Effects of PEEP on the Intracranial System of Patients With Head Injury and Subarachnoid Hemorrhage: The Role of Respiratory System Compliance

Caricato, Anselmo; Conti, Giorgio; Corte, Francesco Della; Mancino, Aldo; Santilli, Federico; Sandroni, Claudio; Proietti, R.; Antonelli, Massimo

doi:10.1097/01.ta.0000152806.19198.db

Cited by 180 publications

(154 citation statements)

References 28 publications

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“…Another reasonable concern is the possible detrimental relationship between ICP and the sustained high mean airway pressures (mP aw ) necessary for HFOV. There are numerous papers on the effect of positive end expiratory pressure (PEEP) on ICP, and it is common practice not to employ high levels of PEEP in patients with intracranial hypertension [4,7,10]. The sustained mean airway pressure used during HFOV may be viewed by some clinicians as high PEEP; however, we did not find any significant harmful effect of these pressures in our patients.…”

Section: Discussioncontrasting

confidence: 53%

Use of High Frequency Oscillatory Ventilation (HFOV) in Neurocritical Care Patients

et al. 2007

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Introduction-Adult respiratory distress syndrome (ARDS) can be a common problem associated with the treatment of acute brain injury. High frequency oscillatory ventilation (HFOV) is a developing therapy for the treatment of ARDS in adult patients that can be life saving. However, often patients with acute, severe brain injury demonstrate intracranial hypertension (hICP) due to a variety of injuries (e.g., traumatic brain injury, mass lesion, acute hydrocephalus). There is concern over the use of HFOV due to its effects on intracranial pressure in patients with hICP.

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Section: Discussioncontrasting

confidence: 53%

Use of High Frequency Oscillatory Ventilation (HFOV) in Neurocritical Care Patients

et al. 2007

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“…Concerns about the worsening of ICP with PEEP have not been confirmed [127,128]. In any case, it must be titrated at the lowest possible level.…”

Section: Initial Neurologic Evaluation Of the Trauma Patientmentioning

confidence: 99%

Critical Care Issues in the Early Management of Severe Trauma

García

2006

Surgical Clinics of North America

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Violent trauma and road traffic injuries kill more than 2.5 million people in the world every year. It has been calculated by the World Health Organization that in 2002 there occurred 1.6 million violent deaths [1] and 1.2 million deaths from traffic injury [2], for a combined mortality of 48 deaths per 100,000 population per year.Most trauma deaths occur at the scene or in the first hour after trauma, with a proportion from 34% to 50% occurring in hospitals [3]. These deaths could be prevented by optimization of trauma care. Preventability of trauma deaths has been reported as high as 76% [4] and as low as 1% in mature trauma systems [5,6].Prehospitalization procedures, elapsed time to hospital arrival are, of course, vital to the whole trauma scenario, but errors made in the in-hospital phase of care are responsible for one third to two thirds of the reported by different authors [7,8]. Of these, intensive care unit (ICU) errors are among the most frequent and significant. Errors in the ICU management of trauma patients were studied by Duke and colleagues [9]. They reported 165 ICU trauma deaths. Two hundred fifty-eight errors occurred in 81 patients (52%), and 134 of them contributed to death in 52 patients (34%). ICU errors were classified as management errors (82%), diagnostic (9%), technique (5%), and system inadequacies (4%). Davis and colleagues [10] identified critical care errors in 30% of 125 trauma deaths with errors. These errors contributed to 48% of all preventable deaths.The most common critical care errors are related to airway and respiratory management, fluid resuscitation, neurotrauma diagnosis and support, and delayed diagnosis of critical lesions [9,10].It is imperative for the general surgeon who takes care of trauma patients to know how to deal with these critical aspects, to reduce preventable morbidity and mortality. In the next segment, the situations in which the participation of the surgeon is crucial, during the initial phases of reanimation and stabilization of the critically traumatized patient will be discussed. Airway and ventilation managementAirway and respiratory management errors are the most common of those identified by several authors [9][10][11] The cardinal manifestation is a sudden or a rapidly progressing desaturation, frequently accompanied by tachycardia and arrhytmias, and occasionally by agitation. Hypertension announces the cardiovascular collapse, and bradicardia appears immediately after the total collapse [12]. The symptoms should not be attributed to agitation when it is present, and other possible causes must be ruled out before. Diagnosing the complication involves a directed physical examination, the analysis of the airway pressures and ventilator volumes, chest radiographs, and sometimes the measurement of arterial blood gases (ABG), and the urinary bladder pressure ( Table 1).The emergency conditions in which the access to the airways must be gained, the displacement to diagnosis areas or operating room and the agitation, often present, make the critical...

