Club de revistas tumores supratentoriales 4
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This study investigated the effects of an alveolar recruitment maneuver (30 cm H2O for 30 seconds) versus a sham maneuver (5 cm H2O for 30 seconds) on subdural pressure, brain relaxation score, and cerebral perfusion pressure in 21 patients undergoing resection of a supratentorial brain tumor. The recruitment maneuver significantly increased subdural pressure by 4.7 mmHg on average and decreased mean arterial pressure by 9.2 mmHg, resulting in an average 14 mmHg reduction in cerebral perfusion pressure. While the clinical significance of these physiologic changes requires further long-term study, recruitment maneuvers may not be recommended for routine use in neurosurgery patients until more is understood about potential long
![RESULTADOS
Table 1 Characteristics of the study population
Variable Overall (n=21) Recruitment Maneuver Sham Maneuver
Age, mean (SD) 52 (17)
Body mass index, mean (SD) 27 (11)
Tumour diameter (mm) mean (SD) 35 (22)
Midline shift present, n (%) 6 (29)
Recurrent tumour, n (%) 5 (24)
Right-sided tumour, n (%) 10 (50)
Tumour type, n (%)
Glioblastoma 2 (9.5)
Glioma 9 (42.9)
Meningioma 6 (28.6)
Metastasis 4 (19)
Recruitment maneuver first, n (%) 11 (52)
Baseline Measurements
Baseline PaCO2 (mmHg), mean (SD) 36 (3) 35 (3)
Baseline SDP (mmHg), mean (SD) 12 (4) 12 (4)
Baseline BRS, median [IQR] 2 [1-2] 2 [1-2]
Baseline MAP (mmHg), mean (SD) 67 (8) 67 (9)
Baseline HR (beatsÁmin-1
), mean (SD) 58 (7) 58 (7)
BRS = brain relaxation score; HR = heart rate; IQR = interquartile range; MAP = mean arterial pressure; PaCO2 = arterial partial pressure of
carbon dioxide; SD = standard deviation;SDP = subdural pressure
Table 2 Effects of the recruitment and sham maneuvers on outcome variables
Recruitment maneuver during brain tumor resection](https://image.slidesharecdn.com/clubderevistastumoressupratentoriales4-170901134220/85/Club-de-revistas-tumores-supratentoriales-4-10-320.jpg)
![RESULTADOS
volatile anesthesia (desflurane or sevoflurane). Fourteen
participants (67%) received mannitol prior to the study
intervention, and all participants received dexamethasone.
Baseline subdural pressure, BRS, MAP, HR, and PaCO2
were similar between the two treatment groups (Table 1).
The recruitment maneuvers were not abandoned in any
Mean arterial pressure decreased significantly more in the
recruitment maneuver compared with the sham maneuver
(mean difference, -9.0 mmHg; 95% CI, -12.5 to -5.6; P
0.0001). As a result of the increased subdural pressure
and decreased MAP, the calculated cerebral perfusion
pressure (MAP-SDP) decreased an average of 14 mmHg
Baseline PaCO2 (mmHg), mean (SD) 36 (3) 35 (3)
Baseline SDP (mmHg), mean (SD) 12 (4) 12 (4)
Baseline BRS, median [IQR] 2 [1-2] 2 [1-2]
Baseline MAP (mmHg), mean (SD) 67 (8) 67 (9)
Baseline HR (beatsÁmin-1
), mean (SD) 58 (7) 58 (7)
BRS = brain relaxation score; HR = heart rate; IQR = interquartile range; MAP = mean arterial pressure; PaCO2 = arterial partial pressure of
carbon dioxide; SD = standard deviation;SDP = subdural pressure
Table 2 Effects of the recruitment and sham maneuvers on outcome variables
Variable Recruitment Sham Difference (95% CI) P value
