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Low tidal volume ventilation for patients undergoing laparoscopic surgery: a secondary analysis of a randomised clinical trial. BMC Anesthesiol 2023; 23:71. [PMID: 36882701 PMCID: PMC9990198 DOI: 10.1186/s12871-023-01998-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 01/30/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND We recently reported the results for a large randomized controlled trial of low tidal volume ventilation (LTVV) versus conventional tidal volume (CTVV) during major surgery when positive end expiratory pressure (PEEP) was equal between groups. We found no difference in postoperative pulmonary complications (PPCs) in patients who received LTVV. However, in the subgroup of patients undergoing laparoscopic surgery, LTVV was associated with a numerically lower rate of PPCs after surgery. We aimed to further assess the relationship between LTVV versus CTVV during laparoscopic surgery. METHODS We conducted a post-hoc analysis of this pre-specified subgroup. All patients received volume-controlled ventilation with an applied PEEP of 5 cmH2O and either LTVV (6 mL/kg predicted body weight [PBW]) or CTVV (10 mL/kg PBW). The primary outcome was the incidence of a composite of PPCs within seven days. RESULTS Three hundred twenty-eight patients (27.2%) underwent laparoscopic surgeries, with 158 (48.2%) randomised to LTVV. Fifty two of 157 patients (33.1%) assigned to LTVV and 72 of 169 (42.6%) assigned to conventional tidal volume developed PPCs within 7 days (unadjusted absolute difference, - 9.48 [95% CI, - 19.86 to 1.05]; p = 0.076). After adjusting for pre-specified confounders, the LTVV group had a lower incidence of the primary outcome than patients receiving CTVV (adjusted absolute difference, - 10.36 [95% CI, - 20.52 to - 0.20]; p = 0.046). CONCLUSION In this post-hoc analysis of a large, randomised trial of LTVV we found that during laparoscopic surgeries, LTVV was associated with a significantly reduced PPCs compared to CTVV when PEEP was applied equally between both groups. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry no: 12614000790640.
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Bablekos GD, Michaelides SA, Analitis A, Lymperi MH, Charalabopoulos KA. Comparative changes in tissue oxygenation between laparoscopic and open cholecystectomy. J Clin Med Res 2015; 7:232-41. [PMID: 25699119 PMCID: PMC4330015 DOI: 10.14740/jocmr2086w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2015] [Indexed: 01/30/2023] Open
Abstract
Background Previous studies examined the effect of laparoscopic cholecystectomy (LC) versus open cholecystectomy (OC) on physiological variables of the respiratory system. In this study we compared changes in arterial blood gases-related parameters between LC and OC to assess their comparative influence on gas exchange. Methods We studied 28 patients, operated under identical anesthetic protocol (LC: 18 patients, OC: 10 patients). Measurements were made on the morning before surgery (BS), the second (AS2) and the eighth (AS8) postoperative day. Studied parameters, including alveolar-arterial difference in PO2 ((A-a)DO2) and oxygen content (Oct in vol%), were statistically compared. Results On AS2 a greater increase was found in ((A-a)DO2) for the OC compared to LC (4.673 ± 0.966 kPa versus 3.773 ± 1.357 kPa, respectively). Between BS and AS2, Oct in vol% decreased from 17.55 ± 1.90 to 15.69 ± 1.88 in the LC and from 16.99 ± 2.37 to 14.62 ± 2.23 in the OC, whilst a reduction (P = 0.093) between AS2 and AS8 was also found for the open method. Besides, on AS2, SaO2% decrease was greater in OC compared to LC (P = 0.096). Conclusions On AS2, the greater increase in OC-((A-a)DO2) associated with Oct in vol% and SaO2% findings also in OC group suggest that LC might be associated with lower risk for impaired tissue oxygenation.
