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Paolo Pelosi - One of the best experts on this subject based on the ideXlab platform.
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Intraabdominal Pressure Targeted Positive End-expiratory Pressure during Laparoscopic Surgery: An Open-label, Nonrandomized, Crossover, Clinical Trial.
Anesthesiology, 2020Co-Authors: Guido Mazzinari, Oscar Díaz-cambronero, Jose Miguel Alonso-iñigo, Nuria Garcia-gregorio, Begoña Ayas-montero, Jose Luis Ibañez, Ary Serpa Neto, Lorenzo Ball, Marcelo Gama De Abreu, Paolo PelosiAbstract:BACKGROUND: Pneumoperitoneum for laparoscopic surgery is associated with a rise of driving Pressure. The authors aimed to assess the effects of positive end-expiratory Pressure (PEEP) on driving Pressure at varying Intraabdominal Pressure levels. It was hypothesized that PEEP attenuates pneumoperitoneum-related rises in driving Pressure. METHODS: Open-label, nonrandomized, crossover, clinical trial in patients undergoing laparoscopic cholecystectomy. "Targeted PEEP" (2 cm H2O above Intraabdominal Pressure) was compared with "standard PEEP" (5 cm H2O), with respect to the transpulmonary and respiratory system driving Pressure at three predefined Intraabdominal Pressure levels, and each patient was ventilated with two levels of PEEP at the three Intraabdominal Pressure levels in the same sequence. The primary outcome was the difference in transpulmonary driving Pressure between targeted PEEP and standard PEEP at the three levels of Intraabdominal Pressure. RESULTS: Thirty patients were included and analyzed. Targeted PEEP was 10, 14, and 17 cm H2O at Intraabdominal Pressure of 8, 12, and 15 mmHg, respectively. Compared to standard PEEP, targeted PEEP resulted in lower median transpulmonary driving Pressure at Intraabdominal Pressure of 8 mmHg (7 [5 to 8] vs. 9 [7 to 11] cm H2O; P = 0.010; difference 2 [95% CI 0.5 to 4 cm H2O]); 12 mmHg (7 [4 to 9] vs.10 [7 to 12] cm H2O; P = 0.002; difference 3 [1 to 5] cm H2O); and 15 mmHg (7 [6 to 9] vs.12 [8 to 15] cm H2O; P < 0.001; difference 4 [2 to 6] cm H2O). The effects of targeted PEEP compared to standard PEEP on respiratory system driving Pressure were comparable to the effects on transpulmonary driving Pressure, though respiratory system driving Pressure was higher than transpulmonary driving Pressure at all Intraabdominal Pressure levels. CONCLUSIONS: Transpulmonary driving Pressure rises with an increase in Intraabdominal Pressure, an effect that can be counterbalanced by targeted PEEP. Future studies have to elucidate which combination of PEEP and Intraabdominal Pressure is best in term of clinical outcomes.
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an official ats ers esicm sccm srlf statement prevention and management of acute renal failure in the icu patient an international consensus conference in intensive care medicine
American Journal of Respiratory and Critical Care Medicine, 2010Co-Authors: Laurent Brochard, Robert L Danner, Alain F. Broccard, Sheldon Magder, Fekri Abroug, Laurent Papazian, Franco Laghi, Miquel Ferrer, Matthew Brenner, Paolo PelosiAbstract:Objectives: To address the issues of Prevention and Management of Acute Renal Failure in the ICU Patient, using the format of an International Consensus Conference.Methods and Questions: Five main questions formulated by scientific advisors were addressed by experts during a 2-day symposium and a Jury summarized the available evidence: (1) Identification and definition of acute kidney insufficiency (AKI), this terminology being selected by the Jury; (2) Prevention of AKI during routine ICU Care; (3) Prevention in specific diseases, including liver failure, lung Injury, cardiac surgery, tumor lysis syndrome, rhabdomyolysis and elevated Intraabdominal Pressure; (4) Management of AKI, including nutrition, anticoagulation, and dialysate composition; (5) Impact of renal replacement therapy on mortality and recovery.Results and Conclusions: The Jury recommended the use of newly described definitions. AKI significantly contributes to the morbidity and mortality of critically ill patients, and adequate volume rep...
