RAAC en chirurgie thoraciqueou

Améliorer le parcours des pa7ents à risque péri-opératoire

élevéPr Emmanuel LorneService d’Anesthésie

CHU d’Amiens

Conflits d’interêts

• MSD: conférences

Réhabilitation amélioré après chirurgie = Parcours amélioré centré sur le patient

Qualitatif centré sur le Patient

Définir les objectifsAmélioration qualitative de la prise en charge centrée sur

le patient

Récupera7on rapide des capacités physiques et psychiques antérieures

Diminu7on mortalité morbidité

Diminution durée de séjours

Définir les objectifsAmélioration qualitative de la prise en charge centrée sur

le patient

Récuperation rapide des capacités physiques et psychiques antérieures

Diminution mortalité morbidité

Diminution durée de séjours

Phase d’inves=ssement

Bénéfice pa=ent+

sociétal

Principes communs à tous les parcours de RAAC

PeropératoireVoies mini-invasivesEquilibre hydrique

Anesthésieanalgésie

Pré-opératoireInformationPréparationphysique et

psychologique

Post opératoire

Réalimentation précoce

Déambulationanalgésie

Particularités de la chirurgie : exemple de la chirurgie thoracique• La durée d’hospitalisation conditionnée par l’incidence des

complications chirurgicales. • plusieurs facteurs pour raccourcir cette période : • contrôle de la douleur aiguë postopératoire, • reprise rapide de la nutrition, • mobilisation rapide, • réduction de la durée des drainages et du nombre de drains.

Prépara&on pré-opératoire

Préparation alimentaire

Kuzu World J Surg 2006

APPENDIX: DEFINITIONS OF OUTCOMES

! Abscess (intraperitoneal/extraperitoneal): requiresoperative or spontaneous drainage of an abdominalpurulent collection.

! Anastomotic leakage: discharge of bowel content via adrain, wound, or abnormal orifice.

! Atelectasis: confirmed by chest radiography, requiringbronchoscopy.

! Bronchopleural fistula: confirmed by chest radiography.! Cardiac failure: symptoms or signs of left ventricular or

congestive cardiac failure that require an alterationfrom preoperative therapeutic measures.

! Cerebrovascular accident: development of a new andpersistent (> 48 hours) central neurologic deficit.

! Chest infection: production of purulent sputum withpositive bacteriologic cultures, with or without chestradiographic changes or pyrexia, or consolidation seenon chest radiography.

! Coexisting disease: A history of congestive heartfailure, myocardial infarction, angina, or cerebrovascu-lar disease was defined as cardiovascular disease.Chronic obstructive lung disease, respiratory insuffi-ciency, or bronchial asthma was defined as respiratory

disease. Diabetes mellitus included types I and II.Chronic liver disease documented by either biopsy orby persistently elevated serum transaminases wasdefined as liver disease. All of the patients withcoexisting diseases were self-dependent and werenot hospitalized because of these pathologies.

! Deep hemorrhage: postoperative bleeding requiringreexploration.

! Deep venous thrombosis and/or graft thrombosis:clinical evidence that necessitated full-dose anticoag-ulation or radiologic documentation.

! Emphyema: radiologic changes and documentation ofa pathologic organism in the pleural fluid.

! Gastrointestinal hemorrhage: gastrointestinal bloodloss of sufficient abundance requiring transfusion oftwo or more units of blood during any 24-hour period forbleeding.

! Hepatic dysfunction: a postoperative rise in total serumbilirubin > 2.0 mg/dl above on-study levels (excludedfrom this complication were patients who underwentpancreatic and biliary tract procedures).

! Hypotension: a fall in systolic blood pressure below90 mmHg for more than 2 hours.

! Impaired renal function: an increase in blood urea of> 5 mmol/L from preoperative levels.

