Intraoperative Beatmung bei Erwachsenen

Zusammenfassung

Die Beatmungstherapie kann offenbar nicht nur bei Patienten mit akutem Lungenversagen einen Einfluss auf den Krankheitsverlauf haben. Lungenprotektive Beatmungskonzepte werden daher auch für die Narkosebeatmung propagiert. Dieser Beitrag diskutiert verschiedene Aspekte der Beatmungstherapie in Narkose und berücksichtigt dabei auch die zunehmende Verbreitung von Adipositas bei erwachsenen Patienten.

Abstract

Avoiding postoperative pulmonary complications (PPC) is an important goal for anesthesiologists during general anesthesia, and ventilation strategies may play a role. It seems reasonable to apply knowledge from lessons we learned from ventilation of intensive care unit patients aiming at avoiding ventilator associated lung injury. Ventilation associated lung injuries occur frequently and are associated with substantial morbidity and mortality. Strategies of lung protective ventilation, like lower tidal volumes and the use of positive end-expiatory pressure (PEEP), can usually be transferred safely to perioperative ventilation, although some issues such as hemodynamic side effects must be considered. For some reasons, however, current evidence is conflicting and there is no consensus on ventilatory perioperative management to avoid PPCs so far. This paper briefly summarizes physiological backgrounds in a functional context, current evidence, and provides some recommendations at “expert” opinion level for perioperative ventilation procedures.

Especially in patients at risk and/or during surgery with higher surgical trauma and inflammation, we recommend limiting tidal volume to 6 – 8 ml/kg predicted body weight and the use of PEEP, which should be individualized e.g. by minimizing driving pressure. Recruitment maneuvers may be considered and should be carried out by using the ventilator.

Obese patients are an increasing entity and can be challenging during anesthesia and ventilation. From a physiological point of view, these patients require much higher ventilation pressures as currently used, although recent evidence is not in favor of using moderately higher PEEP, which is matter of discussion.

Kernaussagen

• Für die zeitlich meist sehr begrenzte intraoperative Beatmung ist der komplikationsreduzierende Effekt einer lungenprotektiven Beatmung wie beim ARDS nur selten eindeutig nachweisbar.

• Je nach Patienteneigenschaften, Vorerkrankungen, geplantem OP-Verfahren und damit verbundener Entzündungsreaktion auf das operative Trauma spielt eine protektive Beatmung aber ggf. eine wichtige Rolle.

• Dabei bedarf es selbstverständlich einer detaillierten OP-Vorbereitung, aber noch viel mehr einer guten Kommunikation im interdisziplinärem OP-Team.

• Insbesondere bei Risikokonstellationen lassen sich vermutlich unmittelbare und langfristige postoperative Komplikationen durch die Grundregeln der lungenprotektiven Beatmung reduzieren: V_T 6 – 8 ml/kg Idealgewicht, PEEP 8 – 12 cmH₂O (bei Adipösen individualisiert um 20 cmH₂O), niedriger Driving Pressure.

• Dabei müssen Patienteneigenschaften, Lagerung und OP-Verfahren sowie eine adäquate Kreislauftherapie bei gleichzeitiger Volumenrestriktion beachtet werden.

• In der unmittelbar postoperativen Phase können Oberkörperhochlagerung und nichtinvasive Beatmung hilfreich sein. Eine patientenadaptierte Schmerztherapie bildet die Grundlage einer effektiven Atemtherapie und beugt damit postoperativen pulmonalen Komplikationen vor.

Schlüsselwörter

intraoperative Beatmung - Tidalvolumen - PEEP - Rekrutierungsmanöver - Adipositas

Key words

Lung injury - positive end-expiratory pressure - postoperative pulmonary complications - mechanical ventilation - tidal volume - recruitment maneuver

