Positive end-expiratory pressure and the incidence of postoperative pulmonary complications in patients undergoing general anaesthesia

AIM OF THE STUDY

To evaluate the effect of intraoperative positive end-expiratory pressure and driving pressure on the development of postoperative pulmonary complications.

METHOD

The prospective study included 83 patients undergoing abdominal surgery and receiving general anaesthesia. Patients were divided into two groups: with low intraoperative positive end-expiratory pressure (0-2cm H2O) and with high intraoperative positive end-expiratory pressure (8-10cm H2O). The primary endpoint is the development of postoperative pulmonary complications during follow-up.

RESULTS

The incidence of postoperative pulmonary complications in the group of low intraoperative positive end-expiratory pressure was 9.8%, while in the group of high positive end-expiratory pressure was 7.1% (p = 0.6), demonstrating that high positive end-expiratory pressure used during general anaesthesia does not affect the frequency of complications (odds ratio = 0.71, p = 0.6). In the multivariate analysis that controls for all confounders, driving pressure resulted in a significant and independent risk factor for complications.

CONCLUSION

High intraoperative positive end-expiratory pressure does not affect the frequency of postoperative pulmonary complications. The increase in driving pressure is a risk factor for complications. Positive end-expiratory pressure is easily implemented, and its use does not result in significant economic costs.

Incidence and risk factors of postoperative pulmonary complications after oral cancer surgery with free flap reconstruction: A single center study

BACKGROUND

Postoperative pulmonary complications (PPCs) increase the risk of morbidity and mortality in patients who underwent oral cancer surgery with free flap reconstruction. The association between PPC and preoperative risk factors has been investigated; however, reports on intraoperative factors are limited. Therefore, we investigated PPC incidence and its associated preoperative and intraoperative risk factors in these patients.

METHODS

We retrospectively analyzed medical records of patients who underwent free flap reconstruction between 2009 and 2019. PPC was defined as presence of atelectasis, pneumonia, and respiratory failure based on radiological confirmation and clinical symptoms during hospitalization. Mortality, hospital stay, preoperative factors (including age and tumor stages), American Society of Anesthesiologists (ASA) classification, and intraoperative factors (including intraoperative fluids and medications) were recorded.

RESULTS

PPC incidence among the 993 patients included in this study was 25.8% (256 patients). Six patients with PPCs died; death was not observed among patients without PPCs (p < 0.001). Patients with PPCs had longer hospitalization than those without PPCs (30.3 vs 23.3 days; p < 0.001). Tumor stage (stage I: reference; stage II [OR]: 3.3, p = 0.019; stage III: 4.4, p = 0.002; stage IV: 4.8, p = 0.002), age (OR: 1.0; p < 0.001), and ASA grade >2 (OR: 1.4; p = 0.020) were independent risk factors of PPC; using labetalol was a borderline significant factor (OR: 1.4; p = 0.050).

CONCLUSION

The PPC incidence was 25.8% in patients undergoing oral cancer surgery with free flap reconstruction. Tumor stage, age, and ASA >2 were risk factors of developing PPC.

Prophylactic Postoperative Noninvasive Ventilation in Adults Undergoing Upper Abdominal Surgery: A Systematic Review and Meta-Analysis

OBJECTIVES

Postoperative pulmonary complications (PPCs) are a leading cause of morbidity and mortality following upper abdominal surgery. Applying either noninvasive ventilation (NIV) or continuous positive airway pressure (CPAP) in the early postoperative period is suggested to prevent PPC. We aimed to assess whether postoperative NIV or CPAP or both prevent PPCs compared with standard care in adults undergoing upper abdominal surgery, including in those identified at higher PPC risk. Additionally, the different interventions used were evaluated to assess whether there is a superior approach.

DATA SOURCES

We searched PubMed, Embase' CINAHL, CENTRAL, and Scopus from inception to May 17, 2021.

STUDY SELECTION

We performed a systematic search of the literature for randomized controlled trials evaluating prophylactic NIV and/or CPAP in the postoperative period.

DATA EXTRACTION

Two authors independently performed study selection and data extraction. Individual study risk of bias was assessed using the PEDro scale, and certainty in outcomes was assessed using the Grading of Recommendations Assessment, Development, and Evaluation framework.

DATA SYNTHESIS

We included 17 studies enrolling 6,108 patients. No significant benefit was demonstrated for postoperative NIV/CPAP to reduce PPC (risk ratio [RR], 0.89; 95% CI, 0.78-1.01; very low certainty), including in adults identified at higher PPC risk (RR, 0.91; 95% CI, 0.77-1.07; very low certainty). No intervention approach was identified as superior, and no significant benefit was demonstrated when comparing: 1) CPAP (RR, 0.90; 95% CI, 0.79-1.04; very low certainty), 2) NIV (RR, 0.68; 95% CI, 0.41-1.13; very low certainty), 3) continuous NIV/CPAP (RR, 0.90; 95% CI, 0.77-1.05; very low certainty), or 4) intermittent NIV/CPAP (RR, 0.66; 95% CI, 0.39-1.10; very low certainty) to standard care.