Table 5.Association between the severity of malnutrition, diagnoses, morbidity, and mortality according to various nutrition scores

Subjective Global Assessment

CharcteristicMalnourished(n = 268)

Well nourished(n = 192) P

Age (years), mean (SD), median (IQR) 58.9 (14.8),63 (19)

50.2 (13.5),51(20)

<0.001

No. of GI patients GIS 198 (73.9%) 98 (51.0%) <0.001No. of cancer patients 184 (68.7%) 109 (56.8%) 0.009No. curative cancer surgera 157 (85.3%) 101 (92.7%) 0.061No. with coexisting illness 80 (29.9%) 33 (17.2%) 0.002No. of vascular patients 32 (11.9%) 13 (6.8%) 0.066Morbidity 100 (37.3%) 31(16.1%) <0.001Infectious complications

Severe 33 (12.3%) 7 (3.6%) 0.001Nonsevere 50 (18.7%) 14 (7.3%) 0.001

NonInfectious complicationsSevere 44 (16.4%) 17 (8.9%) 0.018Nonsevere 14 (5.2%) 9 (4.7%) 0.795

Mortality 15 (5.6%) 5 (2.6%) 0.121Time to return to normal activities mean (SD) 8.91 (9.44),

median (IQR) 6.0 (5.0)6.85 (12.22),5.0 (4.75)

<0.001

Length of hospital stay, (days) mean (SD) 20.78 (12.63),median (IQR) 18.0 (14.75)

17.77 (14.27),15.0 (10.0)

0.001

386 Kuzu et al.: Preoperative Nutritional Risk Assessment

loss of secreted albumin is 4 %. However, various patho-logical conditions may impact albumin metabolism. Re-duction in synthesis secondary to hepatocyte damage,deficiency in amino acid intake, diseases involving acuteor chronic inflammation may result in increased loss. Inaddition, serum albumin levels are also reduced in case ofprotein malnutrition, nephrotic syndrome, protein-losing enteropathy, burn, constructive pericarditis, ataxia

telangiectasia and tumor-associated mesenteric blockageand mucosal diseases such as inflammatory bowel diseaseand hemodilution [17]. As a result, in the case of defi-ciency of protein, the building block of the body, all bodyfunctions will slow down, even stop. Obviously, this trig-gers development of morbidity and mortality [4, 7, 9]. Al-though there are studies advocating that complications inmalnourished patients are caused by reduced immunity ñ

Fig. 2 Patientsí postoperative complications graphic

Fig. 3 Drainage days graphic

Kaya et al. Journal of Cardiothoracic Surgery (2016) 11:14 Page 6 of 8RESEARCH ARTICLE Open Access

Is preoperative protein-rich nutritioneffective on postoperative outcome innon-small cell lung cancer surgery? Aprospective randomized studySeyda Ors Kaya, Tevfik Ilker Akcam*, Kenan Can Ceylan, Ozgur Samancılar, Ozgur Ozturk and Ozan Usluer

Abstract

Objective: Protein-rich nutrition is necessary for wound healing after surgery. In this study, the benefit of preoperativenutritional support was investigated for non-small cell lung cancer patients who underwent anatomic resection.

Methods: A prospective study was planned with the approval of our institutional review board. Fifty-eight patientswho underwent anatomic resection in our department between January 2014 and December 2014 were randomized.Thirty-one patients were applied a preoperative nutrition program with immune modulating formulae (enriched witharginine, omega-3 fatty acids and nucleotides) for ten days. There were 27 patients in the control group who were fedwith only normal diet. Patients who were malnourished, diabetic or who had undergone bronchoplastic procedures orneoadjuvant therapy were excluded from the study. Patientsí baseline serum albumin levels, defined as the serumalbumin level before any nutrition program, and the serum albumin levels on the postoperative third day werecalculated and recorded with the other data.

Results: Anatomic resection was performed by thoracotomy in 20 patients, and 11 patients were operated byvideothoracoscopy in the nutrition program group. On the other hand 16 patients were operated by thoracotomy and11 patients were operated by videothoracoscopy in the control group. In the control group, the patientsí albuminlevels decreased to 25.71 % of the baseline on the postoperative third day, but this reduction was only 14.69 % fornutrition program group patients and the difference was statistically significant (p < 0.001). Complications developed in12 patients (44.4 %) in the control group compared to 6 patients in the nutrition group (p = 0.049). The mean chesttube drainage time was 6 (1ñ 42) days in the control group against 4 (2ñ 15) days for the nutrition program group(p = 0.019).

