Impact of the modality of mechanical ventilation on bleeding during pituitary surgery: A single blinded randomized trial.
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ABSTRACT:
SUBMITTER: Le Guen M
PROVIDER: S-EPMC6756699 | biostudies-literature | 2019 Sep
REPOSITORIES: biostudies-literature
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Impact of the modality of mechanical ventilation on bleeding during pituitary surgery: A single blinded randomized trial.
Le Guen Morgan M Paternot Alexis A Declerck Agnes A Feliot Elodie E Gayat Etienne E Gaillard Stephan S Fischler Marc M
Medicine 20190901 38
<h4>Background</h4>Bleeding modifies the surgeon's view of the field during transsphenoidal endoscopic pituitary surgery. Since ventilation can alter venous return, we compared the effect of volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV) on intraoperative bleeding.<h4>Methods</h4>Eighty-six patients were randomized to VCV or PCV in this single blinded study; comparisons concerned 42 in the PCV group and 43 in the VCV group.<h4>Results</h4>Intraoperative bleeding, t ...[more]
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Project description:Introduction and aim:Studies regarding asynchrony in patients in the cardiac postoperative period are still only a few. The main objective of our study was to compare asynchronies incidence and its index (AI) in 3 different modes of ventilation (volume-controlled ventilation [VCV], pressure-controlled ventilation [PCV] and pressure-support ventilation [PSV]) after ICU admission for postoperative care. Methods:A prospective parallel randomised trialin the setting of a non-profitable hospital in Brazil. The participants were patients scheduled for cardiac surgery. Patients were randomly allocated to VCV or PCV modes of ventilation and later both groups were transitioned to PSV mode. Results:All data were recorded for 5 minutes in each of the three different phases: T1) in assisted breath, T2) initial spontaneous breath and T3) final spontaneous breath, a marking point prior to extubation. Asynchronies were detected and counted by visual inspection method by two independent investigators. Reliability, inter-rater agreement of asynchronies, asynchronies incidence, total and specific asynchrony indexes (AIt and AIspecific) and odds of AI ?10% weighted by total asynchrony were analysed. A total of 17 patients randomly allocated to the VCV (n=9) or PCV (n=8) group completed the study. High inter-rated agreement for AIt (ICC 0.978; IC95%, 0,963-0.987) and good reliability (r=0.945; p<0.001) were found. Eighty-two % of patients presented asynchronies, although only 7% of their total breathing cycles were asynchronous. Early cycling and double triggering had the highest rates of asynchrony with no difference between groups. The highest odds of AI ?10% were observed in VCV regardless the phase: OR 2.79 (1.36-5.73) in T1 vs T2, p=0.005; OR 2.61 (1.27-5.37) in T1 vs T3, p=0.009 and OR 4.99 (2.37-10.37) in T2 vs T3, p<0.001. Conclusions:There was a high incidence of breathing asynchrony in postoperative cardiac patients, especially when initially ventilated in VCV. VCV group had a higher chance of AI ?10% and this chance remained high in the following PSV phases.
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Project description:Background: Leukocyte and platelet-rich fibrin (L-PRF) may be considered a co-adjuvant intervention that may play a key role in blood coagulation and tissue repair after nail surgeries. The aim of this study was to determine the effectiveness of L-PRF versus nitrofurazone on the post-surgical bleeding and wound cicatrization period in patients with bilateral onychocryptosis during surgeries of chemical matrixectomies with 88% phenol solution. Methods: A randomized single-blind clinical trial was registered with the European Clinical Trials Database (EudraCT) with identification number 2016-002048-18. Twenty healthy participants with bilateral onychocryptosis (n = 40) were recruited and bilaterally received both protocols for both halluces. Patients with a mean age mean of 45.55 ± 12.19 years attended a specialized foot and ankle surgery clinic. Both halluces of each patient were randomized and allocated to receive L-PRF (experimental group; n = 20 halluces) or nitrofurazone (control group; n = 20 halluces) interventions in conjunction with surgery of chemical matrixectomies with 88% phenol solution for bilateral ingrown of toenail border (medial and lateral). Patients were blinded to their intervention in each hallux. The primary outcome measurement was post-surgical bleeding. The secondary outcome measurements were post-surgical pain intensity, inflammation, infection, analgesic intake, and wound cicatrization period. Results: Statistically significant differences (p < 0.001) were found between both groups showing a reduction for wound cicatrization period and post-surgical bleeding for the L-PRF intervention with respect to nitrofurazone treatment. The rest of the outcome measurements did not show any statistically significant differences (p > 0.05). Conclusions: L-PRF rather than nitrofurazone in conjunction with chemical matrixectomies performed with 88% phenol solution reduced the wound cicatrization period and bleeding after nail surgery. Thus, L-PRF may be considered a first-line co-adjuvant intervention for patients who suffer from nail problems, such as onychocryptosis, that require surgical procedures.