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Affiliation(s)
- George D Bablekos
- Department of Experimental Physiology, Medical School, Democritous University of Thrace, 68100 Dragana, Alexandroupolis, Greece ; Technological Educational Institute (T.E.I.) of Athens, Agiou Spyridonos 28 Street, 12243 Egaleo, Athens, Greece
| | - Stylianos A Michaelides
- "Sismanogleio" General Hospital, First Thoracic Medicine Department, Sismanogleiou 1 Street, 15126 Maroussi, Athens, Greece
| | - Antonis Analitis
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Mikras Asias 75 Street, 11527 Goudi, Athens, Greece
| | - Maria H Lymperi
- Department of Experimental Physiology, Medical School, National and Kapodistrian University of Athens, Mikras Asias 75 Street, 11527 Goudi, Athens, Greece
| | - Konstantinos A Charalabopoulos
- Department of Experimental Physiology, Medical School, Democritous University of Thrace, 68100 Dragana, Alexandroupolis, Greece
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Bablekos GD, Michaelides SA, Analitis A, Charalabopoulos KA. Effects of laparoscopic cholecystectomy on lung function: A systematic review. World J Gastroenterol 2014; 20:17603-17617. [PMID: 25516676 PMCID: PMC4265623 DOI: 10.3748/wjg.v20.i46.17603] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 03/17/2014] [Accepted: 06/17/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To present and integrate findings of studies investigating the effects of laparoscopic cholecystectomy on various aspects of lung function.
METHODS: We extensively reviewed literature of the past 24 years concerning the effects of laparoscopic cholecystectomy in comparison to the open procedure on many aspects of lung function including spirometric values, arterial blood gases, respiratory muscle performance and aspects of breathing control, by critically analyzing physiopathologic interpretations and clinically important conclusions. A total of thirty-four articles were used to extract information for the meta-analysis concerning the impact of the laparoscopic procedure on lung function and respiratory physiopathology. The quality of the literature reviewed was evaluated by the number of their citations and the total impact factor of the corresponding journals. A fixed and random effect meta-analysis was used to estimate the pooled standardized mean difference of studied parameters for laparoscopic (LC) and open (OC) procedures. A crude comparison of the two methods using all available information was performed testing the postoperative values expressed as percentages of the preoperative ones using the Mann-Whitney two-sample test.
RESULTS: Most of the relevant studies have investigated and compared changes in spirometric parameters.The median percentage and interquartile range (IQR) of preoperative values in forced vital capacity (FVC), forced expiratory volume in 1 s and forced expiratory flow (FEF) at 25%-75% of FVC (FEF25%-75%) expressed as percentage of their preoperative values 24 h after LC and OC were respectively as follows: [77.6 (73.0, 80.0) L vs 55.4 (50.0, 64.0) L, P < 0.001; 76.0 (72.3, 81.0) L vs 52.5 (50.0, 56.7) L, P < 0.001; and 78.8 (68.8, 80.9) L/s vs 60.0 (36.1, 66.1) L/s, P = 0.005]. Concerning arterial blood gases, partial pressure of oxygen [PaO2 (kPa)] at 24 or 48 h after surgical treatment showed reductions that were significantly greater in OC compared with LC [LC median 1.0, IQR (0.6, 1.3); OC median 2.4, IQR (1.2, 2.6), P = 0.019]. Fewer studies have investigated the effect of LC on respiratory muscle performance showing less impact of this surgical method on maximal respiratory pressures (P < 0.01); and changes in the control of breathing after LC evidenced by increase in mean inspiratory impedance (P < 0.001) and minimal reduction of duty cycle (P = 0.01) compared with preoperative data.
CONCLUSION: Laparoscopic cholecystectomy seems to be associated with less postoperative derangement of lung function compared to the open procedure.
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Valenza F, Chevallard G, Fossali T, Salice V, Pizzocri M, Gattinoni L. Management of mechanical ventilation during laparoscopic surgery. Best Pract Res Clin Anaesthesiol 2010; 24:227-41. [PMID: 20608559 DOI: 10.1016/j.bpa.2010.02.002] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Laparoscopy is widely used in the surgical treatment of a number of diseases. Its advantages are generally believed to lie on its minimal invasiveness, better cosmetic outcome and shorter length of hospital stay based on surgical expertise and state-of-the-art equipment. Thousands of laparoscopic surgical procedures performed safely prove that mechanical ventilation during anaesthesia for laparoscopy is well tolerated by a vast majority of patients. However, the effects of pneumoperitoneum are particularly relevant to patients with underlying lung disease as well as to the increasing number of patients with higher-than-normal body mass index. Moreover, many surgical procedures are significantly longer in duration when performed with laparoscopic techniques. Taken together, these factors impose special care for the management of mechanical ventilation during laparoscopic surgery. The purpose of the review is to summarise the consequences of pneumoperitoneum on the standard monitoring of mechanical ventilation during anaesthesia and to discuss the rationale of using a protective ventilation strategy during laparoscopic surgery. The consequences of chest wall derangement occurring during pneumoperitoneum on airway pressure and central venous pressure, together with the role of end-tidal-CO2 monitoring are emphasised. Ventilatory and non-ventilatory strategies to protect the lung are discussed.