SDP change, mean (SD) 4.7 (3.6) 0.8 (1.8) 3.9 (2.2 to 5.6) 0.001
BRS change, median [IQR] 0 [0-0] 0 [0-0] 0 (-1 to 1) 1.00
MAP change, mean (SD) -9.2 (7.2) -0.2 (1.5) -9.0 (-12.5 to -5.6) 0.001
HR change, mean (SD) -5.5 (5.1) 0.8 (1.1) -6.3 (-8.7 to -3.9) 0.001
BRS = brain relaxation score; CI = confidence interval; HR = heart rate; IQR = interquartile range; MAP = mean arterial pressure; SD = standard
deviation; SDP = subdural pressure. SDP and MAP reported in mmHg; HR reported in beats per minute
MRA à PPC = -14 mmHg (95% CI, 4 to 24)](https://image.slidesharecdn.com/clubderevistastumoressupratentoriales4-170901134220/85/Club-de-revistas-tumores-supratentoriales-4-11-320.jpg)
Club de revistas tumores supratentoriales 4
- 1. Grupo Neuroanestesia HUFSFB REPORTS OF ORIGINAL INVESTIGATIONS Effects of an alveolar recruitment maneuver on subdural pressure, brain swelling, and mean arterial pressure in patients undergoing supratentorial tumour resection: a randomized crossover study Effets d’une manœuvre de recrutement alve´olaire sur la pression sous-durale, l’œde`me ce´re´bral et la tension arte´rielle moyenne chez les patients subissant une re´section de tumeur sus-tentorielle: une e´tude croise´e randomise´e Alana M. Flexman, MD, FRCPC . Peter A. Gooderham, MD, FRCSC . Donald E. Griesdale, MD, MSc, FRCPC . Ruth Argue, BScN . Brian Toyota, MD, FRCSC Received: 22 August 2016 / Revised: 11 January 2017 / Accepted: 13 March 2017 Ó Canadian Anesthesiologists’ Society 2017 REPORTS OF ORIGINAL INVESTIGATIONS Effects of an alveolar recruitment maneuver on subdural pressure, brain swelling, and mean arterial pressure in patients undergoing supratentorial tumour resection: a randomized crossover study Effets d’une manœuvre de recrutement alve´olaire sur la pression sous-durale, l’œde`me ce´re´bral et la tension arte´rielle moyenne chez les patients subissant une re´section de tumeur sus-tentorielle: une e´tude croise´e randomise´e Alana M. Flexman, MD, FRCPC . Peter A. Gooderham, MD, FRCSC . Donald E. Griesdale, MD, MSc, FRCPC . Ruth Argue, BScN . Brian Toyota, MD, FRCSC Received: 22 August 2016 / Revised: 11 January 2017 / Accepted: 13 March 2017 Ó Canadian Anesthesiologists’ Society 2017 Abstract Purpose Although recruitment maneuvers have been advocated as part of a lung protective ventilation strategy, their effects on cerebral physiology during elective neurosurgery are unknown. Our objectives were to determine the effects of an alveolar recruitment maneuver on subdural pressure (SDP), brain relaxation Methods In this prospective crossover study, patients scheduled for resection of a supratentorial brain tumour were randomized to undergo either a recruitment maneuver (30 cm of water for 30 sec) or a ‘‘sham’’ maneuver (5 cm of water for 30 sec), followed by the alternative intervention after a 90-sec equilibration period. Subdural pressure was measured through a dural DOI 10.1007/s12630-017-0863-7
- 2. INTRODUCCIÓN • MRA à Oxigenación, reclutamiento alveolar, disminución stress alveolar • Ventilación protectora • MRA + BVC + PEEP à < Mortalidad à SDRA • Potencial beneficio à Neuroquirurgicos • Efecto Altas presiones intratoracias à PIC, PPC • TCE à Afectación à Electiva??
