Driving Pressure During General Anesthesia for Open Abdominal Surgery (DESIGNATION): study protocol of a randomized clinical trial

DESIGNATION–investigators, Liselotte Hol, Sunny G L H Nijbroek, Ary Serpa Neto, Marcelo Gama de Abreu, Paolo Pelosi, Sabrine N T Hemmes, Leon P H J Aarts, Ronald D L Akkerman, Juliette J E Albersen, Caterina Aurilio, Denise Battaglini, Hans D de Boer, Annemieke Boom, Christa Boer, Tammo Brouwer, Wolfgang F F A Buhre, Carolina S E Bulte, Gitara M Edward-Rutten, Marc B Godfried, Hendrik J F Helmerhorst, Jan Hofland, Hester Hoogenboom, W Ten Hoope, Bernard M Houweling, Ragnar Huhn, Wanda Konijn, Ankie W M M Koopman-van Gemert, Dianne J de Korte-de Boer, Minke C Kortekaas, Felix van Lier, Benedikt Preckel, Mandana Rad, Pasquale Sansone, André Stamkot, Robert Jan Stolker, Bram Thiel, Johannes F H Ubben, Michel M R F Struys, Bastiaan A In 't Veld, Hermann Wrigge, Miriam Zeillemaker-Hoekstra, Tim van der Zwan, Johannes H M J Zwijsen, Markus W Hollmann, Marcus J Schultz, DESIGNATION–investigators, Liselotte Hol, Sunny G L H Nijbroek, Ary Serpa Neto, Marcelo Gama de Abreu, Paolo Pelosi, Sabrine N T Hemmes, Leon P H J Aarts, Ronald D L Akkerman, Juliette J E Albersen, Caterina Aurilio, Denise Battaglini, Hans D de Boer, Annemieke Boom, Christa Boer, Tammo Brouwer, Wolfgang F F A Buhre, Carolina S E Bulte, Gitara M Edward-Rutten, Marc B Godfried, Hendrik J F Helmerhorst, Jan Hofland, Hester Hoogenboom, W Ten Hoope, Bernard M Houweling, Ragnar Huhn, Wanda Konijn, Ankie W M M Koopman-van Gemert, Dianne J de Korte-de Boer, Minke C Kortekaas, Felix van Lier, Benedikt Preckel, Mandana Rad, Pasquale Sansone, André Stamkot, Robert Jan Stolker, Bram Thiel, Johannes F H Ubben, Michel M R F Struys, Bastiaan A In 't Veld, Hermann Wrigge, Miriam Zeillemaker-Hoekstra, Tim van der Zwan, Johannes H M J Zwijsen, Markus W Hollmann, Marcus J Schultz

Abstract

Background: Intraoperative driving pressure (ΔP) is associated with development of postoperative pulmonary complications (PPC). When tidal volume (VT) is kept constant, ΔP may change according to positive end-expiratory pressure (PEEP)-induced changes in lung aeration. ΔP may decrease if PEEP leads to a recruitment of collapsed lung tissue but will increase if PEEP mainly causes pulmonary overdistension. This study tests the hypothesis that individualized high PEEP, when compared to fixed low PEEP, protects against PPC in patients undergoing open abdominal surgery.

Methods: The "Driving prESsure durIng GeNeral AnesThesIa for Open abdomiNal surgery trial" (DESIGNATION) is an international, multicenter, two-group, double-blind randomized clinical superiority trial. A total of 1468 patients will be randomly assigned to one of the two intraoperative ventilation strategies. Investigators screen patients aged ≥ 18 years and with a body mass index ≤ 40 kg/m2, scheduled for open abdominal surgery and at risk for PPC. Patients either receive an intraoperative ventilation strategy with individualized high PEEP with recruitment maneuvers (RM) ("individualized high PEEP") or one in which PEEP of 5 cm H2O without RM is used ("low PEEP"). In the "individualized high PEEP" group, PEEP is set at the level at which ΔP is lowest. In both groups of the trial, VT is kept at 8 mL/kg predicted body weight. The primary endpoint is the occurrence of PPC, recorded as a collapsed composite of adverse pulmonary events.

Discussion: DESIGNATION will be the first randomized clinical trial that is adequately powered to compare the effects of individualized high PEEP with RM versus fixed low PEEP without RM on the occurrence of PPC after open abdominal surgery. The results of DESIGNATION will support anesthesiologists in their decisions regarding PEEP settings during open abdominal surgery.

Trial registration: Clinicaltrials.gov, NCT03884543. Registered on 21 March 2019.

Keywords: Compliance; Intraoperative ventilation; Mechanical ventilation; Positive end-expiratory pressure; Postoperative complications; Postoperative pulmonary complications; Pulmonary complications; Recruitment maneuver; ΔP.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Consolidated Standards of Reporting Trials (CONSORT) diagram for the “Driving prESsure durIng GeNeral AnesThesIa for Open abdomiNal surgery” (DESIGNATION) trial
Fig. 2
Fig. 2
Examples of the “ΔP–PEEP” graph. The arrow represents the optimal PEEP
Fig. 3
Fig. 3
Overview of the intervention: the recruitment maneuvers and decremental PEEP trial. See text for a detailed description of the recruitment maneuvers and the decremental PEEP trial. The numbers projected in each bar represent the duration of each step in seconds
Fig. 4
Fig. 4
Schedule for enrolment and assessments (SPIRIT 2013 figure). ICU intensive care unit, PEEP positive end-expiratory pressure, POD postoperative day

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