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Safety and efficacy evaluation of the automatic stepwise recruitment maneuver in the neonatal population: An in vivo interventional study. Can anesthesiologists safely perform automatic lung recruitment maneuvers in neonates?

Publicated to:PEDIATRIC ANESTHESIA. 31 (9): 1003-1010 - 2021-09-01 31(9), DOI: 10.1111/pan.14243

Authors: Serrano Zueras C; Guilló Moreno V; Santos González M; Gómez Nieto FJ; Hedenstierna G; García Fernández J

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Abstract

Background: A new software has recently been incorporated in almost all new anesthesia machines to enable automatic lung recruitment maneuvers. To date, no studies have assessed the safety and efficacy of these automatic software programs in the neonatal population. Aims: We aimed to evaluate the safety and efficacy of the lung recruitment maneuver performed using the automatic stepwise recruitment maneuver software of the FLOW-i 4.3 Anesthesia System® in a healthy and live neonatal model. Methods: Eight male newborn piglets were included in the study. The lung recruitment maneuver was performed in pressure-controlled ventilation with a constant driving pressure (15 cmH2O) in a stepwise increasing positive end-expiratory pressure (PEEP) model. The target peak inspiratory pressure (PIP) was 30 cmH2O and PEEP was 15 cmH2O. The maneuver lasted for 39 seconds. The hemodynamic variables were monitored using the PICCO® system. The following respiratory parameters were monitored: oxygen saturation, fraction of inspired oxygen, partial pressure of oxygen and carbon dioxide in the arterial blood, end-tidal carbon dioxide pressure, PIP, plateau pressure, PEEP, static compliance (Cstat), and dynamic compliance (Cdyn). Safety was evaluated by assessing the accuracy of the software, need for not interrupting the maneuver, hemodynamic stability, and absence of adverse respiratory events with the lung recruitment maneuver. Efficacy was evaluated by improvement in Cstat and Cdyn after performing the lung recruitment maneuver. Results: All lung recruitment maneuvers were safely performed as scheduled without any interruptions. No pneumothorax or other side effects were observed. Hemodynamic stability was maintained during the lung recruitment maneuver. We observed an improvement of 33% in Cdyn and 24% in Cstat after the maneuver. Conclusions: The automatic stepwise recruitment maneuver software of the FLOW-i 4.3 Anesthesia System® is safe and efficacious in a healthy neonatal model. We did not observe any adverse respiratory or hemodynamic events during the implementation of the lung recruitment maneuver in the pressure-controlled ventilation mode using a stepwise increasing PEEP (30/15 cmH2O) approach.

Keywords

automatic stepwise recruitment maneuvermechanical ventilationneonatesrecruitment maneuverAutomatic stepwise recruitment maneuverMechanical ventilationNeonatesRecruitment maneuverSafety

Quality index

Bibliometric impact. Analysis of the contribution and dissemination channel

The work has been published in the journal PEDIATRIC ANESTHESIA due to its progression and the good impact it has achieved in recent years, according to the agency Scopus (SJR), it has become a reference in its field. In the year of publication of the work, 2021, it was in position , thus managing to position itself as a Q2 (Segundo Cuartil), in the category Anesthesiology and Pain Medicine. Notably, the journal is positioned en el Cuartil Q3 for the agency WoS (JCR) in the category Pediatrics.

From a relative perspective, and based on the normalized impact indicator calculated from World Citations from Scopus Elsevier, it yields a value for the Field-Weighted Citation Impact from the Scopus agency: 1.36, which indicates that, compared to works in the same discipline and in the same year of publication, it ranks as a work cited above average. (source consulted: ESI Nov 14, 2024)

This information is reinforced by other indicators of the same type, which, although dynamic over time and dependent on the set of average global citations at the time of their calculation, consistently position the work at some point among the top 50% most cited in its field:

  • Field Citation Ratio (FCR) from Dimensions: 3.36 (source consulted: Dimensions Jun 2025)

Specifically, and according to different indexing agencies, this work has accumulated citations as of 2025-06-23, the following number of citations:

  • WoS: 5
  • Scopus: 8
  • OpenCitations: 5

Impact and social visibility

From the perspective of influence or social adoption, and based on metrics associated with mentions and interactions provided by agencies specializing in calculating the so-called "Alternative or Social Metrics," we can highlight as of 2025-06-23:

  • The use, from an academic perspective evidenced by the Altmetric agency indicator referring to aggregations made by the personal bibliographic manager Mendeley, gives us a total of: 13.
  • The use of this contribution in bookmarks, code forks, additions to favorite lists for recurrent reading, as well as general views, indicates that someone is using the publication as a basis for their current work. This may be a notable indicator of future more formal and academic citations. This claim is supported by the result of the "Capture" indicator, which yields a total of: 13 (PlumX).

With a more dissemination-oriented intent and targeting more general audiences, we can observe other more global scores such as:

  • The Total Score from Altmetric: 4.7.
  • The number of mentions on the social network X (formerly Twitter): 8 (Altmetric).

Leadership analysis of institutional authors

There is a significant leadership presence as some of the institution’s authors appear as the first or last signer, detailed as follows: Last Author (GARCIA FERNANDEZ, JAVIER).