Conclusions: Our study showed that preoperative nutrition is beneficial in decreasing the complications and chesttube removal time in non-small cell lung cancer patients that were applied anatomic resection with a reduction of25 % in the postoperative albumin levels of non-malnourished patients who underwent resection.

Keywords: Albumin, Lung cancer, Preoperative-nutrition

* Correspondence: tevfikilkerakcam@hotmail.comDepartment of Thoracic Surgery, Dr. Suat Seren Chest Diseases and ThoracicSurgery Training and Research Hospital, Izmir, Turkey

© 2016 Kaya et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Kaya et al. Journal of Cardiothoracic Surgery (2016) 11:14 DOI 10.1186/s13019-016-0407-1

!"#$%&'()&*#+%),-.'*/*

0'1(%2#,(#$+(21(#3%'45(

Préparation alimentaire du patient malnutrit

Régime hyperpro-dique per os recommandé:-7 jour avant la chirurgie en cas d’un bilan biologiquenutri-nonel perturbé (albumine (<30 g/l) et pré-albumine (150 mg/l.)).

Jeûne préopératoire• La prise d’une solution glucidique la

veille (ex : jus de raisin) et deuxheures avant l’intervention estrecommandée chez les patients n’ayant pas de troubles de la vidangegastrique. • La dose de charge en glucides

préconisée est (selon les produits) d’environ 100g la veille et 50g 2H avant l’intervention.

!"#$%"%&'()*$+,-'./0*0&*"0-$'"%&('"0! !"#$%&'()*+,+-)-+." #//+0)0#

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13&'# #5- +"#//+0)0#:

7Steffens D, et al. Br J Sports Med 2018;0:1ñ9. doi:10.1136/bjsports­ 2017­ 098032

Review

!"#$%#&!!&'"()%*+,"-+!%.*&/0+0$-0&123%4($%0*"+!%5(67789%+//$//$,%:;+!"02% &#% !"#$% ;/"()% 0<$% =(0$*(+0"&(+!% >&(0"($(-$% ?&-"$02%@+!$% ?<&*0% #&*1% +(,% *$.&*0$,% +% /")("#"-+(0% 1$+(% ,"##$*$(-$%at 1 month (MD −3.70; P=0.002) and 3 months (MD −4.10; A6B3BBC9% .&/0&.$*+0"D$E% #+D&;*"()% 0<$% $F$*-"/$% )*&;.3GH% I<$%&0<$*%0*"+!%5(67J9%+//$//$,%:;+!"02%&#%!"#$%;/"()%0<$%1$(0+!%+(,%.<2/"-+!%-&1.&($(0%&#%0<$%A*&/0+0$%>+(-$*%=(,$F%+0%0<$%.&/0&.K$*+0"D$%#&!!&'K;.3%I<$*$%'+/%(&%/")("#"-+(0%,"##$*$(-$%L$0'$$(%0<$%)*&;./%#&*%$"0<$*%0<$%1$(0+!%&*%.<2/"-+!%-&1.&($(0%/-&*$/3G8%I<$%:;+!"02%&#%$D",$(-$%'+/%D$*2%!&'%50+L!$%M93

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

Comparison with other studiesN<"!$% 0<$% #"(,"()/% #*&1% &;*% *$D"$'% +*$% /&1$'<+0% "(% !"($%'"0<%.*$D"&;/%*$D"$'/E%&;*%/0;,2%.*&D",$/%<")<$*K:;+!"02%$D",$(-$%+(,%