- 3. OBJETIVO • “Our objectives were to determine the effects of an alveolar recruitment maneuver on subdural pressure (SDP), brain relaxation score (BRS), and cerebral perfusion pressure among patients undergoing supratentorial tumour resection”
- 4. METODOLOGÍA • Vancouver General Hospital • Clinical Research Ethics Board of the University of British Columbia • ClinicalTrials.gov (NCT02093117) • 30 cm of water continuous airway pressure for 30 sec • ‘‘sham’’ recruitment maneuver: 5 cm of water for 30 sec • brief 90-sec equilibration period à 30-sec baseline measurement
- 5. METODOLOGÍA 0 1 Recruitment Maneuver Sham Time (min) Baseline Treatment Period #2Equilibration 30 seconds 30 seconds 90 seconds 30 seconds 3.5 Treatment Period #1 Randomization R Sham Recruitment Maneuver SD0 SD2SD1 2.5 3.0 Baseline 30 seconds SD0 0.5 Fig. 1 The randomized crossover study design involved two treatment periods of either a recruitment maneuver of 30 cm H2O for 30 sec, or a sham procedures of 5 cm H2O for 30 sec, separated by an equilibration period of 120 sec. Subdural pressure (SD) was measured prior to and at the end of each treatment period Recruitment maneuver during brain tumor resection
- 6. METODOLOGÍA • Inclusión • Adultos • ASA I – III • Tumor supratentorial • Exclusión • Alteración neurológica • PIC > 20 mmHg • Enf Cardiaca • Sepsis • Hipovolemia • Patología pulmonar
- 7. • ASA + LAI • Inducción a discreción • Remifentanil 0.05-0.3 mcg/kg/min + sevoflurane o desflurane 0.5-0.7 MAC • Rocuronio • VC 6-8 ml/kg à PaCO2 32-38 mmHg • Dexametasona, manitol • Supino + lateral • J: 22G/0.9-mm à Subdural (PIC) à c/5 seg • Relajación cerebral à Neurocirujano (1-4) • PPC (PAM-PIC) à c/ 5 seg METODOLOGÍA
- 8. • MSD à 7.0 (5.5) mmHg. • Type I error of 0.05, a type II error of 0.2, and a two-sided • Approximately 22 patients à ≠ 3.5 mmHg • Shapiro-Wilk W-test • Student’s t test and Wilcoxon signed-rank test • Spearman’s rank correlation coefficient. METODOLOGÍA
- 9. • 22 pacientes à 21 • Fentanyl, lidocaine, propofol, and rocuronium à 100% • TIVA à 1 (NVPO) • 14 (67%) à Manitol RESULTADOS
- 10. RESULTADOS Table 1 Characteristics of the study population Variable Overall (n=21) Recruitment Maneuver Sham Maneuver Age, mean (SD) 52 (17) Body mass index, mean (SD) 27 (11) Tumour diameter (mm) mean (SD) 35 (22) Midline shift present, n (%) 6 (29) Recurrent tumour, n (%) 5 (24) Right-sided tumour, n (%) 10 (50) Tumour type, n (%) Glioblastoma 2 (9.5) Glioma 9 (42.9) Meningioma 6 (28.6) Metastasis 4 (19) Recruitment maneuver first, n (%) 11 (52) Baseline Measurements Baseline PaCO2 (mmHg), mean (SD) 36 (3) 35 (3) Baseline SDP (mmHg), mean (SD) 12 (4) 12 (4) Baseline BRS, median [IQR] 2 [1-2] 2 [1-2] Baseline MAP (mmHg), mean (SD) 67 (8) 67 (9) Baseline HR (beatsÁmin-1 ), mean (SD) 58 (7) 58 (7) BRS = brain relaxation score; HR = heart rate; IQR = interquartile range; MAP = mean arterial pressure; PaCO2 = arterial partial pressure of carbon dioxide; SD = standard deviation;SDP = subdural pressure Table 2 Effects of the recruitment and sham maneuvers on outcome variables Recruitment maneuver during brain tumor resection
