Intra-operative adherence to lung-protective ventilation: a prospective observational study

Patel, Jaimin; Baker, R.H.J.; Yeung, Joyce; Small, Charlotte

doi:10.1186/s13741-016-0033-4

Cited by 18 publications

(13 citation statements)

References 31 publications

(47 reference statements)

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“…All patients in this study received many of the elements of lung protective ventilation, and, in this context, the additive benefit of optimising positive end expiratory pressure may not be apparent. Although lung protective ventilation is a particularly attractive intervention, as it has no associated financial cost, the fidelity of its implementation in routine practice (as described in large scale audit data from the US and the UK134135136) is often disappointing.…”

Section: Discussionmentioning

confidence: 99%

Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis

Odor

Bampoe

Gilhooly

et al. 2020

BMJ

136

120

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OBJECTIVE To identify, appraise, and synthesise the best available evidence on the efficacy of perioperative interventions to reduce postoperative pulmonary complications (PPCs) in adult patients undergoing non-cardiac surgery. DESIGNSystematic review and meta-analysis of randomised controlled trials. DATA SOURCESMedline, Embase, CINHAL, and CENTRAL from January 1990 to December 2017. ELIGIBILITY CRITERIARandomised controlled trials investigating short term, protocolised medical interventions conducted before, during, or after non-cardiac surgery were included. Trials with clinical diagnostic criteria for PPC outcomes were included. Studies of surgical technique or physiological or biochemical outcomes were excluded. DATA EXTRACTION AND SYNTHESISReviewers independently identified studies, extracted data, and assessed the quality of evidence. Metaanalyses were conducted to calculate risk ratios with 95% confidence intervals. Quality of evidence was summarised in accordance with GRADE methods. The primary outcome was the incidence of PPCs. Secondary outcomes were respiratory infection, atelectasis, length of hospital stay, and mortality. Trial sequential analysis was used to investigate the reliability and conclusiveness of available evidence. Adverse effects of interventions were not measured or compared. RESULTS117 trials enrolled 21 940 participants, investigating 11 categories of intervention. 95 randomised controlled trials enrolling 18 062 participants were included in meta-analysis; 22 trials were excluded from meta-analysis because the interventions were not sufficiently similar to be pooled. No high quality evidence was found for interventions to reduce the primary outcome (incidence of PPCs). Seven interventions had low or moderate quality evidence with confidence intervals indicating a probable reduction in PPCs: enhanced recovery pathways (risk ratio 0.35, 95% confidence interval 0.21 to 0.58), prophylactic mucolytics (0.40, 0.23 to 0.67), postoperative continuous positive airway pressure ventilation (0.49, 0.24 to 0.99), lung protective intraoperative ventilation (0.52, 0.30 to 0.88), prophylactic respiratory physiotherapy (0.55, 0.32 to 0.93), epidural analgesia (0.77, 0.65 to 0.92), and goal directed haemodynamic therapy (0.87, 0.77 to 0.98). Moderate quality evidence showed no benefit for incentive spirometry in preventing PPCs. Trial sequential analysis adjustment confidently supported a relative risk reduction of 25% in PPCs for prophylactic respiratory physiotherapy, epidural analgesia, enhanced recovery pathways, and goal directed haemodynamic therapies. Insufficient data were available to support or refute equivalent relative risk reductions for other interventions. CONCLUSIONSPredominantly low quality evidence favours multiple perioperative PPC reduction strategies. Clinicians may choose to reassess their perioperative care pathways, but the results indicate that new trials with a low risk of bias are needed to obtain conclusive evidence of efficacy for many of these interventions. STUDY REGIS...