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Project description:BackgroundWith the evolution and adoption of video-assisted thoracoscopic surgery (VATS), options for anesthesia control have also seen major developments. Intubated anesthesia with single lung mechanical ventilation VATS (MV-VATS) is considered the standard of care in VATS. However, this type of ventilation strategy has been associated with several adverse effects, which can trigger complications and increase the overall surgical risk. In order to avoid intubated anesthesia related adverse effects, non-intubated spontaneous ventilation VATS (SV-VATS) strategies have been proposed in recent years and widely applied.MethodsWe established a two-arm parallel multicenter randomized controlled trial for comparative analysis of the outcomes of patients undergoing either SV-VATS or MV-VATS for spontaneous pneumothorax. Outcomes of interest include safety during operation, total analgesic dose, recovery time, postoperative complication rates, postoperative pain score, length of hospitalization, inflammation index, medical cost, etc. The recruitment target is 316 patients. Patients will be eligible if their chest CT is diagnosed with “localized lung bullae” and need VATS resection. Patients will be randomized into the SV-VATS (test group) or MV-VATS (control group) after signing informed consent and surgical anesthesia evaluation.DiscussionThis protocol has been approved by the Research Ethics Committee of the First Affiliated Hospital of Guangzhou Medical university. Results will be presented at national and international meetings and conferences and published in peer-reviewed journals. We will also disseminate the main results to all participants in a letter. Non-intubated SV-VATS offered a more individual choice of anesthetics and surgical method for spontaneous pneumothorax patients.Trial registrationNCT03016858; pre-results.
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Project description:Postoperative pulmonary complications are a leading cause of morbidity and mortality after cardiac surgery. There are no recommendations on mechanical ventilation associated with cardiopulmonary bypass (CPB) during surgery and anesthesiologists perform either no ventilation (noV) at all during CPB or maintain low tidal volume (LTV) ventilation. Indirect evidence points towards better pulmonary outcomes when LTV is performed but no large-scale prospective trial has yet been published in cardiac surgery.The MECANO trial is a single-center, double-blind, randomized, controlled trial comparing two mechanical ventilation strategies, noV and LTV, during cardiac surgery with CPB. In total, 1500 patients are expected to be included, without any restrictions. They will be randomized between noV and LTV on a 1:1 ratio. The noV group will receive no ventilation during CPB. The LTV group will receive 5 breaths/minute with a tidal volume of 3 mL/kg and positive end-expiratory pressure of 5 cmH2O. The primary endpoint will be a composite of all-cause mortality, early respiratory failure defined as a ratio of partial pressure of oxygen/fraction of inspired oxygen <200 mmHg at 1 hour after arrival in the ICU, heavy oxygenation support (defined as a patient requiring either non-invasive ventilation, mechanical ventilation or high-flow oxygen) at 2 days after arrival in the ICU or ventilator-acquired pneumonia defined by the Center of Disease Control. Lung recruitment maneuvers will be performed in the noV and LTV groups at the end of surgery and at arrival in ICU with an insufflation at +30 cmH20 for 5 seconds. Secondary endpoints are those composing the primary endpoint with the addition of pneumothorax, CPB duration, quantity of postoperative bleeding, red blood cell transfusions, revision surgery requirements, length of stay in the ICU and in the hospital and total hospitalization costs. Patients will be followed until hospital discharge.The MECANO trial is the first of its kind to compare in a double-blind design, a no-ventilation to a low-tidal volume strategy for mechanical ventilation during cardiac surgery with CPB, with a primary composite outcome including death, respiratory failure and postoperative pneumonia.ClinicalTrials.gov, NCT03098524 . Registered on 27 February 2017.
