Influence of patient positioning on shunting during one-lung ...
Influence of patient positioning on shunting during one-lung ...
Influence of patient positioning on shunting during one-lung ...
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<str<strong>on</strong>g>Influence</str<strong>on</strong>g> <str<strong>on</strong>g>of</str<strong>on</strong>g> <str<strong>on</strong>g>patient</str<strong>on</strong>g><br />
<str<strong>on</strong>g>positi<strong>on</strong>ing</str<strong>on</strong>g> <strong>on</strong> <strong>shunting</strong><br />
<strong>during</strong> <strong>on</strong>e-<strong>lung</strong> ventilati<strong>on</strong>:<br />
supine vs. lateral decubitus.<br />
L. Biesemans<br />
E. Vandermeersch<br />
Table <str<strong>on</strong>g>of</str<strong>on</strong>g> c<strong>on</strong>tent<br />
1. Introducti<strong>on</strong><br />
2. Methods<br />
3. Results<br />
4. Discussi<strong>on</strong><br />
5. C<strong>on</strong>clusi<strong>on</strong><br />
6. References<br />
1
1. Introducti<strong>on</strong><br />
o Gravity induced blood flow redistributi<strong>on</strong><br />
towards dependent ventilated <strong>lung</strong>:<br />
limiting arterial desaturati<strong>on</strong> in lat.<br />
decubitus<br />
o Study: document redistributi<strong>on</strong><br />
o n=48 c<strong>on</strong>secutive pts./no selecti<strong>on</strong><br />
o thoracic interventi<strong>on</strong>s: OLV in lat. decubitus<br />
2. Methods (I)<br />
o Premedicati<strong>on</strong>: 0.5mg<br />
alprazolam<br />
o Thoracic epidural<br />
catheter: not used perop.<br />
o Inducti<strong>on</strong>:<br />
o 4 µg/kg/min prop<str<strong>on</strong>g>of</str<strong>on</strong>g>ol<br />
o 0.25 → 0.15 µg/kg/min<br />
remifentanil<br />
o 0.15 mg/kg cisatracurium<br />
o neosynephrine infusi<strong>on</strong><br />
(sBP 20% <str<strong>on</strong>g>of</str<strong>on</strong>g> baseline)<br />
o Inserti<strong>on</strong> DL-ET<br />
2
2. Methods (II)<br />
1. DLV: 50% O2-air, ET CO2: 35 mmHg<br />
o parameters + art./mixed ven. blood samples<br />
2. OLV-supine:<br />
o<br />
o<br />
o<br />
o<br />
clamping airway to operative side<br />
operative side open to atmosphere<br />
close operative side to atmosphere at max.<br />
insufflati<strong>on</strong> <str<strong>on</strong>g>of</str<strong>on</strong>g> ventilated <strong>lung</strong><br />
evoluti<strong>on</strong> oxygen saturati<strong>on</strong><br />
o parameters + art./mixed ven. blood samples after 10<br />
min.<br />
2. Methods (III)<br />
3. OLV-lat. decubitus: turning pt. under OLV<br />
o parameters + art./ mixed ven. blood samples after 10<br />
min.<br />
4. OLV-lat. decubitus: n<strong>on</strong>-dependent <strong>lung</strong><br />
open to atmosphere: 5 min. passive<br />
ventilati<strong>on</strong> out <str<strong>on</strong>g>of</str<strong>on</strong>g> phase<br />
o<br />
Parameters + art./mixed ven. blood samples<br />
3
3. Results (I)<br />
Patient Distributi<strong>on</strong><br />
N=48 (30 <strong>lung</strong> + 18<br />
n<strong>on</strong>-<strong>lung</strong>)<br />
N<strong>on</strong>-Lung, 18,<br />
38%<br />
Lung , 30, 62%<br />
Right lat.<br />
Decubitus, 24,<br />
50%<br />
Positi<strong>on</strong>ing for Operati<strong>on</strong><br />
24 left lat. decub., 24<br />
right lat. decub.<br />
Left lat.<br />
Decubitus, 24,<br />
50%<br />
3. Results (II): Figure 1<br />
Significant ↓ saturati<strong>on</strong> after 4 min. OLV<br />
100<br />
oxygen saturati<strong>on</strong> (%)<br />
95<br />
90<br />
*<br />
85<br />
0 1 2 3 4 5 6 7 8 9 10<br />
time (min) after clamping <strong>on</strong>e <strong>lung</strong><br />
4
3. Results (III): figure 2<br />
OLV-SP: ↓PaO2:<br />
92±30 mmHg<br />
OVL-LD: ↑PaO2:<br />
100±33 mmHg (not<br />
sign.)<br />
PO2 (mmHg)<br />
300<br />
200<br />
100<br />
*<br />
*<br />
*<br />
*<br />
*<br />
OLV p atm: ↑PaO2:<br />
143±34 mmHg<br />
0<br />
DLV<br />
DLV<br />
OLV-SP<br />
OLV-SP<br />
OLV-lD<br />
OLV-LD<br />
OLV-Patm<br />
OLV-Patm<br />
3. Results (IV): figure 3: evoluti<strong>on</strong> <str<strong>on</strong>g>of</str<strong>on</strong>g><br />
mixed venous p oxygen<br />
Verloop pO2 v<br />
pO2 v (mm Hg)<br />
90<br />
80<br />
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
0 1 2 3 4 5<br />
1=DVL,2=OVL ruglig, 3=OLV zijlig, 4=OLV Patm<br />
5
3. Results (V): figure 4: separati<strong>on</strong> <str<strong>on</strong>g>of</str<strong>on</strong>g><br />