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Affiliation(s)
- Franco Valenza
- Università degli Studi di Milano, Dipartimento di Anestesiologia, Terapia Intensiva e Scienze Dermatologiche, Via Festa del Perdono n.7, Milano, Italy.
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Duggan M, Kavanagh BP. Perioperative modifications of respiratory function. Best Pract Res Clin Anaesthesiol 2010; 24:145-55. [DOI: 10.1016/j.bpa.2009.12.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Busley R, Blobner M, Jelen-esselborn S, Feussner H, Kochs E. Intraperitoneal local anaesthetics via subphrenic catheter following laparoscopic cholecystectomy: Pain relief and pulmonary function. MINIM INVASIV THER 2009. [DOI: 10.3109/13645709909153165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
The increasing popularity of minimally invasive surgery has grown concurrently with the demand for ambulatory surgery. Standard outpatient procedures such as tubal ligation are now being joined by ambulatory laparoscopic cholecystectomy. In order for ambulatory minimally invasive surgery to succeed, patient selection must be appropriate, careful attention paid to the physiologic changes of pneumoperitoneum, and pain and nausea treated pre-emptively.
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Affiliation(s)
- S B Jones
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas 75390-9068, USA.
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Pang CK, Yap J, Chen PP. The effect of an alveolar recruitment strategy on oxygenation during laparascopic cholecystectomy. Anaesth Intensive Care 2003; 31:176-80. [PMID: 12712781 DOI: 10.1177/0310057x0303100206] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
This prospective randomized controlled trial examined the effect of an "alveolar recruitment strategy" (ARS) in healthy patients having laparoscopic cholecystectomy. Twenty-four consecutive ASA 1 or 2 patients were randomly allocated to an ARS or control group. All patients were manually ventilated to a maximal airway pressure of 25 to 30 cmH2O or a tidal volume of 10 ml/kg during induction of general anaesthesia. After intubation, the control group was ventilated with standardized mechanical ventilation settings. The ARS group was manually ventilated to an airway pressure of 40 cmH2O for 10 breaths over one minute, followed by mechanical ventilation with similar standardized settings plus 5 cmH2O positive end-expiratory pressure. Blood pressure, heart rate, arterial oxygen and carbon dioxide tension (PaO2 and PaCO2) was measured pre-induction, 20 minutes post induction but before abdominal insufflation, 20 minutes after abdominal insufflation, and 20 minutes after arrival in the recovery room. Demographic and operation data were similar. The ARS group pre-insufflation PaO2 [30.16 (9.43)] was higher than the control group [22.19 (9.08)] (P = 0.047). There was a significant difference in PaO2 between the ARS [23.94 (4.87)] and control [17.26 (3.93)] groups during the post-insufflation period (P = 0.001). There were no significant differences in PaO2 between the groups during baseline and recovery periods. No adverse effects were reported. ARS improved arterial oxygenation intraoperatively in healthy patients having laparoscopic cholecystectomy, without clinical cardiovascular compromise or respiratory complication. We conclude that this alveolar recruitment strategy is a useful method of increasing arterial oxygenation.
