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GENERAL ARTICLES

The Effects of the Alveolar Recruitment Maneuver and Positive End-Expiratory Pressure on Arterial Oxygenation During Laparoscopic Bariatric Surgery

Francis X. Whalen, MD^*, Ognjen Gajic, MD, Geoffrey B. Thompson, MD, Michael L. Kendrick, MD, Florencia L. Que, MD, Brent A. Williams, MS, Michael J. Joyner, MD^*, Rolf D. Hubmayr, MD, David O. Warner, MD^*, and Juraj Sprung, MD, PhD^*

*Departments of Anesthesiology and Surgery, Division of Pulmonary and Critical Care Medicine, and Department of Health Sciences Research, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota

Address correspondence and reprint requests to Juraj Sprung, MD, PhD, Department of Anesthesiology, Mayo Clinic, Mayo Clinic College of Medicine, Mary Brigh 2-752, 200 First St. SW, Rochester, MN 55905. Address e-mail to Sprung.juraj{at}mayo.edu.

Abnormalities in gas exchange that occur during anesthesia are mostly caused by atelectasis, and these alterations are more pronounced in morbidly obese than in normal weight subjects. Sustained lung insufflation is capable of recruiting the collapsed areas and improving oxygenation in healthy patients of normal weight. We tested the effect of this ventilatory strategy on arterial oxygenation (Pao₂) in patients undergoing laparoscopic bariatric surgery. After pneumoperitoneum was accomplished, the recruitment group received up to 4 sustained lung inflations with peak inspiratory pressures up to 50 cm H₂O, which was followed by ventilation with 12 cm H₂O positive end-expiratory pressure (PEEP). The patient's lungs in the control group were ventilated in a standard fashion with PEEP of 4 cm H₂O. Variables related to gas exchange, respiratory mechanics, and hemodynamics were compared between recruitment and control groups. We found that alveolar recruitment effectively increased intraoperative Pao₂ and temporarily increased respiratory system dynamic compliance (both P < 0.01). The effects of alveolar recruitment on oxygenation lasted as long as the trachea was intubated, and lungs were ventilated with high PEEP, but soon after tracheal extubation, all the beneficial effects on oxygenation disappeared. The mean number of vasopressor treatments given during surgery was larger in the recruitment group compared with the control group (3.0 versus 0.8; P = 0.04). In conclusion, our data suggest that the use of alveolar recruitment may be an effective mode of improving intraoperative oxygenation in morbidly obese patients. Our results showed the effect to be short lived and associated with more frequent intraoperative use of vasopressors.

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