CONCLUSIONS

These findings suggest routine provision of either prophylactic NIV or CPAP following upper abdominal surgery may not be effective to reduce PPCs' including in those identified at higher risk.

External validation based on transfer learning for diagnosing atelectasis using portable chest X-rays

Background

Although there has been a large amount of research focusing on medical image classification, few studies have focused specifically on the portable chest X-ray. To determine the feasibility of transfer learning method for detecting atelectasis with portable chest X-ray and its application to external validation, based on the analysis of a large dataset.

Methods

From the intensive care chest X-ray medical information market (MIMIC-CXR) database, 14 categories were obtained using natural language processing tags, among which 45,808 frontal chest radiographs were labeled as “atelectasis,” and 75,455 chest radiographs labeled “no finding.” A total of 60,000 images were extracted, including positive images labeled “atelectasis” and positive X-ray images labeled “no finding.” The data were categorized into “normal” and “atelectasis,” which were evenly distributed and randomly divided into three cohorts (training, validation, and testing) at a ratio of about 8:1:1. This retrospective study extracted 300 X-ray images labeled “atelectasis” and “normal” from patients in ICUs of The First Affiliated Hospital of Jinan University, which was labeled as an external dataset for verification in this experiment. Data set performance was evaluated using the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and positive predictive values derived from transfer learning training.

Results

It took 105 min and 6 s to train the internal training set. The AUC, sensitivity, specificity, and accuracy were 88.57, 75.10, 88.30, and 81.70%. Compared with the external validation set, the obtained AUC, sensitivity, specificity, and accuracy were 98.39, 70.70, 100, and 86.90%.

Conclusion

This study found that when detecting atelectasis, the model obtained by transfer training with sufficiently large data sets has excellent external verification and acculturate localization of lesions.

Effect of sigh in lateral position on postoperative atelectasis in adults assessed by lung ultrasound: a randomized, controlled trial

Background

Postoperative atelectasis occurs in 90% of patients receiving general anesthesia. Recruitment maneuvers (RMs) are not always effective and frequently associated with barotrauma and hemodynamic instability. It is reported that many natural physiological behaviors interrupted under general anesthesia could prevent atelectasis and restore lung aeration. This study aimed to find out whether a combined physiological recruitment maneuver (CPRM), sigh in lateral position, could reduce postoperative atelectasis using lung ultrasound (LUS).

Methods

We conducted a prospective, randomized, controlled trial in adults with open abdominal surgery under general anesthesia lasting for 2 h or longer. Subjects were randomly allocated to either control group (C-group) or CPRM-group and received volume-controlled ventilation with the same ventilator settings. Patients in CPRM group was ventilated in sequential lateral position, with the addition of periodic sighs to recruit the lung. LUS scores, dynamic compliance (Cdyn), the partial pressure of arterial oxygen (PaO₂) and fraction of inspired oxygen (FiO₂) ratio (PaO₂/FiO₂), and other explanatory variables were acquired from each patient before and after recruitment.

Results

Seventy patients were included in the analysis. Before recruitment, there was no significant difference in LUS scores, Cdyn and PaO₂/FiO₂ between CPRM-group and C-group. After recruitment, LUS scores in CPRM-group decreased significantly compared with C-group (6.00 [5.00, 7.00] vs. 8.00 [7.00, 9.00], p = 4.463e-11 < 0.05), while PaO₂/FiO₂ and Cdyn in CPRM-group increased significantly compared with C-group respectively (377.92 (93.73) vs. 309.19 (92.98), p = 0.008 < 0.05, and 52.00 [47.00, 60.00] vs. 47.70 [41.00, 59.50], p = 6.325e-07 < 0.05). No hemodynamic instability, detectable barotrauma or position-related complications were encountered.

Conclusions

Sigh in lateral position can effectively reduce postoperative atelectasis even without causing severe side effects. Further large-scale studies are necessary to evaluate it’s long-term effects on pulmonary complications and hospital length of stay.

Trial registration

ChiCTR1900024379. Registered 8 July 2019, 

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01748-9.

The effect of ultrasound-guided lung recruitment maneuvers on atelectasis in lung-healthy patients undergoing laparoscopic gynecologic surgery: a randomized controlled trial

BACKGROUND

Atelectasis is the primary cause of hypoxemia during general anesthesia. This study aimed to evaluate the impact of the combination of recruitment maneuvers (RM) and positive end-expiratory pressure (PEEP) on the incidence of atelectasis in adult women undergoing gynecologic laparoscopic surgery using pulmonary ultrasound.

