Associations of dynamic driving pressure and mechanical power with postoperative pulmonary complications-posthoc analysis of two randomised clinical trials in open abdominal surgery

Michiel T U Schuijt^{1

2}, Liselotte Hol¹, Sunny G Nijbroek¹, Sanchit Ahuja³, David van Meenen^{1

2}, Guido Mazzinari⁴, Sabrine Hemmes³, Thomas Bluth⁵, Lorenzo Ball^{6

7}, Marcelo Gama-de Abreu^{8

9}, Paolo Pelosi^{6

7}, Marcus J Schultz^{1

10

11

12}, Ary Serpa Neto^{1

13

14

15

16}

Affiliations

¹ Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands.
² Department of Anaesthesiology, Amsterdam UMC, location AMC, Amsterdam, The Netherlands.
³ Department of Anaesthesiology, Pain Management & Perioperative Medicine, & Outcomes Research Consortium Cleveland Clinic, Henry Ford Health System, Detroit, Michigan, The United States of America.
⁴ Department of Anaesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain.
⁵ Department of Anaesthesiology and Critical Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
⁶ Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
⁷ Department of Anaesthesia and Critical Care, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy.
⁸ Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, Ohio, The United States of America.
⁹ Department of Outcomes Research, Anaesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, The United States of America.
¹⁰ Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.
¹¹ Nuffield Department of Medicine, University of Oxford, Oxford, The United Kingdom.
¹² Department of Medical Affairs, Hamilton Medical AG, Bonaduz, Switzerland.
¹³ Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia.
¹⁴ Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia.
¹⁵ Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.
¹⁶ Cardio-Pulmonary Department, Pulmonary Division, Faculdade de Medicina, Instituto do Coração, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil.

PMID: 35480074
PMCID: PMC9035701
DOI: 10.1016/j.eclinm.2022.101397

Associations of dynamic driving pressure and mechanical power with postoperative pulmonary complications-posthoc analysis of two randomised clinical trials in open abdominal surgery

Michiel T U Schuijt et al. EClinicalMedicine. 2022.

. 2022 Apr 16:47:101397.

doi: 10.1016/j.eclinm.2022.101397. eCollection 2022 May.

Authors

Affiliations

¹ Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands.
² Department of Anaesthesiology, Amsterdam UMC, location AMC, Amsterdam, The Netherlands.
³ Department of Anaesthesiology, Pain Management & Perioperative Medicine, & Outcomes Research Consortium Cleveland Clinic, Henry Ford Health System, Detroit, Michigan, The United States of America.
⁴ Department of Anaesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain.
⁵ Department of Anaesthesiology and Critical Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
⁶ Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
⁷ Department of Anaesthesia and Critical Care, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy.
⁸ Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, Ohio, The United States of America.
⁹ Department of Outcomes Research, Anaesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, The United States of America.
¹⁰ Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.
¹¹ Nuffield Department of Medicine, University of Oxford, Oxford, The United Kingdom.
¹² Department of Medical Affairs, Hamilton Medical AG, Bonaduz, Switzerland.
¹³ Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia.
¹⁴ Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia.
¹⁵ Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.
¹⁶ Cardio-Pulmonary Department, Pulmonary Division, Faculdade de Medicina, Instituto do Coração, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil.

PMID: 35480074
PMCID: PMC9035701
DOI: 10.1016/j.eclinm.2022.101397

Abstract

Background: While an association of the intraoperative driving pressure with postoperative pulmonary complications has been described before, it is uncertain whether the intraoperative mechanical power is associated with postoperative pulmonary complications.

Methods: Posthoc analysis of two international, multicentre randomised clinical trials (ISRCTN70332574 and NCT02148692) conducted between 2011-2013 and 2014-2018, in patients undergoing open abdominal surgery comparing the effect of two different positive end-expiratory pressure (PEEP) levels on postoperative pulmonary complications. Time-weighted average dynamic driving pressure and mechanical power were calculated for individual patients. A multivariable logistic regression model adjusted for confounders was used to assess the independent associations of driving pressure and mechanical power with the occurrence of a composite of postoperative pulmonary complications, the primary endpoint of this posthoc analysis.