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“…In the literature, several ventilation strategies including volume control ventilation, pressure control ventilation, recruitment maneuvers, and PEEP application are discussed for the management of ventilation and oxygenation problems caused by increased intraabdominal pressure and head-down position (19)(20)(21)(22)(23). The importance of PEEP application for maintaining adequate gas exchange while preventing ventilator-induced lung injury is especially emphasized (7,10,22,23).…”

Section: Discussionmentioning

confidence: 99%

Effects of positive end-expiratory pressure on intracranial pressure during pneumoperitoneum and Trendelenburg position in a porcine model*

Bedirli¹,

Emmez²,

Ünal³

et al. 2017

Turk J Med Sci

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IntroductionRobot-assisted laparoscopic surgery has developed greatly and is becoming a standard technique for radical prostatectomy. It is widely preferred for pelvic surgeries because of its important advantages that minimize postoperative morbidity and mortality. Robotic surgeries in the pelvic region, including radical prostatectomy, rectum resection, and gynecologic procedures, usually require a steep Trendelenburg position and carbon dioxide pneumoperitoneum to secure the surgical field. Pneumoperitoneum combined with steep Trendelenburg position may cause significant changes in cardiovascular, respiratory, and neurophysiological parameters (1,2). Both the increase in abdominal pressure as a result of carbon dioxide insufflation and the head-down position have been shown to impair respiratory functions during the procedure by pushing the diaphragm upward and reducing lung volume and respiratory compliance, thus inducing atelectasis formation (3,4).Background/aim: This study was undertaken to evaluate the effects of positive end-expiratory pressure (PEEP) levels on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) and to determine the appropriate PEEP level during steep Trendelenburg position combined with pneumoperitoneum. Materials and methods:Ten pigs were included in this study. Pneumoperitoneum and Trendelenburg position were maintained and PEEP titration was initiated. Arterial pressure, heart rate, arterial blood gas, ICP, and CPP were recorded at the following time points: baseline (T0), 30 min after positioning and pneumoperitoneum (T1), PEEP 5 (T2), PEEP 10 (T3), PEEP 15 (T4), and PEEP 20 (T5).Results: MAP significantly increased at T1 compared to T0 and decreased at T4 and T5 compared to T1. ICP was 9.5 mmHg and CPP was 69.3 mmHg at T0. CO 2 insufflation and steep Trendelenburg position did not cause any significant difference in ICP and CPP. ICP increased and CPP decreased significantly at T4 and T5 compared to both T0 and T1. PaO 2 and PaO 2 /FiO 2 decreased significantly at T1 and T2 compared to T0, while both increased significantly at T3, T4, and T5 compared to T1. Conclusion:PEEP of 10 cmH 2 O was effective for providing oxygenation while preserving hemodynamic stability, ICP, and CPP in this model.

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Effects of PEEP on the Intracranial System of Patients With Head Injury and Subarachnoid Hemorrhage: The Role of Respiratory System Compliance

Abstract: In patients with low Crs, PEEP has no significant effect on cerebral and systemic hemodynamics. Monitoring of Crs may be useful for avoiding deleterious effects of PEEP on the intracranial system of patients with normal Crs.

Cited by 180 publications

References 28 publications

Use of High Frequency Oscillatory Ventilation (HFOV) in Neurocritical Care Patients

Use of High Frequency Oscillatory Ventilation (HFOV) in Neurocritical Care Patients

Critical Care Issues in the Early Management of Severe Trauma

Effects of positive end-expiratory pressure on intracranial pressure during pneumoperitoneum and Trendelenburg position in a porcine model*

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