Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942009000200005
Brazilian Journal of Anesthesiology
Scientific Article

Análise dos efeitos da manobra de recrutamento alveolar na oxigenação sanguínea durante procedimento bariátrico

Analysis of the effects of the alveolar recruitment maneuver on blood oxygenation during bariatric surgery

Alda Paiva de Souza; Márcia Buschpigel; Ligia Andrade Silva Telles Mathias; Carlos Alberto Malheiros; Vera Lucia dos Santos Alves

http://dx.doi.org/10.1590/S0034-70942009000200005 Braz J Anesthesiol, vol.59, n2, p.177-186, 2009
PDF Português
PDF English
Downloads: 1
Views: 1251

Resumo

JUSTIFICATIVAS E OBJETIVOS: A manobra de recrutamento alveolar (MRA) é indicada no tratamento de atelectasias intraoperatórias. O objetivo do presente estudo foi comparar duas técnicas de MRA por meio da resposta da relação PaO2/FiO2 e da soma [PaO2+PaCO2], em pacientes obesos grau III. MÉTODO: Estudo prospectivo aberto em pacientes adultos, obesos grau III, submetidos a procedimento cirúrgico bariátrico em ventilação controlada a volume, pressão positiva no final da expiração (PEEP) de 5 cmH2O e divididos em três grupos: G CONT: PEEP de 5 cmH2O; G MRA10/15/20 após sutura da aponeurose: aumento progressivo da PEEP para 10,15 e 20 cmH2O, pausa de 40 segundos e manutenção de cada valor da PEEP por 2 minutos; G MRA30: após sutura da aponeurose: aumento súbito da PEEP para 30 cmH2O, 40 segundos de pausa e manutenção da PEEP em 30 cmH2O por dois minutos. Foram analisadas as variáveis frequência cardíaca, pressão arterial média, sistólica, diastólica, pressão média das vias aéreas (P MVA) e de platô (P PLAT), pressão arterial de oxigênio (PaO2), pressão arterial de CO2 (PaCO2), relação PaO2/FiO2 (fração inspiratória de oxigênio) e soma [PaO2+PaCO2]. RESULTADOS: As variáveis que apresentaram diferença estatística significativa entre os três grupos foram: P PLAT, P MVA, PaO2, relação PaO2/FiO2 e soma [PaO2+PaCO2] (p < 0,0001). Na comparação dos grupos dois a dois, verificou-se diferença estatística significativa para as variáveis P PLAT e P MVA: G CONT X G MRA10/15/20 e G CONT X G MRA30 e para as variáveis relação PaO2/FiO2 e soma [PaO2+PaCO2]: G CONT X G MRA30. CONCLUSÕES: A técnica de MRA com aumento súbito da PEEP para 30 cm H2O mostrou a melhor resposta da relação PaO2/FiO2.

Palavras-chave

CIRURGIA, COMPLICAÇÕES, VENTILAÇÃO, VENTILAÇÃO

Abstract

BACKGROUND AND METHDS: Alveolar recruitment maneuver (ARM) is indicated in the treatment of intraoperative atelectasis. The objective of the present study was to compare two techniques of ARM using the response of the PaO2/FiO2 ratio and [PaO2 + PaCO2] in patients with grade III obesity. METHODS: This was an open prospective study with adult patients with grade III obesity who underwent bariatric surgery under volume-controlled mechanical ventilation with positive end-expiratory pressure (PEEP) of 5 cmH2O, divided in three groups: G CONT: PEEP of 5 cmH2O; G ARM10/15/20 after suture of the aponeurosis: progressive increase in PEEP to 10, 15, and 20 cmH2O with a 40-second pause and maintaining each level of PEEP for 2 minutes; and G ARM30 after suture of the aponeurosis: sudden increase in PEEP to 30 cmH2O with a 40-second pause and maintaining a PEEP of 30 for 2 minutes. Heart rate, mean arterial pressure, systolic and diastolic blood pressure, mean (P AW) and plateau (P PLAT) airways pressure, partial pressure of oxygen (PaO2), partial pressure of carbon dioxide (PaCO2), PaO2/FiO2 ratio (inspired fraction of oxygen), and [PaO2 + PaCO2] were analyzed. RESULTS: The following parameters showed statistically significant differences among the study groups: P PLAT, P AW, PaO2, PaO2/FiO2 ratio, and [PaO2 + PaCO2] (p < 0.0001). Comparing the groups two by two, the following parameters showed statistically significant differences: for P PLAT and P AW: G CONT x G2ARM10/15/20 and G CONT x G ARM30; and for PaO2/FiO2 ratio and [PaO2 + PaCO2]: G CONT x G ARM30. CONCLUSIONS: Alveolar recruitment maneuver with sudden increase of PEEP to 30 cmH2O showed a better response of the PaO2/FiO2 ratio.

Keywords

COMPLICATIONS, SURGERY, VENTILATION, VENTILATION

References

Perilli V, Sollazzi L, Bozza P. The effects of the reverse trendelenburg position on respiratory mechanics and blood gases in morbidly obese patients during bariatric surgery. Anesth Analg. 2000;91:1520-1525.

Coussa M, Proietti S, Schnyder P. Prevention of atelectasis formation during the induction of general anesthesia in morbidly obese patients. Anesth Analg. 2004;98:1491-1495.