METHODS

In this study, 42 patients with healthy lungs undergoing laparoscopic gynecologic surgery were randomly divided into the recruitment maneuver group (RM group; 6 cm H₂O PEEP and RM) or the control group (C group; 6 cm H₂O PEEP and no RM), 21 patients in each group. Volume-controlled ventilation was used in all selected patients, with a tidal volume of 6-8 mL·kg^-1 of ideal body weight. When atelectasis was detected, patients in the RM group received ultrasound-guided RM, while those in the C group received no intervention. The incidence and severity of atelectasis were determined using lung ultrasound scores.

RESULTS

A total of 41 patients were investigated. The incidence of atelectasis was lower in the RM group (40%) than in the C group (80%) 15 min after arrival in the post-anesthesia care unit (PACU). Meanwhile, lung ultrasound scores (LUSs) were lower in the RM group compared to the C group. In addition, the differences in the LUS between the two groups were mainly due to the differences in lung ultrasound scores in the posterior regions. However, this difference did not persist after 24 h of surgery.

CONCLUSIONS

In conclusion, the combination of RM and PEEP could reduce the incidence of atelectasis in patients with healthy lungs 15 min after arrival at the PACU; however, it disappeared within 24 h after surgery.

TRIAL REGISTRATION

(Prospectively registered): ChiCTR2000033529 . Registered on 4/6/2020.

An Update on Cardiorespiratory Physiotherapy during Mechanical Ventilation

Physiotherapists are integral members of the multidisciplinary team managing critically ill adult patients. However, the scope and role of physiotherapists vary widely internationally, with physiotherapists in some countries moving away from providing early and proactive respiratory care in the intensive care unit (ICU) and focusing more on early mobilization and rehabilitation. This article provides an update of cardiorespiratory physiotherapy for patients receiving mechanical ventilation in ICU. Common and some more novel assessment tools and treatment options are described, along with the mechanisms of action of the treatment options and the evidence and physiology underpinning them. The aim is not only to summarize the current state of cardiorespiratory physiotherapy but also to provide information that will also hopefully help support clinicians to deliver personalized and optimal patient care, based on the patient's unique needs and guided by accurate interpretation of assessment findings and the current evidence. Cardiorespiratory physiotherapy plays an essential role in optimizing secretion clearance, gas exchange, lung recruitment, and aiding with weaning from mechanical ventilation in ICU. The physiotherapists' skill set and scope is likely to be further optimized and utilized in the future as the evidence base continues to grow and they get more and more integrated into the ICU multidisciplinary team, leading to improved short- and long-term patient outcomes.

Assessment of 2D and 3D imaging for patients undergoing laparoscopic bariatric surgery

&lt;b&gt;Aim:&lt;/b&gt; The aim of this study is to compare the association of 2D and 3D imagery with technical performance and operative time during laparoscopic surgery. &lt;/br&gt;&lt;/br&gt; &lt;b&gt; Material and methods:&lt;/b&gt; A systematic review of the literature was conducted through an online search in databases such as PubMed, Cochrane, Embase and CNKI in order to identify articles published in English and Chinese from 2010 to 2020 that compared the clinical results of 2D and 3D laparoscopic gastric bypass surgery. &lt;/br&gt;&lt;/br&gt; &lt;b&gt; Results:&lt;/b&gt; A total of 50 articles were included in the qualitative analysis. Out of these, 5 articles that met the inclusion criteria were selected for analysis, according to which 3D laparoscopic surgery had a shorter surgery time than 2D laparoscopic surgery. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Conclusions:&lt;/b&gt; Compared with a 2D laparoscopic system, a 3D laparoscopic system can significantly reduce the operative time and errors and can increase the comfort of the surgeons performing laparoscopic gastric bypass surgery.

Expanding unilateral lung collapse using airway pressure release ventilation applied independently to the collapsed lung through the double-lumen endotracheal tube

Unilateral lung collapse (ULC) is a clinical challenge in the intensive care unit and requires sophisticated treatment approaches, especially if the collapse continued over several hours. If not responded to ordinary measures such as postural drainage and bronchoscopy, it may require insertion of a double-lumen endotracheal tube and independent lung ventilation or high-pressure manual re-expansion of the collapsed lung which may result in lung injury. In this article, a safe and gradual re-expansion method using airway pressure release ventilation is presented for the treatment of a ULC.