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incidence and prognosis of Intraabdominal hypertension in a mixed population of critically ill patients a multiple center epidemiological study
Critical Care Medicine, 2005Co-Authors: Manu L N G Malbrai, Paolo Pelosi, Davide Chiumello, David Ihari, Richard Innes, Marco V Ranieri, Monica Del Turco, Alexande Wilme, Nicola Ienza, Vincenzo MalcangiAbstract:Objective: Intraabdominal hypertension is associated with significant morbidity and mortality in surgical and trauma patients. The aim of this study was to assess, in a mixed population of critically ill patients, whether Intraabdominal Pressure at admission was an independent predictor for mortality and to evaluate the effects of Intraabdominal hypertension on organ functions. Design: Multiple-center, prospective epidemiologic study. Setting: Fourteen intensive care units in six countries. Patients: A total of 265 consecutive patients admitted for >24 hrs during the 4-wk study period. Interventions: None. Measurements and Main Results: Intraabdominal Pressure was measured twice daily via the bladder. Data recorded on admission were the patient demographics with Simplified Acute Physiology Score II, Acute Physiology and Chronic Health Evaluation II score, and type of admission; during intensive care stay, Sepsis-Related Organ Failure Assessment score and Intraabdominal Pressure were measured daily together with fluid balance. Nonsurvivors had a significantly higher mean Intraabdominal Pressure on admission than survivors: 11.4 4.8 vs. 9.5 4.8 mm Hg. Independent predictors for mortality were age (odds ratio, 1.04; 95% confidence interval, 1.01‐1.06; p .003), Acute Physiology and Chronic Health Evaluation II score (odds ratio, 1.1; 95% confidence interval, 1.05‐1.15; p < .0001), type of intensive care unit admission (odds ratio, 2.5 medical vs. surgical; 95% confidence interval, 1.24‐5.16; p .01), and the presence of liver dysfunction (odds ratio, 2.5; 95% confidence interval, 1.06‐5.8; p .04). The occurrence of Intraabdominal hypertension during the intensive care unit stay was also an independent predictor of mortality (relative risk, 1.85; 95% confidence interval, 1.12‐3.06; p .01). Patients with Intraabdominal hypertension at admission had significantly higher Sepsis-Related Organ Failure Assessment scores during the intensive care unit stay than patients without Intraabdominal hypertension. Conclusions: Intraabdominal hypertension on admission was associated with severe organ dysfunction during the intensive care unit stay. The mean Intraabdominal Pressure on admission was not an independent risk factor for mortality; however, the occurrence of Intraabdominal hypertension during the intensive care unit stay was an independent outcome predictor. (Crit Care Med 2005; 33:315‐322)
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an increase of abdominal Pressure increases pulmonary edema in oleic acid induced lung injury
American Journal of Respiratory and Critical Care Medicine, 2004Co-Authors: Michael Quintel, Paolo Pelosi, Pietro Caironi, Jurgen P Meinhardt, Thomas Luecke, Peter Herrmann, Paolo Taccone, Christian Rylander, F Valenza, Eleonora CarlessoAbstract:Increased abdominal Pressure is common in intensive care unit patients. To investigate its impact on respiration and hemodynamics we applied Intraabdominal Pressure (aIAP) of 0 and 20 cm H2O (pneumoperitoneum) in seven pigs. The whole-lung computed tomography scan and a complete set of respiratory and hemodynamics variables were recorded both in healthy lung and after oleic acid (OA) injury. In healthy lung, aIAP 20 cm H2O significantly lowered the gas content, leaving the tissue content unchanged. In OA-injured lung at aIAP 0 cm H2O, the gas content significantly decreased compared with healthy lung. The excess tissue mass (edema) amounted to 30 ± 24% of the original tissue weight (455 ± 80 g). The edema was primarily distributed in the base regions and was not gravity dependent. Heart volume, central venous, pulmonary artery, wedge, and systemic arterial Pressures significantly increased. At aIAP 20 cm H2O in OA-injured lung, the central venous and pulmonary artery Pressures further increased. The gas c...
