Preoperative evaluation of the patient with pulmonary disease

Atelectasis in obese patients undergoing laparoscopic bariatric surgery are not increased upon discharge from Post Anesthesia Care Unit

Background

Obese patients frequently develop pulmonary atelectasis upon general anesthesia. The risk is increased during laparoscopic surgery. This prospective, observational single-center study evaluated atelectasis dynamics using Electric Impedance Tomography (EIT) in patients undergoing laparoscopic bariatric surgery.

Methods

We included adult patients with ASA physical status I-IV and a BMI of ≥40. Exclusion criteria were known severe pulmonary hypertension, home oxygen therapy, heart failure, and recent pulmonary infections. The primary outcome was the proportion of poorly ventilated lung regions (low tidal variation areas) and the global inhomogeneity (GI) index assessed by EIT before discharge from the Post Anesthesia Care Unit compared to these same measures prior to initiation of anesthesia.

Results

The median (IQR) proportion of low tidal variation areas at the different analysis points were T1 10.8% [3.6-15.1%] and T5 10.3% [2.6-18.9%], and the mean difference was -0.7% (95% CI: -5.8% -4.5%), i.e., lower than the predefined non-inferiority margin of 5% (p = 0.022). There were no changes at the four additional time points compared to T1 or postoperative pulmonary complications during the 14 days following the procedure.

Conclusion

We found that obese patients undergoing laparoscopic bariatric surgery do not leave the Post Anesthesia Care Unit with increased low tidal variation areas compared to the preoperative period.

Manual sobre cuidados com a ferida pós-pleurostomia aberta

Objetivo: Produzir e validar um manual sobre cuidados com a ferida pós-pleurostomia aberta para profissionais de saúde. Métodos:Trata-se de um relato de experiência. Inicialmente, foram selecionados artigos em português, espanhol e inglês no período de 2010 a 2018 nas bases de dados bibliográficos e sites de busca da Cochrane, SciELO, LILACS, PubMed e Google Acadêmico para o desenvolvimento do material. Foram utilizados os descritores: “toracotomia”, toracostomias”, “cavidade torácica”, “pleura”, “cavidade pleural”, “ferimentos e lesões”. Após consulta, o texto foi elaborado, seguido das ilustrações e a diagramação. O manuscrito concluído foi encaminhado aos especialistas para validação. O índice de validade de conteúdo (IVC) foi utilizado para validar o manual. Resultados: O manual desenvolvido possui trinta e seis páginas e sete capítulos com os seguintes temas: introdução, cuidados com a ferida pós-pleurostomia aberta, limpeza da ferida/debridamento, coberturas, registro dos cuidados, considerações finais e bibliografia. Conclusão: Foi possível desenvolver e validar um manual de cuidados com a ferida pós-pleurostomia aberta para a consulta de profissionais de saúde

Manual on wound care after open-window thoracostomy

Objective: To produce and validate a manual on wound care after open-window thoracostomy for healthcare professionals. Methods: This is an experience report. Initially, articles in Portuguese, Spanish and English were selected from 2010 to 2018 in the Cochrane, SciELO, LILACS, PubMed and Google Academic databases and search sites for the development of the material. The following descriptors were used: “thoracotomy”, “thoracostomies”, “thoracic cavity”, “pleura”, “pleural cavity”, “injuries and lesions”. After consultation, the text was prepared, followed by illustrations and layout design. The completed manuscript was sent to experts for validation. The content validity index (CVI) was used to validate the manual. Results: The manual developed has thirty-six pages and seven chapters with the following themes: introduction, wound care after open-window thoracostomy, wound cleansing/debridement, dressings, care record, final considerations, and bibliography. Conclusion: It was possible to develop and validate a manual on wound care after open-window thoracostomy for the consultation of health professionals.

Atelectasis in Bariatric Surgery: Review Analysis and Key Practical Recommendations

Obesity is a condition that affects multiple organ systems, particularly the cardiovascular and respiratory system. In recent years, bariatric surgery has been reported to be the gold standard in the treatment of morbid obesity. Body mass index alone is insufficient to predict risks related to anaesthesia and surgery. Obesity contributes to significant postoperative atelectasis and is considered an independent risk factor for postoperative atelectasis owing to decreased functional residual capacity. The treatment and reversibility of atelectasis developed in obese patients undergoing bariatric surgery are challenging. Therefore, an optimisation of pulmonary functions before surgery, lung-sparing ventilation during the perioperative period, awareness of potential postoperative complications and knowledge about preventive measures and therapeutic approaches have become increasingly important in bariatric surgery. The aim of this review was to aid clinicians in the management of atelectasis in patients undergoing bariatric surgery during the perioperative and postoperative period.