Findings: In 1191 patients included, postoperative pulmonary complications occurrence was 35.9%. Median time-weighted average driving pressure and mechanical power were 14·0 [11·0-17·0] cmH₂O, and 7·6 [5·1-10·0] J/min, respectively. While driving pressure was not independently associated with postoperative pulmonary complications (odds ratio, 1·06 [95% CI 0·88-1·28]; p=0.534), the mechanical power had an independent association with the occurrence of postoperative pulmonary complications (odds ratio, 1·28 [95% CI 1·05-1·57]; p=0.016). These findings were independent of body mass index or the level of PEEP used, i.e., independent of the randomisation arm.

Interpretation: In this merged cohort of surgery patients, higher intraoperative mechanical power was independently associated with postoperative pulmonary complications. Mechanical power could serve as a summary ventilatory biomarker for the risk for postoperative pulmonary complications in these patients, but our findings need confirmation in other, preferably prospective studies.

Funding: The two original studies were supported by unrestricted grants from the European Society of Anaesthesiology and the Amsterdam University Medical Centers, Location AMC. For this current analysis, no additional funding was requested. The funding sources had neither a role in the design, collection of data, statistical analysis, interpretation of data, writing of the report, nor in the decision to submit the paper for publication.

Keywords: Driving pressure; Intensity of ventilation; Intraoperative; Mechanical power; Mechanical ventilation; Postoperative pulmonary complication.

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Conflict of interest statement

Marcelo Gama de Abreu declares consultations at Ambu, ZOLL, Lungpacer and patents on variable pressure support. Serpa Neto reports lecture fees from Dräger, outside of the submitted work. Schultz reports personal fees from Hamilton (In 2018, Marcus Schultz attended a workshop organized by Hamilton, in which expenses for lodging were covered for all invited experts, participants from abroad had their travel expenses reimbursed, and speakers received a speaker's fee of CHF 800 – this has no relation with the current study. Additionally, Marcus Schultz’ team uses so-called ‘memory boxes’ for capturing ventilation data – these boxes are lent for free, and will be send back at the end of the study for which they are used – this has no relation with the current study) outside of the submitted work. All other authors declare no competing interests.

Figures

**Figure 1**
**CONSORT diagram**. PROBESE: Protective Intraoperative Ventilation With Higher Versus Lower Levels of PEEP in Obese Patients; PROBESE: Protective Intraoperative Ventilation With Higher Versus Lower Levels of PEEP in Obese Patients; ΔP: driving pressure; MP: mechanical power. ARISCAT: Assess Respiratory Risk in Surgical Patients in Catalonia

**Figure 2**
**Intraoperative ventilation parameters during the first five hours of surgery**. First row panels (A and B): mean hourly values of V_T and Ppeak. Second row panels (C and D): mean hourly values of PEEP and FiO₂. Third row panels (E and F): mean hourly values of RR and MP. Fourth row panel (G): mean hourly ΔP values. Circles are means and error bars are 95% confidence intervals. The number of patients is presented below. PBW: predicted body weight; Ppeak: peak pressure; PEEP: positive end–expiratory pressure; FiO2: fraction of inspired oxygen

**Figure 3**
**Multivariable model assessing the association of time–weighted average driving pressure and mechanical power with postoperative pulmonary complications**. Models adjusted for age, gender, ASA classification, ARISCAT score, centre, history of COPD, history of active cancer, history of heart failure, SpO₂, respiratory rate, heart rate, mean arterial blood pressure, fraction of inspired oxygen and end–tidal carbon dioxide in the first hour of intraoperative ventilation, antibiotic prophylaxis, duration of surgery, duration of anaesthesia, use of epidural, type of anaesthesia, amount of blood loss, total amount of fluid administered, transfusion, urine output, emergency procedure and trial. Odds ratios were the adjusted odds ratios associated with a 1–point increment. Values higher than 1 indicate an association with increased risk of postoperative pulmonary complications. CI: confidence interval; ΔP: driving pressure; MP: mechanical power; PEEP: positive end–expiratory pressure.

See this image and copyright information in PMC

References

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1. Neto AS, Hemmes SNT, Barbas CSV, et al. Association between driving pressure and development of postoperative pulmonary complications in patients undergoing mechanical ventilation for general anaesthesia: A meta-analysis of individual patient data. Lancet Respir Med. 2016;4:272–280. - PubMed

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Associations of dynamic driving pressure and mechanical power with postoperative pulmonary complications-posthoc analysis of two randomised clinical trials in open abdominal surgery

Affiliations

Associations of dynamic driving pressure and mechanical power with postoperative pulmonary complications-posthoc analysis of two randomised clinical trials in open abdominal surgery

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

LinkOut - more resources

Full Text Sources