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

Meaning of the studyA&/0&.$*+0"D$% -&1.!"-+0"&(% "/% +% 1+W&*% -&(-$*(% #&*% .+0"$(0/%;(,$*)&"()%&(-&!&)"-+!%/;*)$*23%4;*%*$D"$'%#&;(,%0<+0%.*$&.$*K+0"D$%$F$*-"/$%-&1.+*$,%'"0<%+%-&(0*&!%"(0$*D$(0"&(%&(%.+0"$(0/%;(,$*)&"()%!;()%-+(-$*%/;*)$*2%*$,;-$/%.&/0&.$*+0"D$%-&1.!"-+K0"&(%*+0$/%L2%M8T%+(,%!$()0<%&#%<&/."0+!%/0+2%L2%+!1&/0%G%,+2/E%+(,%/<&;!,%0<$*$#&*$%L$%-&(/",$*$,%+/%+%.*$&.$*+0"D$%/0+(,+*,%

Figure 2 Mean difference for postoperative length of hospital stay (days) in controlled trials on effic acy of preoperative exercise for patients undergoing oesophageal and lung cancer surgery. Studies ordered chronologically. Negative values favour preoperative exercise. MD, mean difference.

Figure 3 Relative risk for number of post­ operative complications in controlled trials on effic acy of preoperative exercise for patients undergoing lung cancer surgery. Studies ordered chronologically. Values <1 favour preoperative exercise. RR, relative risk.

group.bmj.com on February 2, 2018 - Published by http://bjsm.bmj.com/Downloaded from

7Steffens D, et al. Br J Sports Med 2018;0:1ñ9. doi:10.1136/bjsports­ 2017­ 098032

Review

!"#$%#&!!&'"()%*+,"-+!%.*&/0+0$-0&123%4($%0*"+!%5(67789%+//$//$,%:;+!"02% &#% !"#$% ;/"()% 0<$% =(0$*(+0"&(+!% >&(0"($(-$% ?&-"$02%@+!$% ?<&*0% #&*1% +(,% *$.&*0$,% +% /")("#"-+(0% 1$+(% ,"##$*$(-$%at 1 month (MD −3.70; P=0.002) and 3 months (MD −4.10; A6B3BBC9% .&/0&.$*+0"D$E% #+D&;*"()% 0<$% $F$*-"/$% )*&;.3GH% I<$%&0<$*%0*"+!%5(67J9%+//$//$,%:;+!"02%&#%!"#$%;/"()%0<$%1$(0+!%+(,%.<2/"-+!%-&1.&($(0%&#%0<$%A*&/0+0$%>+(-$*%=(,$F%+0%0<$%.&/0&.K$*+0"D$%#&!!&'K;.3%I<$*$%'+/%(&%/")("#"-+(0%,"##$*$(-$%L$0'$$(%0<$%)*&;./%#&*%$"0<$*%0<$%1$(0+!%&*%.<2/"-+!%-&1.&($(0%/-&*$/3G8%I<$%:;+!"02%&#%$D",$(-$%'+/%D$*2%!&'%50+L!$%M93

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

Comparison with other studiesN<"!$% 0<$% #"(,"()/% #*&1% &;*% *$D"$'% +*$% /&1$'<+0% "(% !"($%'"0<%.*$D"&;/%*$D"$'/E%&;*%/0;,2%.*&D",$/%<")<$*K:;+!"02%$D",$(-$%+(,%

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

Meaning of the studyA&/0&.$*+0"D$% -&1.!"-+0"&(% "/% +% 1+W&*% -&(-$*(% #&*% .+0"$(0/%;(,$*)&"()%&(-&!&)"-+!%/;*)$*23%4;*%*$D"$'%#&;(,%0<+0%.*$&.$*K+0"D$%$F$*-"/$%-&1.+*$,%'"0<%+%-&(0*&!%"(0$*D$(0"&(%&(%.+0"$(0/%;(,$*)&"()%!;()%-+(-$*%/;*)$*2%*$,;-$/%.&/0&.$*+0"D$%-&1.!"-+K0"&(%*+0$/%L2%M8T%+(,%!$()0<%&#%<&/."0+!%/0+2%L2%+!1&/0%G%,+2/E%+(,%/<&;!,%0<$*$#&*$%L$%-&(/",$*$,%+/%+%.*$&.$*+0"D$%/0+(,+*,%

Figure 2 Mean difference for postoperative length of hospital stay (days) in controlled trials on effic acy of preoperative exercise for patients undergoing oesophageal and lung cancer surgery. Studies ordered chronologically. Negative values favour preoperative exercise. MD, mean difference.

