, Jeddah, Saudi Arabia.
Hesham F
HF
Talab
Ibrahim Ali
IA
Zabani
Hassan Saad
HS
Abdelrahman
Waleed L
WL
Bukhari
Irfan
I
Mamoun
Majed A
MA
Ashour
Bakr Bin
BB
Sadeq
Sameh Ibrahim
SI
El Sayed
D000328:Adult; D000762:Anesthesia Recovery Period; D050110:Bariatric Surgery / Q000009:adverse effects*; D015992:Body Mass Index; D004311:Double-Blind Method; D005260:Female; D006439:Hemodynamics; D006801:Humans; D007430:Intraoperative Care; D010535:Laparoscopy / Q000009:adverse effects*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000150:complications / Q000601:surgery*; D010100:Oxygen / Q000097:blood; D011175:Positive-Pressure Respiration; D011446:Prospective Studies; D001261:Pulmonary Atelectasis / Q000000981:diagnostic imaging / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D012121:Respiration, Artificial / Q000009:adverse effects / Q000379:methods; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D055815:Young Adult
D010100:Oxygen