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positive end expiratory Pressure improves respiratory function in obese but not in normal subjects during anesthesia and paralysis
Anesthesiology, 1999Co-Authors: Paolo Pelosi, Irene Ravagnan, Gabriella Giurati, Mauro Panigada, Nicola Bottino, Stefano Tredici, Giuditta Eccher, L GattinoniAbstract:BACKGROUND: Morbidly obese patients, during anesthesia and paralysis, experience more severe impairment of respiratory mechanics and gas exchange than normal subjects. The authors hypothesized that positive end-expiratory Pressure (PEEP) induces different responses in normal subjects (n = 9; body mass index 40 kg/m2). METHODS: The authors measured lung volumes (helium technique), the elastances of the respiratory system, lung, and chest wall, the Pressure-volume curves (occlusion technique and esophageal balloon), and the Intraabdominal Pressure (intrabladder catheter) at PEEP 0 and 10 cm H2O in paralyzed, anesthetized postoperative patients in the intensive care unit or operating room after abdominal surgery. RESULTS: At PEEP 0 cm H2O, obese patients had lower lung volume (0.59 +/- 0.17 vs. 2.15 +/- 0.58 l [mean +/- SD], P < 0.01); higher elastances of the respiratory system (26.8 +/- 4.2 vs. 16.4 +/- 3.6 cm H2O/l, P < 0.01), lung (17.4 +/- 4.5 vs. 10.3 +/- 3.2 cm H2O/l, P < 0.01), and chest wall (9.4 +/- 3.0 vs. 6.1 +/- 1.4 cm H2O/l, P < 0.01); and higher Intraabdominal Pressure (18.8 +/-7.8 vs. 9.0 +/- 2.4 cm H2O, P < 0.01) than normal subjects. The arterial oxygen tension was significantly lower (110 +/- 30 vs. 218 +/- 47 mmHg, P < 0.01; inspired oxygen fraction = 50%), and the arterial carbon dioxide tension significantly higher (37.8 +/- 6.8 vs. 28.4 +/- 3.1, P < 0.01) in obese patients compared with normal subjects. Increasing PEEP to 10 cm H2O significantly reduced elastances of the respiratory system, lung, and chest wall in obese patients but not in normal subjects. The Pressure-volume curves were shifted upward and to the left in obese patients but were unchanged in normal subjects. The oxygenation increased with PEEP in obese patients (from 110 +/-30 to 130 +/- 28 mmHg, P < 0.01) but was unchanged in normal subjects. The oxygenation changes were significantly correlated with alveolar recruitment (r = 0.81, P < 0.01). CONCLUSIONS: During anesthesia and paralysis, PEEP improves respiratory function in morbidly obese patients but not in normal subjects.
Guido Mazzinari - One of the best experts on this subject based on the ideXlab platform.
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Intraabdominal Pressure Targeted Positive End-expiratory Pressure during Laparoscopic Surgery: An Open-label, Nonrandomized, Crossover, Clinical Trial.
Anesthesiology, 2020Co-Authors: Guido Mazzinari, Oscar Díaz-cambronero, Jose Miguel Alonso-iñigo, Nuria Garcia-gregorio, Begoña Ayas-montero, Jose Luis Ibañez, Ary Serpa Neto, Lorenzo Ball, Marcelo Gama De Abreu, Paolo PelosiAbstract:BACKGROUND: Pneumoperitoneum for laparoscopic surgery is associated with a rise of driving Pressure. The authors aimed to assess the effects of positive end-expiratory Pressure (PEEP) on driving Pressure at varying Intraabdominal Pressure levels. It was hypothesized that PEEP attenuates pneumoperitoneum-related rises in driving Pressure. METHODS: Open-label, nonrandomized, crossover, clinical trial in patients undergoing laparoscopic cholecystectomy. "Targeted PEEP" (2 cm H2O above Intraabdominal Pressure) was compared with "standard PEEP" (5 cm H2O), with respect to the transpulmonary and respiratory system driving Pressure at three predefined Intraabdominal Pressure levels, and each patient was ventilated with two levels of PEEP at the three Intraabdominal Pressure levels in the same sequence. The primary outcome was the difference in transpulmonary driving Pressure between targeted PEEP and standard PEEP at the three levels of Intraabdominal Pressure. RESULTS: Thirty patients were included and analyzed. Targeted PEEP was 10, 14, and 17 cm H2O at Intraabdominal Pressure of 8, 12, and 15 mmHg, respectively. Compared to standard PEEP, targeted PEEP resulted in lower median transpulmonary driving Pressure at Intraabdominal Pressure of 8 mmHg (7 [5 to 8] vs. 9 [7 to 11] cm H2O; P = 0.010; difference 2 [95% CI 0.5 to 4 cm H2O]); 12 mmHg (7 [4 to 9] vs.10 [7 to 12] cm H2O; P = 0.002; difference 3 [1 to 5] cm H2O); and 15 mmHg (7 [6 to 9] vs.12 [8 to 15] cm H2O; P < 0.001; difference 4 [2 to 6] cm H2O). The effects of targeted PEEP compared to standard PEEP on respiratory system driving Pressure were comparable to the effects on transpulmonary driving Pressure, though respiratory system driving Pressure was higher than transpulmonary driving Pressure at all Intraabdominal Pressure levels. CONCLUSIONS: Transpulmonary driving Pressure rises with an increase in Intraabdominal Pressure, an effect that can be counterbalanced by targeted PEEP. Future studies have to elucidate which combination of PEEP and Intraabdominal Pressure is best in term of clinical outcomes.
Xavier Monnet - One of the best experts on this subject based on the ideXlab platform.
