Individualised positive end-expiratory pressure guided by electrical impedance tomography for robot-assisted laparoscopic radical prostatectomy: a prospective, randomised controlled clinical trial

Felix Girrbach; David Petroff; Susann Schulz; Gunther Hempel; Mirko Lange; Carolin Klotz; Stephanie Scherz; Antonio Giannella-Neto; Alessandro Beda; Alcendino Jardim-Neto; Jens-Uwe Stolzenburg; Andreas W Reske; Hermann Wrigge; Philipp Simon

doi:10.1016/j.bja.2020.05.041

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 Sep;125(3):373-382. doi: 10.1016/j.bja.2020.05.041. Epub 2020 Jul 19.

Affiliations

¹ Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Centre, Leipzig, Germany; Innovation Centre Computer Assisted Surgery, University of Leipzig, Leipzig, Germany.
² Clinical Trial Centre, University of Leipzig, Leipzig, Germany; Integrated Research and Treatment Centre (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany.
³ Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Centre, Leipzig, Germany.
⁴ Laboratory of Pulmonary Engineering, Biomedical Engineering Program, Alberto Luis Coimbra Institute of Post-Graduation and Research in Engineering, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
⁵ Department of Electronic Engineering, BioSiX-Biomedical Signal Processing, Analysis and Simulation Group, Postgraduate Program of Electrical Engineering (PPGEE), Federal University of Minas Gerais, Belo Horizonte, Brazil.
⁶ Laboratory of Pulmonary Engineering, Biomedical Engineering Program, Alberto Luis Coimbra Institute of Post-Graduation and Research in Engineering, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Department of Electronic Engineering, BioSiX-Biomedical Signal Processing, Analysis and Simulation Group, Postgraduate Program of Electrical Engineering (PPGEE), Federal University of Minas Gerais, Belo Horizonte, Brazil.
⁷ Department of Urology, University of Leipzig Medical Centre, Leipzig, Germany.
⁸ Innovation Centre Computer Assisted Surgery, University of Leipzig, Leipzig, Germany; Department of Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Heinrich-Braun-Hospital, Zwickau, Germany.
⁹ Department of Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, Halle, Germany; Integrated Research and Treatment Centre (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany.
¹⁰ Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Centre, Leipzig, Germany; Integrated Research and Treatment Centre (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany. Electronic address: arbeit.simon@gmail.com.

PMID: 32665059
DOI: 10.1016/j.bja.2020.05.041

Abstract

Background: Robot-assisted laparoscopic radical prostatectomy requires general anaesthesia, extreme Trendelenburg positioning and capnoperitoneum. Together these promote impaired pulmonary gas exchange caused by atelectasis and may contribute to postoperative pulmonary complications. In morbidly obese patients, a recruitment manoeuvre (RM) followed by individualised PEEP improves intraoperative oxygenation and end-expiratory lung volume (EELV). We hypothesised that individualised PEEP with initial RM similarly improves intraoperative oxygenation and EELV in non-obese individuals undergoing robot-assisted prostatectomy.

Methods: Forty males (age, 49-76 yr; BMI <30 kg m^-2) undergoing prostatectomy received volume-controlled ventilation (tidal volume 8 ml kg^-1 predicted body weight). Participants were randomised to either (1) RM followed by individualised PEEP (RM/PEEP_IND) optimised using electrical impedance tomography or (2) no RM with 5 cm H₂O PEEP. The primary outcome was the ratio of arterial oxygen partial pressure to fractional inspired oxygen (Pao₂/F_io₂) before the last RM before extubation. Secondary outcomes included regional ventilation distribution and EELV which were measured before, during, and after anaesthesia. The cardiovascular effects of RM/PEEP_IND were also assessed.

Results: In 20 males randomised to RM/PEEP_IND, the median PEEP_IND was 14 cm H₂O [inter-quartile range, 8-20]. The Pao₂/F_io₂ was 10.0 kPa higher with RM/PEEP_IND before extubation (95% confidence interval [CI], 2.6-17.3 kPa; P=0.001). RM/PEEP_IND increased end-expiratory lung volume by 1.49 L (95% CI, 1.09-1.89 L; P<0.001). RM/PEEP_IND also improved the regional ventilation of dependent lung regions. Vasopressor and fluid therapy was similar between groups, although 13 patients randomised to RM/PEEP_IND required pharmacological therapy for bradycardia.

Conclusion: In non-obese males, an individualised ventilation strategy improved intraoperative oxygenation, which was associated with higher end-expiratory lung volumes during robot-assisted laparoscopic prostatectomy.

Clinical trial registration: DRKS00004199 (German clinical trials registry).

Keywords: electrical impedance tomography; minimally invasive surgery; positive pressure ventilation; pulmonary gas exchange; radical prostatectomy.

Publication types

Randomized Controlled Trial
Research Support, Non-U.S. Gov't

MeSH terms

Aged
Electric Impedance*
Humans
Male
Middle Aged
Positive-Pressure Respiration / methods*
Prospective Studies
Prostatectomy / methods*
Robotic Surgical Procedures / methods*

Associated data

DRKS/DRKS00004199