Assessment of Perioperative Atelectasis Using Lung Ultrasonography in Patients Undergoing Pneumoperitoneum Surgery in the Trendelenburg Position: Aspects of Differences according to Ventilatory Mode

BACKGROUND

During robotic gynecologic pneumoperitoneum surgery in the Trendelenburg position, aeration loss leads to perioperative atelectasis. Recently developed ventilator mode pressure-controlled ventilation volume-guaranteed (PCV-VG) mode could provide adequate ventilation with lower inspiratory pressure compared to volume-controlled ventilation (VCV); we hypothesized that PCV-VG mode may be beneficial in reducing perioperative atelectasis via low tidal volume (V_T) of 6 mL/kg ventilation during robotic gynecologic pneumoperitoneum surgery in the Trendelenburg position. We applied lung ultrasound score (LUS) for detecting perioperative atelectasis. We aimed to compare perioperative atelectasis between VCV and PCV-VG with a low V_T of 6 mL/kg during pneumoperitoneum surgery in the Trendelenburg position using LUS.

METHODS

Patients scheduled for robotic gynecologic surgery were randomly allocated to the VCV (n = 41) or PCV-VG group (n = 41). LUS, ventilatory, and hemodynamic parameters were evaluated at T1 (before induction), T2 (10 minutes after induction in the supine position), T3 (10 minutes after desufflation of CO₂ in the supine position), and T4 (30 minutes after emergence from anesthesia in the recovery room).

RESULTS

Eighty patients (40 with PCV-VG and 40 with VCV) were included. Demographic data showed no significant differences between the groups. The total LUS has changed from baseline to T4, 0.63 (95% confidence interval [CI], 0.32, 0.94) to 1.77 (95% CI, 1.42, 2.21) in the VCV group and 0.86 (95% CI, 0.56, 1.16) to 1.43 (95% CI, 1.08, 1.78) in the PCV-VG group (P = 0.170). In both groups, total LUS increased significantly compared to the baseline values.

CONCLUSION

Using a low V_T of 6 mL/kg during pneumoperitoneum surgery in the Trendelenburg position, our study showed no evidence that PCV-VG ventilation was superior to VCV in terms of perioperative atelectasis.

TRIAL REGISTRATION

Clinical Research Information Service Identifier: KCT0006404.

Physiotherapy Regimens in Esophagectomy and Gastrectomy: a Systematic Review and Meta-Analysis

Background

Esophageal and gastric cancer surgery are associated with considerable morbidity, specifically postoperative pulmonary complications (PPCs), potentially accentuated by underlying challenges with malnutrition and cachexia affecting respiratory muscle mass. Physiotherapy regimens aim to increase the respiratory muscle strength and may prevent postoperative morbidity.

Objective

The aim of this study was to assess the impact of physiotherapy regimens in patients treated with esophagectomy or gastrectomy.

Methods

An electronic database search was performed in the MEDLINE, EMBASE, CENTRAL, CINAHL and Pedro databases. A meta-analysis was performed to assess the impact of physiotherapy on the functional capacity, incidence of PPCs and postoperative morbidity, in-hospital mortality rate, length of hospital stay (LOS) and health-related quality of life (HRQoL).

Results

Seven randomized controlled trials (RCTs) and seven cohort studies assessing prehabilitation totaling 960 patients, and five RCTs and five cohort studies assessing peri- or postoperative physiotherapy with 703 total patients, were included. Prehabilitation resulted in a lower incidence of postoperative pneumonia and morbidity (Clavien–Dindo score ≥ II). No difference was observed in functional exercise capacity and in-hospital mortality following prehabilitation. Meanwhile, peri- or postoperative rehabilitation resulted in a lower incidence of pneumonia, shorter LOS, and better HRQoL scores for dyspnea and physical functioning, while no differences were found for the QoL summary score, global health status, fatigue, and pain scores.

Conclusion

This meta-analysis suggests that implementing an exercise intervention may be beneficial in both the preoperative and peri- or postoperative periods. Further investigation is needed to understand the mechanism through which exercise interventions improve clinical outcomes and which patient subgroup will gain the maximal benefit.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-11122-7.

The Effect of Balloon-Blowing Exercise on Postoperative Pulmonary Functions in Patients Undergoing Total Hip Arthroplasty

General anesthesia, prolonged immobilization, and pain may adversely affect pulmonary function in patients undergoing prosthetic surgery. The aim of this study was to evaluate the effect of balloon-blowing exercises on pulmonary functions in patients undergoing total hip arthroplasty. The patients in the experimental group performed three sets of balloon-blowing exercises in the morning, at noon, and in the evening on the first to third days postoperatively. The increase in forced vital capacity (FVC) values between the control and experimental groups in the postoperative period was statistically significant (p < .001), in favor of the experimental group. The increase in forced expiratory volume during the first second (FEV1)/FVC ratio was found to be significantly higher in the experimental group than in the control group (p < .001). Patients who performed balloon-blowing exercises increased their FVC and FEV1/FVC ratio.

