Management of Intraoperative Mechanical Ventilation to Prevent Postoperative Complications after General Anesthesia: A Narrative Review

Fogagnolo, Alberto; Montanaro, Federica; Al-Husinat, Lou’i; Turrini, Cecilia; Rauseo, Michela; Mirabella, Lucia; Ragazzi, Riccardo; Ottaviani, Irene; Cinnella, Gilda; Volta, Carlo Alberto; Spadaro, Savino

doi:10.3390/jcm10122656

Cited by 11 publications

(10 citation statements)

References 133 publications

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“…We were unable to analyze some variables of interest, such as operative plateau pressure and minute-to-minute documentation of all ventilator settings due to missing documentation and limited resources for manual data abstraction. Lung protective lung ventilation involves multiple ventilator parameters, their interaction with the patient’s physiology, and surgical factors (e.g., laparoscopic surgery with pneumoperitoneum, Trendelenburg position, body habitus) [ 67 ]. The rare nature of PRF also makes analysis complex.…”

Section: Discussionmentioning

confidence: 99%

Outcomes and risk factors for delayed-onset postoperative respiratory failure: a multi-center case-control study by the University of California Critical Care Research Collaborative (UC3RC)

et al. 2022

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Background Few interventions are known to reduce the incidence of respiratory failure that occurs following elective surgery (postoperative respiratory failure; PRF). We previously reported risk factors associated with PRF that occurs within the first 5 days after elective surgery (early PRF; E-PRF); however, PRF that occurs six or more days after elective surgery (late PRF; L-PRF) likely represents a different entity. We hypothesized that L-PRF would be associated with worse outcomes and different risk factors than E-PRF. Methods This was a retrospective matched case-control study of 59,073 consecutive adult patients admitted for elective non-cardiac and non-pulmonary surgical procedures at one of five University of California academic medical centers between October 2012 and September 2015. We identified patients with L-PRF, confirmed by surgeon and intensivist subject matter expert review, and matched them 1:1 to patients who did not develop PRF (No-PRF) based on hospital, age, and surgical procedure. We then analyzed risk factors and outcomes associated with L-PRF compared to E-PRF and No-PRF. Results Among 95 patients with L-PRF, 50.5% were female, 71.6% white, 27.4% Hispanic, and 53.7% Medicare recipients; the median age was 63 years (IQR 56, 70). Compared to 95 matched patients with No-PRF and 319 patients who developed E-PRF, L-PRF was associated with higher morbidity and mortality, longer hospital and intensive care unit length of stay, and increased costs. Compared to No-PRF, factors associated with L-PRF included: preexisiting neurologic disease (OR 4.36, 95% CI 1.81–10.46), anesthesia duration per hour (OR 1.22, 95% CI 1.04–1.44), and maximum intraoperative peak inspiratory pressure per cm H20 (OR 1.14, 95% CI 1.06–1.22). Conclusions We identified that pre-existing neurologic disease, longer duration of anesthesia, and greater maximum intraoperative peak inspiratory pressures were associated with respiratory failure that developed six or more days after elective surgery in adult patients (L-PRF). Interventions targeting these factors may be worthy of future evaluation.

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Section: Discussionmentioning

confidence: 99%

Outcomes and risk factors for delayed-onset postoperative respiratory failure: a multi-center case-control study by the University of California Critical Care Research Collaborative (UC3RC)

et al. 2022

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“…Considering the formula for calculating MP, it can be considered that increasing the respiratory rate to maintain normocapnia, as in our study, resulted in an increase in MP in the normocapnia group during CO 2 pneumoperitoneum. Although there is insufficient clinical evidence to simply compare the meaning of ventilator-induced lung injury or mechanical power in patients under general anesthesia with healthy lungs and critically ill patients with lung injury receiving ventilator care, it is necessary to consider the fact that the respiratory rate, which is often neglected, may have a negative effect on the lungs or induce ventilatorinduced lung injury [26]. Therefore, it is worth noting that the load on the lungs can be reduced by allowing mild hypercapnia rather than excessively setting the respiratory rate to maintain normocapnia.…”

Section: Discussionmentioning

confidence: 99%

Comparison of the Effects of Normocapnia and Mild Hypercapnia on the Optic Nerve Sheath Diameter and Regional Cerebral Oxygen Saturation in Patients Undergoing Gynecological Laparoscopy with Total Intravenous Anesthesia