groups<br />
LEFT LUNG<br />
RIGHT LUNG<br />
300<br />
300<br />
LUNG PATHOLOGY<br />
PO2 (mmHg)<br />
200<br />
100<br />
0<br />
250<br />
DLV<br />
OLV-SP<br />
OLV-LD<br />
OLV-Patm<br />
PO2 (mmHg)<br />
200<br />
100<br />
0<br />
300<br />
DLV<br />
OLV-SP<br />
OLV-LD<br />
OLV-Patm<br />
NOT-LUNG PATHOLOGY<br />
PO2 (mmHg)<br />
200<br />
150<br />
100<br />
50<br />
0<br />
DLV<br />
OLV-SP<br />
OLV-LD<br />
OLV-Patm<br />
PO2 (mmHg)<br />
200<br />
100<br />
0<br />
DLV<br />
OLV-SP<br />
OLV-LD<br />
OLV-Patm<br />
4. Discussi<strong>on</strong> (I)<br />
o Clinical anesthesia, Barash<br />
Thoracical anesthesia, Kaplan<br />
o Lat. decubitus : redistributi<strong>on</strong> <str<strong>on</strong>g>of</str<strong>on</strong>g> blood<br />
flow from n<strong>on</strong>-dependent to dependent<br />
<strong>lung</strong>.<br />
o Blood flow to dependent <strong>lung</strong> signif. greater<br />
than to n<strong>on</strong>-dependent <strong>lung</strong><br />
shunt when turning patiënt.<br />
6
4. Discussi<strong>on</strong> (II)<br />
o Study: not-signif. ↑ sat. and paO2 with<br />
re<str<strong>on</strong>g>positi<strong>on</strong>ing</str<strong>on</strong>g> in lat. decubitus<br />
o type <str<strong>on</strong>g>of</str<strong>on</strong>g> anesthesia and HPV<br />
o prop<str<strong>on</strong>g>of</str<strong>on</strong>g>ol: no inhibiti<strong>on</strong> <str<strong>on</strong>g>of</str<strong>on</strong>g> HPV<br />
o remifentanil: no publicati<strong>on</strong>?<br />
o ↔ literature: thesis Szegedi<br />
o setup: selecti<strong>on</strong> <str<strong>on</strong>g>of</str<strong>on</strong>g> pts. , FIO2, turning under<br />
DLV<br />
4. Discussi<strong>on</strong><br />
Patients<br />
Surgery<br />
FIO2<br />
Turning<br />
Study UZ GHB<br />
c<strong>on</strong>secutive<br />
no selecti<strong>on</strong><br />
reflects clinical<br />
practice<br />
<strong>lung</strong><br />
n<strong>on</strong>-<strong>lung</strong><br />
0.5<br />
OVL supine =><br />
turning under OLV:<br />
direct effect gravity!<br />
Thesis Zsegedi<br />
COPD<br />
<strong>lung</strong><br />
0.4/0.6/1.0<br />
OLV supine =><br />
turning under DLV<br />
=> OLV lat.<br />
decubitus<br />
7
5. C<strong>on</strong>clusi<strong>on</strong><br />
Gravity induced redistributi<strong>on</strong> <str<strong>on</strong>g>of</str<strong>on</strong>g> blood flow<br />
Signif.↑ PaO2 and sat. <strong>during</strong> dependent<br />
OLV<br />
6. References<br />
o Two-<strong>lung</strong> and <strong>on</strong>e-<strong>lung</strong> ventilati<strong>on</strong> in <str<strong>on</strong>g>patient</str<strong>on</strong>g>s with chr<strong>on</strong>ic<br />
obstructive pulm<strong>on</strong>ary disease: the effects <str<strong>on</strong>g>of</str<strong>on</strong>g> <str<strong>on</strong>g>positi<strong>on</strong>ing</str<strong>on</strong>g><br />
and FIO2, Bardoczky et al., Anesth Analg. 2000;90:35-41<br />
o Sequential changes <str<strong>on</strong>g>of</str<strong>on</strong>g> arterial oxygen tensi<strong>on</strong> in supine<br />
positi<strong>on</strong> <strong>during</strong> <strong>on</strong>e-<strong>lung</strong> ventilati<strong>on</strong>, Watanabe et al.,<br />
Anesth Analg. 2000; 90:28-34<br />
o Prop<str<strong>on</strong>g>of</str<strong>on</strong>g>ol does not inhibit hypoxic pulm<strong>on</strong>ary<br />
vasoc<strong>on</strong>stricti<strong>on</strong> in humans, Van Keer et al., J. Clin.<br />
Anesth., 1989, vol. 1, no.4<br />
o The effects <str<strong>on</strong>g>of</str<strong>on</strong>g> remifentanil and thorachic epidural <strong>on</strong><br />
oxygenati<strong>on</strong> and pulm<strong>on</strong>ary shunt fracti<strong>on</strong> <strong>during</strong> <strong>on</strong>e<strong>lung</strong><br />
ventilati<strong>on</strong>, Mark Yew-Ho<strong>on</strong>g Chow et al., J.<br />
Cardiothor. and Vasc. Anesth., Vol. 17, No 1, 2003: pp<br />
69-72<br />
8
Back-up slide I: SD in stead <str<strong>on</strong>g>of</str<strong>on</strong>g> SEM<br />
Significant ↓ saturati<strong>on</strong> after 4 min. OLV<br />
oxygen saturati<strong>on</strong> (%)<br />
100<br />
95<br />
90<br />
85<br />
*<br />
0 1 2 3 4 5 6 7 8 9 10<br />
time (min) after clamping <strong>on</strong>e <strong>lung</strong><br />
Back-up slide II<br />
300<br />
PO2 (mmHg)<br />
200<br />
100<br />
0<br />
DLV<br />
OLV-SP<br />
OLV-lD<br />
OLV-Patm<br />
9