Factors Associated with Occurrence of Atelectasis during Sedation for Imaging in Pediatric Patients: A Retrospective Single Center Cohort Study

Sedation can induce atelectasis which may cause suboptimal image quality. This study aimed to identify factors associated with the occurrence of atelectasis during sedation for imaging in pediatric patients. Patients < 18 years who had undergone whole-body magnetic resonance imaging (MRI) under sedation with propofol or dexmedetomidine were included in this study. The development of atelectasis was visually and quantitatively assessed by coronal short tau inversion recovery images of the thoracic level. Multivariable logistic regression was performed to identify the independent factors associated with the development of atelectasis. Ninety-one patients were included in the analysis. In the multivariable analysis, administration of supplemental oxygen was the only factor significantly associated with the occurrence of atelectasis (adjusted odds ratio, 4.84; 95% confidence interval, 1.48-15.83; p = 0.009). Univariable analysis showed that the use of dexmedetomidine was associated with a lower incidence of atelectasis; however, this could not be verified in the multivariable analysis. Among the pediatric patients who had undergone imaging under sedation, additional oxygen supplementation was the only independent factor associated with atelectasis occurrence. A prospective clinical trial is required to identify the cause-effect relationship between oxygen administration and occurrence of atelectasis during sedation.

Improving the use of the 'COUGH' bundle in Surgical High Dependency Unit, Ninewells Hospital, Dundee

Developing respiratory complications postoperatively is one of the major determinants of longer hospital stay, morbidity, mortality and increased healthcare costs. The incidence of postoperative respiratory complications varies from 1% to 23%. Given that postoperative respiratory complications are relatively common and costly, there have been various studies which look at ways to reduce the risk of these occurring. One such protocol is the ICOUGH bundle which stands for Incentive spirometry, Coughing and deep breathing, Oral care, patient Understanding, Getting out of bed and Head of bed elevation. This has been adapted locally to the Coughing and deep breathing, Oral care, patient Understanding, Getting out of bed and Head of bed elevation (COUGH) bundle which consists of these components excluding incentive spirometry. Within our surgical high dependency unit (HDU), the COUGH bundle should be implemented in patients who have a moderate or high risk of developing postoperative respiratory complications with an Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score of 26 or above. Studies have shown that the ICOUGH bundle has reduced rates of pneumonia and unplanned intubation in general surgical and vascular patients. Baseline data taken from surgical HDU showed that the COUGH bundle was not well implemented. One out of eight patients who had an ARISCAT score greater than 26 had the COUGH bundle implemented on admission to the unit. Three out of eight patients had the ARISCAT score documented in their admission medical review. One patient who should have received the bundle, but did not, developed a hospital acquired pneumonia postoperatively. To address this issue, we aimed to increase awareness surrounding the COUGH bundle and to increase the number of patients who had the COUGH bundle started on admission. This quality improvement project had four cycles (plan, do, study, act) and after these, 100% of patients who had an ARISCAT score of 26 or more had the COUGH bundle implemented.

Risk factor for lung infection in recipients after liver transplantation: A meta-analysis

Lung infection (LI) often occurs in patients with liver transplantation (LT). This meta-analysis was conducted to determine the risk factors associated with LI after LT. We retrieved relevant research published as of February 2020 from eight electronic databases. The studies were reviewed against the inclusion and exclusion criteria. The Z test was used to determine the combined odds ratio (OR) or the standardized mean difference (SMD) of the risk factors. We used the OR and its corresponding 95% confidence interval (CI) or the SMD and its corresponding 95% CI to identify significant differences in risk factors. A total of nine studies were included, comprising a total of 1624 recipients. Six risk factors associated with LI were identified after LT: Model for end-stage liver disease score (MELD score) (SMD = 0.40), Child-Pugh class C (OR = 3.00), intensive care unit (ICU) hospital stay (SMD = 1.35), mechanical ventilation (SMD = 1.03), bilirubin (SMD = 0.39), and atelectasis (OR = 7.28). Although certain risk factors have been identified as important factors for LI after LT, which may provide a basis for clinical prevention, a well-designed prospective study should be conducted to validate the findings of this study.

Effect of Lung Recruitment Maneuvers on Reduction of Atelectasis Determined by Lung Ultrasound in Patients More Than 60 Years Old Undergoing Laparoscopic Surgery for Colorectal Carcinoma: A Prospective Study at a Single Center

Background

Atelectasis occurs in patients of all ages during various surgeries. Previous studies have mainly focused on perioperative atelectasis in infants. However, research on the incidence of atelectasis among elderly patients, particularly those undergoing laparoscopic surgeries, is limited. Therefore, this prospective study aimed to investigate the effect of lung recruitment maneuvers (LRMs) on the reduction of atelectasis determined by lung ultrasound in patients more than 60 years old undergoing laparoscopic surgery for colorectal carcinoma.