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Affiliation(s)
- C K Pang
- Department of Anaesthesiology, Intensive Care and Operating Service, Alice Ho Miu Ling Nethersole Hospital, Tai Po, Hong Kong, SAR
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Hsieh CH. Laparoscopic cholecystectomy for patients with chronic obstructive pulmonary disease. J Laparoendosc Adv Surg Tech A 2003; 13:5-9. [PMID: 12676014 DOI: 10.1089/109264203321235395] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
PURPOSE Laparoscopic cholecystectomy (LC) is accepted as a "gold standard" for treating most gallbladder diseases because it is superior to the open method, causes less postoperative pulmonary dysfunction, and promotes earlier postoperative recovery. The laparoscopically associated adverse effects of a carbon dioxide (CO(2)) pneumoperitoneum, however, such as hypercarbia and arterial acidosis, are more pronounced in patients with chronic obstructive pulmonary disease (COPD). The clinical results of LC for patients with COPD are analyzed in this study. METHODS Twenty-two patients with COPD (group 1) and undergoing LC were compared with 25 control patients without COPD and also undergoing LC (group 2). Patient demographics, intraoperative end-tidal CO(2) (both before and after CO(2) insufflation), and clinical outcome, including surgical duration, length of postoperative hospital stay, and any associated complications, were analyzed. RESULTS The procedure of one group 1 patient was converted to the open method, and this patient was excluded from the study. Comprising the COPD group were 20 patients with mild COPD and one patient with moderate COPD. With similar settings of tidal volume and ventilation rate for the two groups, the measured end-tidal CO(2) value was significantly greater for group 1 than for group 2 patients after the creation of a CO(2) pneumoperitoneum (34.2 +/- 2.7 vs. 30.7 +/- 3.6 mm Hg; P =.012). The duration of surgery was similar for groups 1 and 2 (88.9 +/- 36.0 vs. 83.2 +/- 38.3 minutes), as was the duration of the postoperative hospital stay (3.3 +/- 1.6 vs. 3.4 +/- 2.2 days). No pulmonary complications were noted for any of the patients. CONCLUSIONS LC can be safely performed in COPD patients with mild or even a moderate degree of airway obstruction. Intraoperative CO(2) retention did not complicate the postoperative recovery in terms of the complication rate or the duration of the postoperative hospital stay.
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Affiliation(s)
- Chi-Hsun Hsieh
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan.
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de La Peña M, Togores B, Bosch M, Maimo A, Abad S, Garrido P, Soro JA, Agustí AGN. [Recovery of lung function after laparoscopic cholecystectomy: the role of postoperative pain]. Arch Bronconeumol 2002; 38:72-6. [PMID: 11844438 DOI: 10.1016/s0300-2896(02)75155-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Lung function has been shown to deteriorate after laparoscopic cholecystectomy (LC). The present study evaluated 1) the rate of recovery after LC, and 2) the pathogenic role of postoperative pain in functional deterioration. DESIGN Lung function was measured 24 hours before LC, upon hospital discharge (48-72 h after LC), and 10 days later. All patients received metamizol after LC until discharge (2 g every 6 h i.v.). Half the patients (analgesia group) received tramadol (150 mg i.m.) 30 minutes before lung function testing on the day of hospital discharge. The remaining patients constituted the control group. PATIENTS Twenty healthy subjects (53 4 years old) undergoing LC for gall bladder removal. All signed informed consent forms. Measures and outcomes: Patient characteristics and preoperative lung function results were similar in both groups. LC duration and postoperative course were also similar in both groups. All were discharged without complications within 72 hours after LC. Lung function upon discharge (FVC, FEV1, TLC, PaO2 and AaPO2) had deteriorated in both groups (p<0.001). Deterioration was less marked in the analgesia group (p < 0.05). Ten days later, lung function had normalized for all subjects. CONCLUSIONS These results indicate that after LC, 1) lung function is still abnormal when the patient is discharged from hospital, 2) lung function has fully recovered within 10 days, and 3) postoperative pain contributes significantly to temporary deterioration in lung function.
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Affiliation(s)
- M de La Peña
- Hospital Universitario Son Dureta. Palma de Mallorca, Sección Neumología Complejo Hospitalario de Mallorca, Spain
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Oliveira PGD, Vianna AL, Silva SP, Rodrigues FRA, Martins RLDM. Influência do tabagismo, obesidade, idade e gênero na função pulmonar de pacientes submetidos à colecistectomia videolaparoscópica. Rev Col Bras Cir 2000. [DOI: 10.1590/s0100-69912000000100005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
O presente estudo foi idealizado com o objetivo de avaliar a influência do tabagismo, obesidade, idade e gênero na função pulmonar de pacientes submetidos à colecistectomia videolaparoscópica (CVL). Foi realizada avaliação prospectiva da função respiratória de pacientes submetidos à CVL em caráter eletivo, por espirometria simples, no pré-operatório e nos primeiro e sétimo dias de pós-operatório (OPO). Quarenta e oito pacientes foram avaliados e estratificados em grupos: tabagista/não-tabagista; obeso/não-obeso; idoso/não-idoso; homem/mulher. Os valores da capacidade vital forçada (CVF), volume expiratório forçado 1º segundo (VEF,), fluxos expiratórios forçados 25% (FEF25) e 50% (FEF50) apresentaram redução significante do pré-operatório para o primeiro OPO em todos os grupos, com exceção do FEF25 nos obesos, caracterizando-se assim alteração de padrão restritivo. No sétimo OPO houve recuperação dos parâmetros espirométricos para valores próximos aos níveis do pré-operatório. Não houve diferença significante na variação dos parâmetros espirométricos segundo os fatores de risco, nos mesmos períodos. Em conclusão, nas condições em que foi realizado o presente estudo, a idade, a obesidade, o gênero e o tabagismo não influenciaram, isoladamente ou em associação, as variações nos parâmetros espirométricos do pré-operatório para o primeiro OPO e para o sétimo OPO após a CVL.