Biring MS, Lewis MI, Liu JI. Pulmonary physiologic changes of morbid obesity. Am J Med Sci. 1999;318:293-297.

Slutsky AS. Consensus Conference on Mechanical Ventilation: Part 2. Intensive Care Med. 1994;20:150-162.

Artigas A, Bernard GR, Carlet J. The American-European Consensus Conference on ARDS, part 2: Ventilatory, pharmacologic, supportive therapy, study design strategies, and issues related to recovery and remodeling. Acute respiratory distress syndrome. Am J Respir Crit Care Med. 1998;157:1332-1347.

Beppu OS, Guanaes A. PEEP (Pressão Positiva ao Final da Expiração). Ventilação Mecânica I - Básico: Relatório do II Consenso Brasileiro de Ventilação Mecânica. 2003:327-330.

Benseñor FEM, Auler JOC. P ET CO2 e SpO2 permitem ajuste ventilatório adequado em pacientes obesos mórbidos. Rev Bras Anestesiol. 2004;54:542-552.

Warner DO. Preventing postoperative pulmonary complications: the role of the anesthesiologist. Anesthesiology. 2000;92:1467-1472.

Pelosi P, Croci M, Ravagnan I. The effects of body mass on lung volume, respiratory mechanics, and gas exchange during general anesthesia. Anesth Analg. 1998;87:654-660.

Auler Jr JOC, Galas FRBG, Hajjar LA. Ventilação mecânica no intra-operatório. J Bras Pneumol. 2007;33:137s-141s.

Gander S, Frascarolo P, Suter M. Positive end-expiratory pressure during induction of general anesthesia increases duration of nonhypoxic apnea in morbidly obese patients. Anesth Analg. 2005;100:580-584.

Paisani DM, Chiavegato LD, Faresin SM. Volumes, capacidades pulmonares e força muscular respiratória no pós-operatório de gastroplastia. J Bras Pneumol. 2005;31:125-132.

Hedenstierna G. Atelectasis and gas exchange during anaesthesia. Electromedica. 2003;71:70-73.

Pelosi P, Croci M, Ravagnan I. Total respiratory system, lung, and chest wall mechanics in sedated-paralyzed postoperative morbidly obese patients. Chest. 1996;109:144-151.

Miyoshi E, Margarido CB, Oliveira MAV. Obeso mórbido e anestesia. Atual Anestesiol - Saesp. 2001;6:102-116.

Bardoczky GI, Yernault JC, Houben JJ. Large tidal volume ventilation does not improve oxygenation in morbidly obese patients during anesthesia. Anest Analg. 1995;81:385-388.

Neumann P, Rothen HU, Berglund JE. Positive end-expiratory pressure prevents atelectasis during general anaesthesia even in the presence of a high inspired oxygen concentration. Acta Anaesthesiol Scand. 1999;43:295-301.

Gattinoni L, Caironi P, Cressoni M. Lung recruitment in patients with the acute respiratory distress syndrome. N Eng J Med. 2006;354:1775-1786.

Auler Jr JOC, Miyoshi E, Fernandes CR. The effects of abdominal opening on respiratory mechanics during general anesthesia in normal and morbidly obese patients: a comparative study. Anesth Analg. 2002;94:741-748.

Dyhr T, Nygard E, Laursen N. Both lung recruitment maneuver and PEEP are needed to increase oxygenation and volume after cardiac surgery. Acta Anaesthesiol Scand. 2004;48:187-197.

Richard JC, Maggiore SM, Jonson B. Influence of tidal volume on alveolar recruitment: Respective role of PEEP and a recruitment maneuver. Am J Respir Crit Care Med. 2001;163:1609-1613.

Henzler D, Rossaint R, Kuhlen R. Is there a need for a recruiting strategy in morbidly obese patients undergoing laparoscopic surgery?. Anesth Analg. 2004;98:268.

Whalen FX, Gajic O, Thompson GB. The effects of the alveolar recruitment maneuver and positive end-expiratory pressure on arterial oxygenation during laparoscopic bariatric surgery. Anesth Analg. 2006;102:298-305.

Borges JB, Okamoto VN, Matos GFJ. Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome (ARDS). Am J Respir Crit Care Med. 2006;174:268-278.

Bugedo G, Bruhn A. Is maximal lung recruitment worth it?. Am J Respir Crit Care Med. 2006;174:1159.

Benseñor FEM. Ventilação artificial: anestesia para pacientes com obesidade mórbida. Atual Anestesiol - Saesp. 2005;10:53-58.

Grasso S, Mascia L, Del Turco M. Effects of recruiting maneuver in patients with acute respiratory distress syndrome ventilated with protective ventilatory strategy. Anesthesiology. 2002;96:795-802.

Amato MBP, Barbas CSV, Medeiros DM. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med. 1998;338:347-354.

Mancini MC, Aloé F. Obesidade, Apnéia Obstrutiva do Sono e Distúrbios Respiratórios. Obesidade. 1998:153-170.

5dd687050e8825d94bc8fca6 rba Articles
Links & Downloads
2352-2291 (Electronic) 0104-0014 (Printed)
Braz J Anesthesiol ©2024 All rights reserved.

Braz J Anesthesiol

Share this page
Page Sections