Material/Methods

In this evaluator-blinded clinical study, 42 patients more than 60 years old diagnosed with colorectal carcinoma were randomly grouped either into a lung recruitment maneuver (RM) group or control (C) group. All patients were scheduled for laparoscopic surgery under general anesthesia using the lung-protective ventilation strategy. Lung ultrasonography was carried out at 3 predetermined time intervals. Patients in the RM group received ultrasound-guided recruitment maneuvers once atelectasis was discovered by lung ultrasound. Scores of lung ultrasound were used for assessing the severity of lung atelectasis.

Results

At the end of the operation, the occurrence of atelectasis was 100% in the RM group and 95% in the C group. After RMs, the frequency of atelectasis in the RM group and C group was 50% and 95%, respectively (P<0.01). Postoperative pulmonary complications were not different between the 2 groups.

Conclusions

At a single center, patients more than 60 years old undergoing laparoscopic surgery for colorectal carcinoma had a prevalence of lung atelectasis of 100% and although LRMs significantly reduced the incidence of pulmonary atelectasis, they did not improve postoperative pulmonary complications.

Pulmonary Aspiration During Induction of General Anesthesia

Perioperative pulmonary aspiration of gastric contents can induce complications of varying severity, including aspiration pneumonitis or pneumonia, which may be lethal. A 34-year-old man with no significant medical history presented to Okayama University Hospital for extraction of the third molars and incisive canal cystectomy under general anesthesia. He experienced pulmonary aspiration of clear stomach fluid during mask ventilation after induction. After aspiration occurred, the patient was immediately intubated, and suctioning was performed through the endotracheal tube (ETT). An anteroposterior (AP) chest radiograph was obtained that demonstrated atelectasis in the left lower lobe, in addition to increased peak airway pressures being noted, although SpO2 remained at 96% to 99% at an FiO2 of 1.0. The decision was made to proceed, and the scheduled procedures were completed in approximately 2 hours. A repeat AP chest radiograph obtained at the end of the operation revealed improvement of the atelectasis, and no residual atelectasis was observed on the next day. Although the patient reported following standard preoperative fasting instructions (no fluids for 2 hours preoperatively), more than 50 mL of clear fluid remained in his stomach. Because vomiting can occur despite following NPO guidelines, the need for continued vigilance by anesthesia providers and proper timely management is reinforced.

Effect of Dexmedetomidine Hydrochloride on perioperative inflammation and postoperative lung infection in patients with spinal tuberculosis

Objective

To explore the effect of dexmedetomidine hydrochloride on perioperative inflammation and postoperative lung infection in patients with spinal tuberculosis.

Method

A double-blind control observation was conducted in spinal tuberculosis patients with the use of general anesthesia during the operation. A total of 171 spinal tuberculosis patients who received endotracheal intubation for general anesthesia in Henan University of Chinese Medicine from January 2017 to April 2019 were included. The concentration changes in serum TNF-α and IL-6 were recorded at one hour, six hour and one day after the operation. The incidence of postoperative pulmonary complications of patients were also evaluated.

Results

The results showed that in the experimental group compared with the control group, serum TNF-α and IL-6 concentrations one hour, six hour and one day after the operation were significantly lower (P<0.05). The rate of postoperative pulmonary complications was lower in the experimental group than that in the control group (P<0.05).

Conclusion

Dexmedetomidine hydrochloride has obvious anti-inflammatory effects and can reduce the incidence of pulmonary complications after surgery.

Is postoperative atelectasis following lumbar fusion more prevalent among patients with chronic opioid use?

OBJECTIVE

Chronic opioid use (COU) remains on the rise globally, acting as a marker for patient morbidity and a risk factor for adverse health outcomes. Opioid use is a risk factor for respiratory depression, which may lead to dysfunctional breathing, a known cause of atelectasis. The objective of this study was to determine whether COU is associated with increased rates of postoperative atelectasis among patients undergoing lumbar fusion.

MATERIALS & METHODS

Three State Inpatient Databases were used to identify patients who underwent an elective lumbar fusion through an anterior, posterior or circumferential approach in Florida, Kentucky and New York between 2013-2015. Patients with COU and those with postoperative atelectasis were identified using ICD diagnosis codes. Three operative groups were created and subsequently matched using propensity scores in order to provide comparable cohorts for analysis. Three-to-one propensity score matching was conducted using the variables of age, sex, race, number of chronic diagnoses and geographic state of admission. Multivariable logistic regressions were used to examine the relationship between COU and postoperative atelectasis.

RESULTS

A total of 3618 lumbar fusions were identified. Atelectasis was noted in 1.33 % of NCOU patients and 2.32 % of COU patients. On multivariable analysis, while controlling for the Elixhauser Mortality Index and patient insurance status, COU was significantly associated with atelectasis in posterior lumbar fusion (OR = 2.27; CI: 1.09-4.72; p = 0.028) and circumferential lumbar fusion (OR = 4.68; CI: 1.52-14.45; p = 0.007). The Elixhauser Mortality Index was also significantly associated with atelectasis in posterior lumbar fusion (OR = 1.08; CI: 1.04-1.11; p < 0.001) and circumferential lumbar fusion (OR = 1.09; CI: 1.03-1.16; p = 0.002).