Publikationsverlauf

Artikel online veröffentlicht:
26. Mai 2021

• Literatur

• 1 Slutsky AS, Ranieri VM. Mechanical ventilation: lessons from the ARDSNet trial. Respir Res 2000; 1: 73-77
• 2 Slutsky AS, Ranieri VM. Ventilator-induced lung injury. N Engl J Med 2013; 369: 2126-2136
• 3 Hoegl S, Burns N, Angulo M. et al. Capturing the multifactorial nature of ARDS – “Two-hit” approach to model murine acute lung injury. Physiol Rep 2018; 6: e13648
• 4 Yamada T, Hisanaga M, Nakajima Y. et al. Serum interleukin-6, interleukin-8, hepatocyte growth factor, and nitric oxide changes during thoracic surgery. World J Surg 1998; 22: 783-790
• 5 Serpa Neto A, Hemmes SNT, Barbas CSV. et al. Protective versus conventional ventilation for surgery: a systematic review and individual patient data meta-analysis. Anesthesiology 2015; 123: 66-78
• 6 Hedenstierna G, Edmark L, Aherdan KK. Time to reconsider the pre-oxygenation during induction of anaesthesia. Minerva Anestesiol 2000; 66: 293-296
• 7 Neumann P, Rothen HU, Berglund JE. et al. 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
• 8 Hedenstierna G, Rothen HU. Atelectasis formation during anesthesia: causes and measures to prevent it. J Clin Monit Comput 2000; 16: 329-335
• 9 Girrbach F, Petroff D, Schulz S. et al. Individualised positive end-expiratory pressure guided by electrical impedance tomography for robot-assisted laparoscopic radical prostatectomy: a prospective, randomised controlled clinical trial. Br J Anaesth 2020; 125: 373-382
• 10 Neto AS, Hemmes SNT, Barbas CSV. et al. Association between driving pressure and development of postoperative pulmonary complications in patients undergoing mechanical ventilation for general anaesthesia: a meta-analysis of individual patient data. Lancet Respir Med 2016; 4: 272-280
• 11 Hol L, Nijbroek SGLH, Neto AS. et al. Driving Pressure During General Anesthesia for Open Abdominal Surgery (DESIGNATION): study protocol of a randomized clinical trial. Trials 2020; 21: 198
• 12 Amato MBP, Meade MO, Slutsky AS. et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med 2015; 372: 747-755
• 13 Futier E, Constantin J-M, Paugam-Burtz C. et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med 2013; 369: 428-437
• 14 Karalapillai D, Weinberg L, Peyton P. et al. Effect of intraoperative low tidal volume vs. conventional tidal volume on postoperative pulmonary complications in patients undergoing major surgery: a randomized clinical trial. JAMA 2020; 324: 848-858
• 15 Mazzinari G, Serpa Neto A, Hemmes SNT. et al. ; LAS VEGAS study–investigators; PROtective VEntilation NETwork; Clinical Trial Network of the European Society of Anaesthesiology. The Association of Intraoperative driving pressure with postoperative pulmonary complications in open versus closed abdominal surgery patients – a posthoc propensity score-weighted cohort analysis of the LAS VEGAS study. BMC Anesthesiol 2021; 21: 84
• 16 Canet J, Gallart L, Gomar C. et al. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology 2010; 113: 1338-1350
• 17 Rao SL, Kunselman AR, Schuler HG. et al. Laryngoscopy and tracheal intubation in the head-elevated position in obese patients: a randomized, controlled, equivalence trial. Anesth Analg 2008; 107: 1912-1918
• 18 Gander S, Frascarolo P, Suter M. et al. Positive end-expiratory pressure during induction of general anesthesia increases duration of nonhypoxic apnea in morbidly obese patients. Anesth Analg 2005; 100: 580-584
• 19 Nestler C, Simon P, Petroff D. et al. Individualized positive end-expiratory pressure in obese patients during general anaesthesia: a randomized controlled clinical trial using electrical impedance tomography. Br J Anaesth 2017; 119: 1194-1205
• 20 Reinius H, Jonsson L, Gustafsson S. et al. Prevention of atelectasis in morbidly obese patients during general anesthesia and paralysis: a computerized tomography study. Anesthesiology 2009; 111: 979-987
• 21 Duggan M, Kavanagh BP. Pulmonary atelectasis: a pathogenic perioperative entity. Anesthesiology 2005; 102: 838-854
• 22 Ball L, Hemmes SNT, Serpa Neto A. et al. Intraoperative ventilation settings and their associations with postoperative pulmonary complications in obese patients. Br J Anaesth 2018; 121: 899-908
• 23 Writing Committee for the PROBESE Collaborative Group of the PROtective VEntilation Network (PROVEnet) for the Clinical Trial Network of the European Society of Anaesthesiology. Bluth T, Serpa Neto A. et al. Effect of intraoperative high positive end-expiratory pressure (PEEP) with recruitment maneuvers vs. low PEEP on postoperative pulmonary complications in obese patients: a randomized clinical trial. JAMA 2019; 321: 2292-2305
• 24 Simon P, Girrbach F, Petroff D. et al. Individualized versus fixed positive end-expiratory pressure for intraoperative mechanical ventilation in obese patients – a secondary analysis. Anesthesiology 2021;