Anesthetic considerations for lung resection: preoperative assessment, intraoperative challenges and postoperative analgesia

This article is intended to provide a general overview of the anesthetic management for lung resection surgery including the preoperative evaluation of the patient, factors influencing the intraoperative anesthetic management and options for postoperative analgesia. Lung cancer is the leading cause of death among cancer patients in the United States. In patients undergoing lung resection, perioperative pulmonary complications are the major etiology of morbidity and mortality. Risk stratification of patients should be part of the preoperative assessment to predict their risk of short-term vs. long-term pulmonary complications. Improvements in surgical technique and equipment have made video assisted thoracoscopy and robotically assisted thoracoscopy the procedures of choice for thoracic surgeries. General anesthesia including lung isolation has become essential for optimizing visualization of the operative lung but may itself contribute to pulmonary complications. Protective lung ventilation strategies may not prevent acute lung injury from one-lung ventilation, but it may decrease the amount of overall lung injury by using small tidal volumes, positive end expiratory pressure, low peak and plateau airway pressures and low inspired oxygen fraction, as well as by keeping surgical time as short as possible. Because of the high incidence of chronic post-thoracotomy pain syndrome following thoracic surgery, which can impact a patient's normal daily activities for months to years after surgery, postoperative analgesia is a necessary part of the anesthetic plan. Multiple options such as thoracic epidural analgesia, intravenous narcotics and several nerve blocks can be considered in order to prevent or attenuate chronic pain syndromes. Enhanced recovery after thoracic surgery is a relatively new topic with many elements taken from the experience with colorectal surgery. The goal of enhanced recovery is to improve patient outcome by improving organ function and decreasing postoperative complications, and therefore decreasing length of hospital stay.

Office-Based Sedation/General Anesthesia for COPD Patients, Part II

The safe treatment of patients with chronic obstructive pulmonary disease (COPD) in dental office office-based settings can be quite complex without a current understanding of the etiology, course, severity, and current treatment modalities of the disease. The additional concerns of providing sedation and/or general anesthesia to patients with COPD in settings outside of a hospital demand thorough investigation of individual patient presentation and realistic development of planned treatment that patients suffering from this respiratory condition can tolerate. Along with other co-morbidities, such as advanced age and potential significant cardiovascular compromise, the dental practitioner providing sedation or general anesthesia must tailor any treatment plan to address multiple organ systems and mitigate risks of precipitating acute respiratory failure from inadequate pain and/or anxiety control. Part I of this article covered the epidemiology, etiology, and pathophysiology of COPD. Patient considerations in the preoperative period were also reviewed. Part II will cover which patients are acceptable for sedation/general anesthesia in the dental office-based setting as well as sedation/general anesthesia techniques that may be considered. Postoperative care will also be reviewed.

Intraoperative Acute Respiratory Failure in an Immunocompromised Patient with Human Metapneumovirus

Patient: Male, 31

Final Diagnosis: Pneumonia from Human Metapneumovirus pulmonary infection

Symptoms: Cough • fatigue

Medication: —

Clinical Procedure: Hernia repair

Specialty: Anesthesiology

Office-Based Sedation/General Anesthesia for COPD Patients, Part I

The safe treatment of patients with chronic obstructive pulmonary disease (COPD) in dental office-based settings can be quite complex without a current understanding of the etiology, course, severity, and treatment modalities of the disease. The additional concerns of providing sedation and/or general anesthesia to patients with COPD in settings outside of a hospital demand thorough investigation of individual patient presentation and realistic development of planned treatment that patients suffering from this respiratory condition can tolerate. Along with other comorbidities, such as advanced age and potential significant cardiovascular compromise, the dental practitioner providing sedation or general anesthesia must tailor any treatment plan to address multiple organ systems and mitigate risks of precipitating acute respiratory failure from inadequate pain and/or anxiety control. Part I of this article will cover the epidemiology, etiology, and pathophysiology of COPD. Patient evaluation in the preoperative period will also be reviewed. Part II will cover which patients are acceptable for sedation/general anesthesia in the dental office-based setting as well as sedation/general anesthesia techniques that may be considered.

Perioperative Evaluation of Patients with Pulmonary Conditions Undergoing Non-Cardiothoracic Surgery

This review describes the perioperative management of patients with suspected or established pulmonary conditions undergoing non-cardiothoracic surgery, with a focus on common pulmonary conditions such as obstructive airway disease, pulmonary hypertension, obstructive sleep apnea, and chronic hypoxic respiratory conditions. Considering that postoperative pulmonary complications are common and given the increasing number of surgical procedures and the size of the aging population, familiarity with current guidelines for preoperative risk assessment and intra- and postoperative patient management is recommended to decrease the morbidity and mortality. In particular, smoking cessation and pulmonary rehabilitation are perioperative strategies for improving patients’ short- and long-term outcomes. Understanding the potential risk for pulmonary complications allows the medical team to appropriately plan the intra- and postoperative care of each patient.

Anaesthesia for patient with chronic obstructive pulmonary disease

The chronic obstructive pulmonary disease has become a disease of public health importance. Among the various risk factors, smoking remains the main culprit. In addition to airway obstruction, the presence of intrinsic positive end expiratory pressure, respiratory muscle dysfunction contributes to the symptoms of the patient. Perioperative management of these patients includes identification of modifiable risk factors and their optimisation. Use of regional anaesthesia alone or in combination with general anaesthesia improves pulmonary functions and reduces the incidence of post-operative pulmonary complications.