Figure 3 Relative risk for number of post­ operative complications in controlled trials on effic acy of preoperative exercise for patients undergoing lung cancer surgery. Studies ordered chronologically. Values <1 favour preoperative exercise. RR, relative risk.

group.bmj.com on February 2, 2018 - Published by http://bjsm.bmj.com/Downloaded from

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Prépara&on physique et respiratoire

• Une VNI pré-opératoire peut être indiqué chez les pa9ents avec un VEMS <80%, sécre9ons bronchiques persistentes .• Les séances de kinésithérapie seront réalisées la veille de

l’interven9on.

Perrin C, Resp Med 2007

!"#$%&'()*)+)*,-&).&/0$),)123)4$'1-'56)$7$3)4'8-$',)%4#+96#$-5#&5#8)4! !"#$%&'(&'")*()+%&,"%-.",/+0-"#+(%! !"#$%&'(&1"2,*#10-#"$%&*#/%&3&*0&1#10-+#1(! !42(&(%,01(&#$-(+1"%-0*&56*"1&')&-+"$17

Gestion de la douleur

• ALR systématique

• Debuter les antalgiques pour le post opératoire 30 minutes avant la fin de l’intervention (Paracétamol, AINS).

• La lidocaïne IV peut-être initiée à la dose de 1mg/kg de poids ideal théorique pour les chirurgies n’ayant pas eu d’ALR.

Divisions du nerf rachidien

Blocs du tronc

Peridurale

BPVErector spinae

Serratus

!"#$%&'(')*(+*,('"-%./&'$*%0*%01223/1#4

Dermatome Myotome Sclérotome

The time course of pain scores (VAS) after surgery at restand at coughing is shown in Figs 1 and 2 respectively.The difference in scores between the two groups at coughingand at rest was statistically significant (P<0.05; two-wayrepeated measures ANOVA on ranks). During the stay inthe postoperative anaesthesia care unit, ketorolac wasadministered to two and four patients in the paravertebraland control groups respectively. The number of patients withVAS scores <30 is shown in Fig. 3. In Fig. 4 the upper andlower sensory levels of the thoracic dermatomes using coldare shown for each patient.

Half an hour and 3 h after the operation the median(25th–75th percentiles) cumulative morphine consumption,including nurse administered morphine, in the paravertebralgroup was 7.3 (6.9–8.0) and 21 mg (9.3–28.3) respectively;in the control group it was 6.5 (5.5–8.7) and 20 mg (13–37.3)respectively. The cumulative morphine consumption over

48 h was 69.3 mg (38.8–118.5) in the paravertebral groupand 78.1 mg (38.4–93.5) in the control group (P=0.053; two-way repeated measures ANOVA on ranks). One and threepatients were treated with ketorolac in the paravertebralgroup and the control group respectively. No differ-ence was found for patient satisfaction with their painmanagement.

There was no difference in sedation or the decrease inoxygen saturation after discontinuation of supplementaryoxygen (air test) between the groups. Twenty-four and48 h after surgery the groups did not differ with regard topeak expiratory flow rate (Fig. 5).

The mean length of stay in the postanaesthesia care unitwas 270 (SD 185) and 279 (192) min for the paravertebralgroup and the control group respectively (not significant).The median length of stay in hospital after surgery was 4and 5 days in the paravertebral and the control groups

VA

S (

0–10

0 m

m)

0

20

40

60

80

100 ParavertebralControl

0 h 1 h 2 h 3 h 24 h 48 h

VAS at coughing

Fig 2 Course of pain on coughing during 48 h after surgery. The median,

interquartile range (box) and the 5th and 95th centiles are shown.

The difference between the groups was statistically significant (P<0.05;two-way repeated measures ANOVA on ranks).