- 11. RESULTADOS volatile anesthesia (desflurane or sevoflurane). Fourteen participants (67%) received mannitol prior to the study intervention, and all participants received dexamethasone. Baseline subdural pressure, BRS, MAP, HR, and PaCO2 were similar between the two treatment groups (Table 1). The recruitment maneuvers were not abandoned in any Mean arterial pressure decreased significantly more in the recruitment maneuver compared with the sham maneuver (mean difference, -9.0 mmHg; 95% CI, -12.5 to -5.6; P 0.0001). As a result of the increased subdural pressure and decreased MAP, the calculated cerebral perfusion pressure (MAP-SDP) decreased an average of 14 mmHg Baseline PaCO2 (mmHg), mean (SD) 36 (3) 35 (3) Baseline SDP (mmHg), mean (SD) 12 (4) 12 (4) Baseline BRS, median [IQR] 2 [1-2] 2 [1-2] Baseline MAP (mmHg), mean (SD) 67 (8) 67 (9) Baseline HR (beatsÁmin-1 ), mean (SD) 58 (7) 58 (7) BRS = brain relaxation score; HR = heart rate; IQR = interquartile range; MAP = mean arterial pressure; PaCO2 = arterial partial pressure of carbon dioxide; SD = standard deviation;SDP = subdural pressure Table 2 Effects of the recruitment and sham maneuvers on outcome variables Variable Recruitment Sham Difference (95% CI) P value SDP change, mean (SD) 4.7 (3.6) 0.8 (1.8) 3.9 (2.2 to 5.6) 0.001 BRS change, median [IQR] 0 [0-0] 0 [0-0] 0 (-1 to 1) 1.00 MAP change, mean (SD) -9.2 (7.2) -0.2 (1.5) -9.0 (-12.5 to -5.6) 0.001 HR change, mean (SD) -5.5 (5.1) 0.8 (1.1) -6.3 (-8.7 to -3.9) 0.001 BRS = brain relaxation score; CI = confidence interval; HR = heart rate; IQR = interquartile range; MAP = mean arterial pressure; SD = standard deviation; SDP = subdural pressure. SDP and MAP reported in mmHg; HR reported in beats per minute MRA à PPC = -14 mmHg (95% CI, 4 to 24)
- 12. RESULTADOS resecti respira tumou increa level and th brains respira patien The been regula and e maneu protec maneu increa perfus intraop patien periop types interve Fig. 2 Illustration of the effects of the sham and recruitment maneuvers on subdural pressure (SDP), mean arterial pressure (MAP), and heart rate (HR) in one study participant
- 13. • ∆ SDP ≈ • Edad, (rho, -0.28; P = 0.28) • BMI (rho, 0.14; P = 0.53) • Diámetro del tumor (rho, 0.06; P = 0.80) • Desviación de línea media (P = 0.18). • > SDP: 1º MRA = 1º Placebo DM: -1.2 mmHg, (-4.5 to 2.2; P = 0.47). RESULTADOS
- 14. DISCUSIÓN • > SDP, < PAM y PIC à << PPC 14 mmHg (95% CI, 4 to 24), BRS = • El comportamiento en estos pacientes ambulatorios à TCE • HSAà > PIC 7 mmHg, < PAM 13 mmHg à MRA: 35 cmH2O for 40 seg. • Neuro-UCI à > PIC 3 mmHg, < PAM 11 mmHg à MRA: 60 cmH2O. • Impacto clinico à Largo plazo • Riesgo / Beneficio • Cx de Resección tumor cerebral à Incidencia global 4.4% à Falla respiratoria aguda.
- 15. Limitaciones • SDP ≈ PIC • Validez externa (tumores infratentoriales, prono, otras patologías intracraneales, otras maniobras de reclutamiento). • Manitol à BRS = (Poder) • PPC à Resultados
- 16. CONCLUSIONES • “In conclusion, our study results show that a recruitment maneuver of 30 cmH2O for 30 sec results in an average increase in subdural pressure of 4.7 mmHg (95% CI, 1 to 12), leading to a mean reduction in cerebral perfusion pressure of 14 mmHg (95% CI, 4 to 24) (…) Whether this finding correlates with long-term clinically meaningful outcomes is a potential area of future research that should be investigated prior to recommending routine use of these maneuvers”