Effect of Lung-Protective Ventilation on Changes in Regional Cerebral Oxygen Saturation During Thoracoscopic Surgery in Children: A Prospective, Single-Center, Randomized Controlled Trial

Abstract

Highlights What are the main findings? For children undergoing thoracoscopic surgery with one-lung ventilation, lung-protective ventilation (4–6 mL/kg tidal volume plus 5 cmH2O PEEP) was associated with a markedly lower rate of intraoperative cerebral desaturation (≥20% fall in regional cerebral oxygen saturation), relative to conventional ventilation (8–10 mL/kg tidal volume, no PEEP). Patients receiving lung-protective ventilation exhibited higher nadir regional cerebral oxygen saturation values. Desaturation events decreased by more than 60% (14.6% versus 37.5%). Post-operative pulmonary complication rates fell by over half (14.6% versus 33.3%), and no pneumothorax cases occurred in this group. Median postoperative length-of-stay was one-day shorter in the lung-protective ventilation arm (4.0 versus 5.0 days), reflecting faster clinical recovery. What is the implication of the main finding? Low-tidal-volume ventilation (4–6 mL/kg during one-lung ventilation) was clinically feasible and well-tolerated. It maintained adequate surgical exposure without safety concerns, lending support for considering this protective strategy for pediatric one-lung-ventilation procedures. This work demonstrates the potential value of near-infrared spectroscopy to detect cerebral deoxygenation missed by pulse oximetry. The findings indicate that combined use of this monitor with lung-protective ventilation warrants further evaluation for optimizing paediatric perioperative care. Abstract Background: Low regional cerebral oxygen saturation (rScO2) in children is linked to neurological sequelae. Lung-protective ventilation (LPV) mitigates lung injury but its effect on intraoperative rScO2 is uncertain. Methods: One hundred and four children (<6 years) undergoing thoracoscopic mediastinal mass resection or lobectomy were randomized to LPV (n = 52; tidal volume: 6 mL/kg double-lung ventilation [DLV], 4 mL/kg one-lung ventilation [OLV] + 5 cm H2O PEEP) or Control (n = 52; 10 mL/kg DLV, 8 mL/kg OLV + zero PEEP). rScO2 was monitored continuously. Primary outcome was incidence of low rScO2 during OLV (≥20% decrease from baseline ≥1 min). Secondary outcomes included lowest rScO2, postoperative pulmonary complications (PPCs), and hospital length of stay (LOS). Results: Ninety-six children were analyzed (n = 48/group). Overall low rScO2 incidence during OLV was 25/96 (26%). Significantly low rScO2 incidence occurred with LPV (7/48, 14.6%) versus control (18/48, 37.5%; p = 0.011). The lowest intraoperative rScO2 was significantly higher in the LPV group 76.5 (70.3, 80.0) compared to control 70.5 (60.3, 76.0); p < 0.001. PPC incidence was lower with LPV (7/48, 14.6%) than control (16/48, 33.3%; p = 0.031). Postoperative LOS was shorter in the LPV group 4.0 [4.0–5.0] days versus control group 5.0 [4.3–6.0] days, p < 0.001. Conclusions: Compared to conventional ventilation, an LPV strategy significantly reduces the incidence of low rScO2 during OLV in young children undergoing thoracoscopic surgery. LPV also decreases PPCs and shortens hospital stay. Clinical trial registration: ChiCTR2400092732.