• Domenico Luca Grieco, Andrea Russo, Gian Marco Anzellotti, Bruno Romanò, Filippo Bongiovanni, Antonio M Dell'Anna, Luigi Mauti, Laura Cascarano, Valerio Gallotta, Tommaso Rosà, Francesco Varone, Luca S Menga, Lorenzo Polidori, Marco D'Indinosante, Serena Cappuccio, Claudia Galletta, Lucia Tortorella, Barbara Costantini, Salvatore Gueli Alletti, Liliana Sollazzi, Giovanni Scambia, and Massimo Antonelli.
• Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. Electronic address: dlgrieco@outlook.it.
• J Clin Anesth. 2023 May 1; 85: 111037111037.

UnlabelledStudy objective To assess the effects of a protective ventilation strategy during Trendelenburg pneumoperitoneum surgery on postoperative oxygenation.DesignsParallel-group, randomized trial.SettingOperating room of a university hospital, Italy.PatientsMorbidly obese patients undergoing Trendelenburg pneumoperitoneum gynaecological surgery.InterventionsParticipants were randomized to standard (SV: tidal volume = 10 ml/kg of predicted body weight, PEEP = 5 cmH2O) or protective (PV: tidal volume = 6 ml/kg of predicted body weight, PEEP = 10 cmH2O, recruitment maneuvers) ventilation during anesthesia.MeasurementsPrimary outcome was PaO2/FiO2 one hour after extubation. Secondary outcomes included day-1 PaO2/FiO2, day-2 respiratory function and intraoperative respiratory/lung mechanics, assessed through esophageal manometry, end-expiratory lung volume (EELV) measurement and pressure-volume curves.Main ResultsSixty patients were analyzed (31 in SV group, 29 in PV group). Median [IqR] tidal volume was 350 ml [300-360] in PV group and 525 [500-575] in SV group. Median PaO2/FiO2 one hour after extubation was 280 mmHg [246-364] in PV group vs. 298 [250-343] in SV group (p = 0.64). Day-1 PaO2/FiO2, day-2 forced vital capacity, FEV-1 and Tiffenau Index were not different between groups (all p > 0.10). Intraoperatively, 59% of patients showed complete airway closure during pneumoperitoneum, without difference between groups: median airway opening pressure was 17 cmH2O. In PV group, airway and transpulmonary driving pressure were lower (12 ± 5 cmH2O vs. 17 ± 7, p < 0.001; 9 ± 4 vs. 13 ± 7, p < 0.001), PaCO2 and respiratory rate were higher (48 ± 8 mmHg vs. 42 ± 12, p < 0.001; 23 ± 5 breaths/min vs. 16 ± 4, p < 0.001). Intraoperative EELV was similar between PV and SV group (1193 ± 258 ml vs. 1207 ± 368, p = 0.80); ratio of tidal volume to EELV was lower in PV group (0.45 ± 0.12 vs. 0.32 ± 0.09, p < 0.001).ConclusionsIn obese patients undergoing Trendelenburg pneumoperitoneum surgery, PV did not improve postoperative oxygenation nor day-2 respiratory function. PV was associated with intraoperative respiratory mechanics indicating less injurious ventilation. The high prevalence of complete airway closure may have affected study results.Trial RegistrationProspectively registered on http://clinicaltrials.govNCT03157479 on May 17th, 2017.Copyright © 2022 Elsevier Inc. All rights reserved.

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