CONCLUSION

Higher rates of postoperative atelectasis were found among patients with COU following posterior and circumferential lumbar fusions. The Elixhauser Mortality Index was also independently associated with atelectasis. Knowledge of these risks may allow for earlier identification and intervention in patients who are at risk.

Association between Charlson comorbidity index and complications of endoscopic resection of gastric neoplasms in elderly patients

Background

Although endoscopic resection is safe and effective for gastric epithelial neoplasms, information is limited on its efficacy and safety in extremely elderly patients who have various comorbidities. Further, the relationship between comorbidities and complications of endoscopic resection is not well established. Therefore, we aimed to evaluate the efficacy and safety of endoscopic resection of gastric epithelial neoplasms in extremely elderly patients.

Methods

From October 2008 to December 2017, 4475 consecutive patients underwent endoscopic resection of gastric epithelial neoplasms. Among them, 242 were 75 years or older. We assessed Charlson comorbidity index (CCI) scores, procedural outcomes, and procedure- and sedation-related complications related to endoscopic resection.

Results

Mean patient age was 78.7 ± 3.2 years. Of the 242 patients, 124 (51.2%) had low-grade dysplasia and 112 (46.3%) had adenocarcinoma. The most common comorbidity was hypertension (55.4%), followed by diabetes (23.1%). The mean CCI score was 1.67 ± 1.43. Sixty patients (24.8%) had a CCI score ≥ 3. During the procedure, 10 (4.1%) patients had desaturation that recovered by flumazenil use with mask (n = 2) or Ambu bag (n = 3) ventilation. During subsequent admission, atelectasis or pneumonia occurred in 45 (18.6%) patients, post-procedural bleeding in 12 (5.0%), and perforation in 3 (1.2%). Respiratory complications were more common in patients with a CCI score ≥ 3 (20/60, 33.3%) than in those with a CCI score < 3 (25/182, 13.7%, P = 0.002).

Conclusions

CCI score is related to respiratory complications of endoscopic resection in extremely elderly patients. Endoscopic resection must be performed cautiously, particularly in elderly patients with a high CCI score, to prevent respiratory complications.

Effect of positive end-expiratory pressure on gastric insufflation during induction of anaesthesia when using pressure-controlled ventilation via a face mask: A randomised controlled trial

BACKGROUND

Face mask ventilation (FMV) during induction of anaesthesia is associated with risk of gastric insufflation that may lead to gastric regurgitation and pulmonary aspiration. A continuous positive airway pressure (CPAP) has been shown to reduce gastric regurgitation. We therefore hypothesised that CPAP followed by FMV with positive end-expiratory pressure (PEEP) during induction of anaesthesia would reduce the risk of gastric insufflation.

OBJECTIVE

The primary aim was to compare the incidence of gastric insufflation during FMV with a fixed PEEP level or zero PEEP (ZEEP) after anaesthesia induction. A secondary aim was to investigate the effects of FMV with or without PEEP on upper oesophageal sphincter (UES), oesophageal body and lower oesophageal sphincter (LES) pressures.

DESIGN

A randomised controlled trial.

SETTING

Single centre, Department of Anaesthesia and Intensive Care, Örebro University Hospital, Sweden.

PARTICIPANTS

Thirty healthy volunteers.

INTERVENTIONS

Pre-oxygenation without or with CPAP 10 cmH₂O, followed by pressure-controlled FMV with either ZEEP or PEEP 10 cmH₂O after anaesthesia induction.

MAIN OUTCOME MEASURES

A combined impedance/manometry catheter was used to detect the presence of gas and to measure oesophageal pressures. The primary outcome measure was the cumulative incidence of gastric insufflation, defined as a sudden anterograde increase in impedance of more than 1 kΩ over the LES. Secondary outcome measures were UES, oesophageal body and LES pressures.

RESULTS

The cumulative incidence of gastric insufflation related to peak inspiratory pressure (PIP), was significantly higher in the PEEP group compared with the ZEEP group (log-rank test P < 0.01). When PIP reached 30 cmH₂O, 13 out of 15 in the PEEP group compared with five out of 15 had shown gastric insufflation. There was a significant reduction of oesophageal sphincter pressures within groups comparing pre-oxygenation to after anaesthesia induction, but there were no significant differences in oesophageal sphincter pressures related to the level of PEEP.

CONCLUSION

Contrary to the primary hypothesis, with increasing PIP the tested PEEP level did not protect against but facilitated gastric insufflation during FMV. This result suggests that PEEP should be used with caution after anaesthesia induction during FMV, whereas CPAP during pre-oxygenation seems to be safe.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT02238691.