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Project description:Mechanical ventilation during surgery is a highly complex procedure, particularly in cardiothoracic surgery, where patients need to undergo substantial hemodynamic management, involving large fluid exchanges and pharmacological manipulation of vascular resistance, as well as direct manipulation of the lungs themselves. Cardiothoracic surgery is burdened by a high rate of postoperative pulmonary complication (PPC), comorbidity, and mortality. Recent trials have examined various techniques to preserve lung function, although consensus on best practice has yet to be reached. This might be due to the close relationship between the circulatory and pulmonary systems. The use of a technique designed to prevent pulmonary complication might negatively impact the hemodynamics of an already critical patient. Stress-induced lung injury can occur during surgery for various reasons, some of which have yet to be fully investigated. In cardiac surgery, this damage is mainly ascribed to two events: cardiopulmonary bypass (CPB) and sternotomy. In thoracic surgery, on the other hand, overdistention and permissive hyperoxia, both routinely used on one lung to compensate for the collapse of the other, are generally to blame for lung injury. In recent years "protective" ventilation strategies have been proposed to spare lung parenchyma from stress-induced damage. Despite the growing interest in protective ventilation techniques, there are still no clear international guidelines for mechanical ventilation in cardiothoracic surgery. However, some recent progress has been made, with positive clinical outcomes.
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Project description:PURPOSE:Surgical education videos currently all use a single point of view (POV) with the trainee locked onto a fixed viewpoint, which may not deliver sufficient information for complex procedures. We developed a novel multiple POV video system and evaluated its training outcome compared with traditional single POV. METHODS:We filmed a hip resurfacing procedure performed by an expert attending using 8 cameras in theatre. 30 medical students were randomly and equally allocated to learn the procedure using the multiple POV (experiment group [EG]) versus single POV system (control group [CG]). Participants advanced a pin into the femoral head as demonstrated in the video. We measured the drilling trajectories and compared it with pre-operative plan to evaluate distance of the pin insertion and angular deviations. Two orthopedic attendings expertly evaluated the participants' performance using a modified global rating scale (GRS). There was a pre-video knowledge test that was repeated post-simulation alongside a Likert-scale questionnaire. RESULTS:The angular deviation of the pin in EG was significantly less by 29% compared to CG (p = 0.037), with no significant difference in the entry point's distance between groups (p = 0.204). The GRS scores for EG were 3.5% higher than CG (p = 0.046). There was a 32% higher overall knowledge test score (p<0.001) and 21% improved Likert-scale questionnaire score (p = 0.002) after video-learning in EG than CG, albeit no significant difference in the knowledge test score before video-learning (p = 0.721). CONCLUSION:The novel multiple POV provided significant objective and subjective advantages over single POV for acquisition of technical skills in hip surgery.
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Project description:General anesthesia usually requires mechanical ventilation, which is traditionally accomplished with constant tidal volumes in volume- or pressure-controlled modes. Experimental studies suggest that the use of variable tidal volumes (variable ventilation) recruits lung tissue, improves pulmonary function and reduces systemic inflammatory response. However, it is currently not known whether patients undergoing open abdominal surgery might benefit from intraoperative variable ventilation.The PROtective VARiable ventilation trial ('PROVAR') is a single center, randomized controlled trial enrolling 50 patients who are planning for open abdominal surgery expected to last longer than 3 hours. PROVAR compares conventional (non-variable) lung protective ventilation (CV) with variable lung protective ventilation (VV) regarding pulmonary function and inflammatory response. The primary endpoint of the study is the forced vital capacity on the first postoperative day. Secondary endpoints include further lung function tests, plasma cytokine levels, spatial distribution of ventilation assessed by means of electrical impedance tomography and postoperative pulmonary complications.We hypothesize that VV improves lung function and reduces systemic inflammatory response compared to CV in patients receiving mechanical ventilation during general anesthesia for open abdominal surgery longer than 3 hours. PROVAR is the first randomized controlled trial aiming at intra- and postoperative effects of VV on lung function. This study may help to define the role of VV during general anesthesia requiring mechanical ventilation.Clinicaltrials.gov NCT01683578 (registered on September 3 3012).
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