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beneficial hemodynamic effects of prone positioning in patients with acute respiratory distress syndrome
American Journal of Respiratory and Critical Care Medicine, 2013Co-Authors: Mathieu Jozwiak, Jeanlouis Teboul, Nadia Anguel, Romain Persichini, Serena Silva, Denis Chemla, Christian Richard, Xavier MonnetAbstract:Rationale: The effects of prone positioning during acute respiratory distress syndrome on all the components of cardiac function have not been investigated under protective ventilation and maximal alveolar recruitment.Objectives: To investigate the hemodynamic effects of prone positioning.Methods: We included 18 patients with acute respiratory distress syndrome ventilated with protective ventilation and an end-expiratory positive Pressure titrated to a plateau Pressure of 28–30 cm H2O. Before and within 20 minutes of starting prone positioning, hemodynamic, respiratory, Intraabdominal Pressure, and echocardiographic data were collected. Before prone positioning, preload reserve was assessed by a passive leg raising test.Measurements and Main Results: In all patients, prone positioning increased the ratio of arterial oxygen partial Pressure over inspired oxygen fraction, the Intraabdominal Pressure, and the right and left cardiac preload. The pulmonary vascular resistance decreased along with the ratio of ...
Andreas Prescher - One of the best experts on this subject based on the ideXlab platform.
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collagen fibers in linea alba and rectus sheaths
Journal of Surgical Research, 2001Co-Authors: Hubertus Axer, Diedrich Graf V. Keyserlingk, Andreas PrescherAbstract:Abstract Background. After the description of a general scheme of the architecture of collagen fibers in linea alba and rectus sheaths, variability and differences of fiber architectures were analyzed to describe their functional role. Materials and methods. Using confocal laser scanning microscopy the diameter of each layer of fibril bundles was measured in linea alba and rectus sheaths of 12 human cadavers, and each fibril bundle was classified according to its orientation (oblique I and II, transverse). Results. The mean diameter of fibril bundles in the supraumbilical region of the linea alba was smaller than in the infraumbilical region, and in the supraumbilical region the thickness of the linea alba was smaller than in the infraumbilical region. Analyzing sex-dependent differences in the fiber architecture of the linea alba, a larger amount of transverse fibers relative to oblique fibers were found in females in infraumbilical regions. The thickness of the infraumbilical linea alba was smaller in females than in males, while its width was larger. Conclusions. There exist gender differences in the architecture of the linea alba. However, whether these morphological differences demonstrate the adaptability of this fiber architecture to biomechanical stress in raised Intraabdominal Pressure in pregnancy remains to be proven. The transverse fibers act as a counterpart to the Intraabdominal Pressure whereas the oblique fibers are involved mainly in movements of the trunk.
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regular articlecollagen fibers in linea alba and rectus sheaths ii variability and biomechanical aspects
Journal of Surgical Research, 2001Co-Authors: Hubertus Axer, Diedrich Graf V. Keyserlingk, Andreas PrescherAbstract:Background. After the description of a general scheme of the architecture of collagen fibers in linea alba and rectus sheaths, variability and differences of fiber architectures were analyzed to describe their functional role. Materials and methods. Using confocal laser scanning microscopy the diameter of each layer of fibril bundles was measured in linea alba and rectus sheaths of 12 human cadavers, and each fibril bundle was classified according to its orientation (oblique I and II, transverse). Results. The mean diameter of fibril bundles in the supraumbilical region of the linea alba was smaller than in the infraumbilical region, and in the supraumbilical region the thickness of the linea alba was smaller than in the infraumbilical region. Analyzing sex-dependent differences in the fiber architecture of the linea alba, a larger amount of transverse fibers relative to oblique fibers were found in females in infraumbilical regions. The thickness of the infraumbilical linea alba was smaller in females than in males, while its width was larger. Conclusions. There exist gender differences in the architecture of the linea alba. However, whether these morphological differences demonstrate the adaptability of this fiber architecture to biomechanical stress in raised Intraabdominal Pressure in pregnancy remains to be proven. The transverse fibers act as a counterpart to the Intraabdominal Pressure whereas the oblique fibers are involved mainly in movements of the trunk.
Masatoshi Makuuchi - One of the best experts on this subject based on the ideXlab platform.
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effects of peritoneal insufflation on hepatic and renal blood flow
Surgical Endoscopy and Other Interventional Techniques, 1994Co-Authors: Yasuhiko Hashikura, Seiji Kawasaki, Yasuhiro Munakata, Shinichi Hashimoto, Kenichiro Hayashi, Masatoshi MakuuchiAbstract:The effects of peritoneal insufflation with carbon dioxide on hepatic and renal blood flow have not been reported hitherto. We evaluated these effects in a porcine model of abdominal laparoscopic surgery. Seven anesthetized pigs underwent peritoneal insufflation in a step-wise manner to create Intraabdominal Pressures of 6, 12, 18 and 24 mmHg, and changes in the arterial and venous Pressure, arterial blood gases, and hepatic and renal blood flow were monitored. Both the hepatic and renal blood flow decreased as the Intraabdominal Pressure increased. Therefore, in order to carry out laparoscopic abdominal surgery safely in patients with hepatic or renal impairment, low Intraabdominal Pressures or noninsufflating techniques are recommended.