Spread of sensory block in theparavertebral group

Patients1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Upper sensory levelLower sensory level

T4

T6

T8

T10

T2

T12

Fig 4 The spread of the block is illustrated for each patient with upper and

lower levels of sensory block.

0 h 1 h 2 h 3 h 24 h 48 h

Num

ber

of p

atie

nts

0

2

4

6

8

10

12

14

16

18

20

22 PVB at restControl at restPVB at coughingControl at coughing

VAS ≤30

Fig 3 Number of patients with VAS scores <30 mm (i.e. sufficientanalgesia) during 48 h after surgery at rest and on coughing.

PE

FR

(lit

re m

in–1

)

0

100

200

300

400

500

600

ParavertebralControl

Preop. 24 h 48 h

PEFR

Fig 5 Time course of peak expiratory flow rate (PEFR) preoperatively and

after 24 and 48 h after surgery.

Thoracic paravertebral block after thoracoscopic surgery

819

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isc on April 9, 2013

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367 patients adultes et pédiatriques Blocs paravertebraux thoraciques et lombaires

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Le bloc para vertebral semble identique à la péridurale, mais…• Pas d’études sur la douleur à long terme comparé à la péridurale

thoracique• Les séries sont de faible ampleur• Intérêt du bloc paravertébral sur l’incidence des pneumopathies (vs

péridurale) démontré par une seule étude (Richardson, BJA, 1999)

Comment utiliser au mieux le bloc paravertébral ?

• Dose d’AL élevées plus efficaces que faibles doses

• Volume relativement élevés = 20ml d’AL

• Pas d’effets du type d’AL

• Clonidine ou sufentanil en adjuvant= pas d’intérêt

• Avant chirurgie > après chirurgie

Kotzé, BJA, 2009

Méta-analyse sur 25 études et 763 paRents

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Choix du bloc du tronc

ThoracotomieAnalgésie > 48h

Périduralethoracique BPV Erector

spinae

Thoracoscopie

InfiltrationTrous de trocars

serratus Erectorspinae

KT > 48h

Préven'on des NVPO

• A l’induction à titre systématique 8mg de dexamethasone + 2,5 mg de Droleptan. (dose/Kg). • L’emploi d’un “setron” sera systématique en cas de NVPO

postopératoire ou de score d’Apfel élevé.

Objec&f d’AR per-opératoire

• Capteur d’EEG simplifié type BIS avec cible peropératoire entre 40 et 60. • Ne pas être en dessous de 40 pour eviter l’accumulation

d’hypnotiques. • Monitorage de la fraction expirée en halogené.

Resserrer le compartiment contraint en optimisant

Fu#er, JAMA, 2017

Cardiac index – ml/min/m 2

Baseline 2.5±0.7 2.5±0.6 0.48

End of intervention period 3.1±0.8 3.0±0.8 0.39

VariableStandard Treatment

(N=145)

Individualized Treatment

(N=147) P valueMedian cumulative volume of crystalloid (IQR) – ml 2500 (1825–3225) 2275 (1600–3000) 0.09

During surgery 2000 (1500–2500) 1500 (1000–2000) <0.001

Median cumulative volume of colloid (IQR) – ml 1000 (500–1750) 1000 (500–1500) 0.25

During surgery 1000 (500–1500) 875 (500–1500) 0.12

Moins de remplissage per opératoire pour un résultat identique en terme de débit cardiaque

Pression artériellemoyenne maintenue àuniveau proche de la PAM avant induc#on (+/- 20%). Noradrenaline à pe#tes doses (1 à 10 g/kg/h) si le pa#ent ne répond pas àl’éphédrine.

Remplissage restrictif en chirurgie pulmonaire

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Chirurgiepulmonaire

Chirurgiecolorectale

Chirurgie mineureet courte

• Apports de cristalloïdes à 2-3 ml/kg/h de poids idéal.

• Compensation des pertessanguines volume pour volume par des cristalloïdes.

• En cas de bas debit cardiaqueune expansion volémique de 250 ml de cristalloïde pourraêtre initiée.