Efficacy of Oscillation and Lung Expansion in Reducing Postoperative Pulmonary Complication

BACKGROUND

Postoperative pulmonary complications (PPCs) cause high morbidity and mortality. Targeted treatment for patients at risk for PPCs can improve outcomes. This multicenter prospective trial examined the impact of oscillation and lung expansion (OLE) therapy, using continuous high-frequency oscillation and continuous positive expiratory pressure on PPCs in high-risk patients.

METHODS

In stage I, CPT and ICD codes were queried for patients (n = 210) undergoing thoracic, upper abdominal, or aortic open procedures at 3 institutions from December 2014 to April 2016. Patients were selected randomly. Age, comorbidities, American Society of Anesthesiologists physical status classification scores, and PPC rates were determined. In stage II, 209 subjects were enrolled prospectively from October 2016 to July 2017 using the same criteria. Stage II subjects received OLE treatment and standard respiratory care. The PPCs rate (prolonged ventilation, high-level respiratory support, pneumonia, ICU readmission) were compared. We also compared ICU length of stay (LOS), hospital LOS, and mortality using t-tests and analysis of covariance. Data are mean ± SD.

RESULTS

There were 419 subjects. Stage II patients were older (61.1 ± 13.7 years vs 57.4 ± 15.5 years; p < 0.05) and had higher American Society of Anesthesiologists scores. Treatment with OLE decreased PPCs from 22.9% (stage I) to 15.8% (stage II) (p < 0.01 adjusted for age, American Society of Anesthesiologists score, and operation time). Similarly, OLE treatment reduced ventilator time (23.7 ± 107.5 hours to 8.5 ± 27.5 hours; p < 0.05) and hospital LOS (8.4 ± 7.9 days to 6.8 ± 5.0 days; p < 0.05). No differences in ICU LOS, pneumonia, or mortality were observed.

CONCLUSIONS

Aggressive treatment with OLE reduces PPCs and resource use in high-risk surgical patients.

What are the optimum components in a care bundle aimed at reducing post-operative pulmonary complications in high-risk patients?

Background

Post-operative pulmonary complications (POPC) are common, predictable and associated with increased morbidity and mortality, independent of pre-operative risk. Interventions to reduce the incidence of POPC have been studied individually, but the use of a care bundle has not been widely investigated. The purpose of our work was to use Delphi consensus methodology and an independently chosen expert panel to formulate a care bundle for patients identified as being at high of POPC, as preparation towards an evaluation of its effectiveness at reducing POPC.

Methods

We performed a survey of members of the ESICM POIC section to inform a Delphi consensus and to share their opinions on a care bundle to reduce POPC, the POPC-CB. We formed a team of 36 experts to participate in and complete an email-based Delphi consensus over three rounds, leading to the formulation of the POPC-CB.

Results

The survey had 362 respondents and informed the design of the Delphi consensus. The Delphi consensus resulted in a proposed POPC-CB that incorporates components before surgery-supervised exercise programmes and inspiratory muscle training, during surgery, low tidal volume ventilation with individualised PEEP (positive end-expiratory pressure), use of routine monitoring to avoid hyperoxia and efforts made to limit neuromuscular blockade, and post-operatively, deep breathing exercises and elevation of the head of the bed.

Conclusion

A care bundle has been suggested for evaluation in surgical patients at high risk of POPC. Evaluation of feasibility of both implementation and effectiveness is now indicated.

Performance of Lung Ultrasound in Detecting Peri-Operative Atelectasis after General Anesthesia

The aim of this prospective observational study was to evaluate the performance of lung ultrasound (LUS) in detecting post-operative atelectasis in adult patients under general anesthesia. Forty-six patients without pulmonary comorbidities who were scheduled for elective neurosurgery were enrolled in the study. A total of 552 pairs of LUS clips and thoracic computed tomography (CT) images were ultimately analyzed to determine the presence of atelectasis in 12 prescribed lung regions. The accuracy of LUS in detecting peri-operative atelectasis was evaluated with thoracic CT as gold standard. Levels of agreement between the two observers for LUS and the two observers for thoracic CT were analyzed using the κ reliability test. The quantitative correlation between LUS scores of aeration and the volumetric data of atelectasis in thoracic CT were further evaluated. LUS had reliable performance in post-operative atelectasis, with a sensitivity of 87.7%, specificity of 92.1% and diagnostic accuracy of 90.8%. The levels of agreement between the two observers for LUS and for thoracic CT were both satisfactory, with κ coefficients of 0.87 (p < 0.0001) and 0.93 (p < 0.0001), respectively. In patients in the supine position, LUS scores were highly correlated with the atelectasis volume of CT (r = 0.58, p < 0.0001). Thus, LUS provides a fast, reliable and radiation-free method to identify peri-operative atelectasis in adults.