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Section: Discussionmentioning

confidence: 99%

Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis

Odor

Bampoe

Gilhooly

et al. 2020

BMJ

136

120

View full text Add to dashboard Cite

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“…It is defined as “the delivery of a tidal volume between 6 and 8 ml/kg/predicted body weight, a peak pressure of less than 30 cmH2O, and the use of positive end expiratory pressure of 6-8 cmH2O” (Patel et al 2016). In a meta-analysis of 15 studies, the authors found a dose-response curve between the size of tidal volume and pulmonary complications (Serpa Neto et al 2015).…”

Section: Methodsmentioning

confidence: 99%

American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on prevention of postoperative infection within an enhanced recovery pathway for elective colorectal surgery

Holubar

Hedrick²,

Gupta

et al. 2017

Perioper Med

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BackgroundColorectal surgery (CRS) patients are an at-risk population who are particularly vulnerable to postoperative infectious complications. Infectious complications range from minor infections including simple cystitis and superficial wound infections to life-threatening situations such as lobar pneumonia or anastomotic leak with fecal peritonitis. Within an enhanced recovery pathway (ERP), there are multiple approaches that can be used to reduce the risk of postoperative infections.MethodsWith input from a multidisciplinary, international group of experts and through a focused (non-systematic) review of the literature, and use of a modified Delphi method, we achieved consensus surrounding the topic of prevention of postoperative infection in the perioperative period for CRS patients.DiscussionAs a part of the first Perioperative Quality Initiative (POQI-1) workgroup meeting, we sought to develop a consensus statement describing a comprehensive, yet practical, approach for reducing postoperative infections, specifically for CRS within an ERP. Surgical site infection (SSI) is the most common postoperative infection. To reduce SSI, we recommend routine use of a combined isosmotic mechanical bowel preparation with oral antibiotics before elective CRS and that infection prevention strategies (also called bundles) be routinely implemented as part of colorectal ERPs. We recommend against routine use of abdominal drains. We also give consensus guidelines for reducing pneumonia, urinary tract infection, and central line-associated bloodstream infection (CLABSI).

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“…Levin and colleagues 64 noted a significant reduction from 9 to 8.3 ml kg À1 (P¼0.01) between 2008 and 2011, and a prospective study of 406 patients in the UK in 2016 showed median tidal volumes of 8.4 ml kg À1 predicted body weight. 115 Extremes of weight and female sex are risk factors for inadvertent high-volume ventilation. 113 116 It must be emphasized that VT in these studies is always set based on predicted or ideal body weight rather than real weight.…”

Section: Low Tidal Volumementioning

confidence: 99%

Postoperative pulmonary complications

Miskovic

Lumb

2017

British Journal of Anaesthesia

753

596

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Postoperative pulmonary complications (PPCs) are common, costly, and increase patient mortality. Changes to the respiratory system occur immediately on induction of general anaesthesia: respiratory drive and muscle function are altered, lung volumes reduced, and atelectasis develops in > 75% of patients receiving a neuromuscular blocking drug. The respiratory system may take 6 weeks to return to its preoperative state after general anaesthesia for major surgery. Risk factors for PPC development are numerous, and clinicians should be aware of non-modifiable and modifiable factors in order to recognize those at risk and optimize their care. Many validated risk prediction models are described. These have been useful for improving our understanding of PPC development, but there remains inadequate consensus for them to be useful clinically. Preventative measures include preoperative optimization of co-morbidities, smoking cessation, and correction of anaemia, in addition to intraoperative protective ventilation strategies and appropriate management of neuromuscular blocking drugs. Protective ventilation includes low tidal volumes, which must be calculated according to the patient's ideal body weight. Further evidence for the most beneficial level of PEEP is required, and on-going randomized trials will hopefully provide more information. When PEEP is used, it may be useful to precede this with a recruitment manoeuvre if atelectasis is suspected. For high-risk patients, surgical time should be minimized. After surgery, nasogastric tubes should be avoided and analgesia optimized. A postoperative mobilization, chest physiotherapy, and oral hygiene bundle reduces PPCs.

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Intra-operative adherence to lung-protective ventilation: a prospective observational study

Cited by 18 publications

References 31 publications

Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis

Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis

American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on prevention of postoperative infection within an enhanced recovery pathway for elective colorectal surgery

Postoperative pulmonary complications

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