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www.chestpubs.org CHEST / 139 / 3 / MARCH, 2011 535

operative lung and surgical manipulation during OLV result in relative organ ischemia and tissue damage. Higher F io 2 during OLV can, therefore, lead to an increased production of radical oxygen species, pro-inØ ammatory cytokines, and subsequent lung injury on reventilation-induced reperfusion. 11,30,31 In this regard, Douzinas et al 32 recommended that reperfu-sion should occur at a lower F io 2 because hypoxemic reperfusion has been shown to attenuate the reperfu-sion syndrome.

In our study, Pa co 2 was higher in the PV group during OLV. However, mean Pa co 2 values remained

homogeneous gas distribution and avoidance of regional overdistension, as seen through CT scans, 28 as compared with the volume-controlled mode.

Exposure to 100% oxygen can lead to absorption atelectasis 24 and signiÆ cantly increased pulmonary capillary permeability, with consequent increases in lymphatic Ø ow. 29 Furthermore, the collapse of the

Figure 3. Pulmonary complications between the CV and PV groups. Pa o 2 /F io 2 measurements , 300 mm Hg and/or newly developed lung lesions (lung inÆ ltration and atelectasis) within 72 h of the operation were counted as pulmonary complication. The numbers of patients are represented as values. * P , .05 by Fisher exact test; † P , .05 by x 2 test. ALI 5 acute lung injury; P/F , 300 5 Pa o 2 /F io 2 values , 300 mm Hg. See Figure 1 legend for expansion of other abbreviations.

Figure 2. Postoperative Pa o 2 /F io 2 values between the CV and PV groups. Pa o 2 /F io 2 measurements at 2 h after the ICU arrival (POD0) and at 3:00 am on postoperative day 1 (POD1) are shown. Data are expressed as mean 6 SD with a Mann-Whitney rank sum test for POD0 and t test for POD1. POD 0 5 Pa o 2 /F io 2 measure-ments at 2 h after the ICU arrival; POD1 5 Pa o 2 /F io 2 measure-ments at 3:00 am on postoperative day 1. * P , .05. See Figure 1 legend for expansion of abbreviations.

Table 3– Characteristics of Ventilator Parameters and Intraoperative Arterial Blood Gas Analysis

Characteristic

CV PV

Tbaseline TOLV 15 TOLV 60 TTLV 15 Tbaseline TOLV 15 TOLV 60 TTLV 15

V t , mL 551 6 85 542 6 101 543 6 97 522 6 127 562 6 80 369 6 62 a,b 361 6 53 a,b 518 6 96RR, bpm 9.4 6 0.9 9.1 6 1.4 9.4 6 1.5 9.6 6 3.0 9.7 6 0.9 12.0 6 2.1 a,b 12.8 6 1.9 a,b 9.7 6 1.2PIP, cm H 2 O 18 6 2 23 6 3 b 23 6 2 b 19 6 4 18 6 2 18 6 4 a 18 6 3 a 19 6 4Pplateau, cm H 2 O 15 6 2 19 6 3 b 19 6 3 b 16 6 4 15 6 3 18 6 4 a,b 18 6 3 a,b 16 6 4Compliance, mL/cm H 2 O 31.9 6 4.5 24.7 6 4.3 b 24.4 6 3.9 b 30.4 6 7.9 32.6 6 6.1 28.9 6 7.4 a 27.7 6 6.5 a,b 32.1 6 10.4PEEP, cm H 2 O 0.7 6 0.9 0.8 6 1.1 1.0 6 1.2 1.0 6 1.3 0.7 6 0.9 4.6 6 1.4 a,b 4.8 6 1.0 a,b 1.6 6 1.9F io 2 0.58 6 0.12 0.95 6 0.02 b 0.96 6 0.01 b 0.64 6 0.18 0.56 6 0.07 0.62 6 0.12 a 0.67 6 0.16 a,b 0.58 6 0.13 a Pa o 2, mm Hg 290 6 79 240 6 102 249 6 107 301 6 109 291 6 60 118 6 42 a,b 135 6 55 a,b 273 6 75Pa co 2, mm Hg 34.8 6 5.3 36.0 6 4.5 35.4 6 4.0 38.9 6 5.7 c 36.4 6 4.4 d 39.1 6 4.9 a 39.0 6 3.6 a 38.1 6 4.5pH 7.46 6 0.03 7.46 6 0.04 7.45 6 0.03 7.41 6 0.05 c 7.45 6 0.04 e 7.42 6 0.04 a 7.42 6 0.04 a 7.41 6 0.04Hematocrit, % 35.4 6 3.9 35.3 6 3.7 35.0 6 3.7 33.7 6 3.9 35.5 6 3.4 35.2 6 3.6 34.3 6 3.8 33.4 6 3.8 f Sp o 2 , 95% 1 2PIP . 30 cm H 2 O 15 0