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Wetterslev J, Hansen EG, Kamp-Jensen M, Roikjaer O, Kanstrup IL. PaO2 during anaesthesia and years of smoking predict late postoperative hypoxaemia and complications after upper abdominal surgery in patients without preoperative cardiopulmonary dysfunction. Acta Anaesthesiol Scand 2000; 44:9-16. [PMID: 10669265 DOI: 10.1034/j.1399-6576.2000.440103.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The incidence of late postoperative hypoxaemia and complications after upper abdominal surgery is 20-50% among cardiopulmonary healthy patients. Atelectasis development during anaesthesia and surgery is the main hypothesis to explain postoperative hypoxaemia. This study tested the predictive value of PaO2<19 kPa during combined general and thoracic epidural anaesthesia and the preoperative functional residual capacity (FRC) reduction in the 30 degree head tilt-down position for the development of late prolonged postoperative hypoxaemia, PaO2<8.5 kPa for a minimum of 3 out of 4 days, and other complications. Forty patients without cardiopulmonary morbidity, assessed by ECG, spirometry, FRC and diffusion capacity preoperatively, underwent upper abdominal surgery. PaO2 during anaesthesia and preoperative FRC reduction were compared to known risk factors for the development of hypoxaemia and complications: age, pack-years of smoking and duration of operation. The effect of optimizing pulmonary compliance with peroperative positive end-expiratory pressure (PEEP) on postoperative hypoxaemia and complications was evaluated in a blinded and randomized manner. RESULTS Late prolonged postoperative hypoxaemia and other complications were found in 37% and 38% of the patients, respectively. Patients with PaO2>19 kPa during anaesthesia with F(I)O2=0.33 exhibited a risk, irrespective of PEEP status, of suffering late prolonged hypoxaemia of 0% (0;23) and patients with PaO2<19 kPa a risk of 52% (32;71), P<0.005. Having smoked more than 20 pack-years was associated with a 47% (19;75) higher incidence of postoperative complications than having smoked less than 20 pack-years, P<0.006. CONCLUSIONS PaO2 during anaesthesia and smoked pack-years provide new tools evaluating patients undergoing upper abdominal surgery in order to predict the patients who develop late postoperative hypoxaemia and complications.
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Affiliation(s)
- J Wetterslev
- Department of Anaesthesiology and Intensive Care, Herlev University Hospital, Denmark
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Chabas E, Gomar C, Villalonga A, Sala X, Taura P. Postoperative respiratory function in children after abdominal surgery. A comparison of epidural and intramuscular morphine analgesia. Anaesthesia 1998; 53:393-7. [PMID: 9613308 DOI: 10.1046/j.1365-2044.1998.00325.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Thirty children undergoing urological and abdominal surgery were entered into a randomised trial comparing the effects of epidural and intramuscular morphine on postoperative respiratory function. The forced vital capacity and the forced expired volume in 1 s were measured before and 6 h after surgery and on each of the following seven days. Significant decreases (p < 0.01) in forced vital capacity and forced expired volume in 1 s were seen after surgery. After the first postoperative day, a gradual recovery in pulmonary function was observed but the measured parameters had not returned to their pre-operative control values by the end of the study. There were no statistically significant differences between the two groups during the study with respect to forced vital capacity and forced expired volume in 1 s. The quality of analgesia was better in the epidural morphine group than in the intramuscular morphine group. The incomplete recovery of pulmonary function suggests that pain is not the only cause of postoperative respiratory changes in these patients.
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Affiliation(s)
- E Chabas
- Department of Anaesthesia, Hospital Clinic, Barcelona, Spain
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