Data are expressed as mean 6 SD. Between groups, t test for all continuous variables. Within groups, one-way analysis of variance and Tukey honestly signÆ cant different test as post hoc. Compliance is respiratory system compliance, V t /PIP. PEEP 5 peak end-expiratory pressure; PIP 5 peak airway pressure; Pplateau 5 plateau airway pressure; RR 5 respiratory rate; Sp o 2 5 oxygen saturation by pulse oximetry; Tbaseline 5 baseline time after anesthetic induction and before ventilation strategy application; TOLV 15 5 15 min after initiation of OLV; TOLV 60 5 60 min after initiation of OLV; TTLV 15 5 15 min after the end of OLV; V t 5 tidal volume. See Table 1 and 2 legends for expansion of other abbreviations. a P , .05 compared with the counterpart of the CV group. b P , .05 compared with the Tbaseline and TTLV 15 . c P , .05 compared with the Tbaseline, TOLV 15 , and TOLV 60. d P , .05 compared with the TOLV 15 , TOLV 60. e P , .05 compared with the TOLV 15 , TOLV 60 , and TTLV 15 . f P , .05 compared with the Tbaseline.

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Protocole de re-expansion pulmonaire peri-opératoire• Pression de plateau+10 cmH2O pendant 30 secondes avec contrôle

visuel du chirurgien)• VNI post-opératoire systématique, • Kinesithérapie

Extuba'on

• En pression positive, après ouverture des yeux et réponse à un ordresimple. • Fraction expirée en desflurane <0,5% ou sevoflurane <0,2%. • Volume courant supérieur ou égal à 6ml/kg de poids théorique.

Apport en oxygène :

• Non systématique.

• O2 pour :

• SpO2 supérieure à 95% à l’aide de lunettes nasales. • Le masque facial est reservé au patient ayant une Spo2 inferieure à 90%.

• Si BPCO ou SAOS ou obésité (IMC >35) 1 à 2 séances de ventilation

non invasive seront prescrites et debutées en SSPI à J0 puis à J1, J2 ±

J3. Durée de 3 fois 30 minutes (12).

•

Drainage Thoracique:

• Il faudrait prioriser le drainage de la cavité thoracique avec un seul drain. Selon la pathologie un deuxième drain peut être indiqué.• Un système de drainage mobile doit être priorisé avec quantification

électronique des pertes liquidiennes et gazeuses (Thopaz).

Différentes étapes de la mobilisation en chirurgie thoracique

J0Si bullage 0 : ablation de

drain

J1Ablation des drains

Ablation des drains -> Sortie du service

Bord de lit dès que possibleFauteuil dès le soir de l’intervention .

Fauteuil x2/jour (8h au total à J1, toute la journée à partir de J2)VerticalisationMobilisations manuelles analytiques et renforcement musculaire des MSCycloergomètre (MI)

IDEM +Déambulation dans le couloir

Critères de sortie des patients (tous doivent être présents)• douleur contrôlée par les analgésiques oraux (EVA ≤3).• alimenta=on solide et bien tolérée.• pas de perfusions.• Capacité à se mobiliser de manière indépendante ou au même

niveau qu’avant l’interven=on.• SpO2> 94% en air ambient ou équivalente à celle du pré-opératoire

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