Park

Jung

Park

et al. 2021

JCM

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Cerebral hemodynamics may be altered by hypercapnia during a lung-protective ventilation (LPV), CO2 pneumoperitoneum, and Trendelenburg position during general anesthesia. The purpose of this study was to compare the effects of normocapnia and mild hypercapnia on the optic nerve sheath diameter (ONSD), regional cerebral oxygen saturation (rSO2), and intraoperative respiratory mechanics in patients undergoing gynecological laparoscopy under total intravenous anesthesia (TIVA). Sixty patients (aged between 19 and 65 years) scheduled for laparoscopic gynecological surgery in the Trendelenburg position. Patients under propofol/remifentanil total intravenous anesthesia were randomly assigned to either the normocapnia group (target PaCO2 = 35 mmHg, n = 30) or the hypercapnia group (target PaCO2 = 50 mmHg, n = 30). The ONSD, rSO2, and respiratory and hemodynamic parameters were measured at 5 min after anesthetic induction (Tind) in the supine position, and at 10 min and 40 min after pneumoperitoneum (Tpp10 and Tpp40, respectively) in the Trendelenburg position. There was no significant intergroup difference in change over time in the ONSD (p = 0.318). The ONSD increased significantly at Tpp40 when compared to Tind in both normocapnia and hypercapnia groups (p = 0.02 and 0.002, respectively). There was a significant intergroup difference in changes over time in the rSO2 (p < 0.001). The rSO2 decreased significantly in the normocapnia group (p = 0.01), whereas it increased significantly in the hypercapnia group at Tpp40 compared with Tind (p = 0.002). Alveolar dead space was significantly higher in the normocapnia group than in the hypercapnia group at Tpp40 (p = 0.001). In conclusion, mild hypercapnia during the LPV might not aggravate the increase in the ONSD during CO2 pneumoperitoneum in the Trendelenburg position and could improve rSO2 compared to normocapnia in patients undergoing gynecological laparoscopy with TIVA.

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“…Mechanical ventilation increases the risk of ventilatorinduced lung injuries such as barotrauma and increased vascular permeability [1]. Pulmonary complications, such as pneumonia and atelectasis, can be caused by intraoperative mechanical ventilation [2,3]. In particular, prolonged mechanical ventilation (PMV) is associated with a high mortality rate, the occurrence of pulmonary complications, prolonged hospitalization, and an unfavorable discharge destination [4][5][6].…”

Section: Introductionmentioning

confidence: 99%

“…Intraoperative mechanical ventilation and lung, cardiac, or abdominal surgery may lead to postoperative lung complications [2,3,[8][9][10][11], and bed rest causes a decline in muscle strength and respiratory functionality [12]; therefore, pre-and postoperative rehabilitation protocols are important for risk reduction and management of acute pulmonary complications and muscle loss [13,14]. However, there have been few studies examining interventions for rehabilitation of chronic pulmonary complications caused by PMV.…”

Section: Introductionmentioning

confidence: 99%

Effect of positioning and expiratory rib-cage compression on atelectasis in a patient who required prolonged mechanical ventilation: a case report

Hosoe¹,

Tanaka²,

Hamasaki³

et al. 2022

J Med Case Reports

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Background Pulmonary complications can be caused by intraoperative mechanical ventilation. In particular, prolonged mechanical ventilation is associated with a high mortality rate, a risk of pulmonary complications, prolonged hospitalization, and an unfavorable discharge destination. Pre- and postoperative rehabilitation are important for the resolution of pulmonary complications in acute cases. However, there has been a lack of studies on interventions for pulmonary rehabilitation of patients with chronic pulmonary complications caused by prolonged mechanical ventilation. Accordingly, we describe the effect of pulmonary rehabilitation in such a patient. Case presentation We examined a 63-year-old Japanese woman with hypoxic–ischemic encephalopathy after subarachnoid hemorrhage who required prolonged mechanical ventilation. Radiographic and computed tomographic images revealed atelectasis of the right upper lobe. In addition, this atelectasis reduced the tidal volume, minute volume, and oxygen saturation and caused an absence of breath sounds in the right upper lobe during auscultation. We aimed to ameliorate the patient’s atelectasis and improve her ventilation parameters by using positioning and expiratory rib-cage compression after endotracheal suctioning. Specifically, the patient was seated in Fowler’s position, and mild pressure was applied to the upper thorax during expiration, improving her inspiratory volume. Immediately, breath sounds were audible in the right upper lobe. Furthermore, resolution of the patient’s atelectasis was confirmed with chest radiography performed on the same day. In addition, her ventilation parameters (tidal volume, minute volume, and oxygen saturation) improved. Conclusions Our results indicate that physical therapists should consider application of specific positioning and expiratory rib-cage compression in patients who exhibit atelectasis because of prolonged mechanical ventilation.

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Management of Intraoperative Mechanical Ventilation to Prevent Postoperative Complications after General Anesthesia: A Narrative Review

Cited by 11 publications

References 133 publications

Outcomes and risk factors for delayed-onset postoperative respiratory failure: a multi-center case-control study by the University of California Critical Care Research Collaborative (UC3RC)

Outcomes and risk factors for delayed-onset postoperative respiratory failure: a multi-center case-control study by the University of California Critical Care Research Collaborative (UC3RC)

Comparison of the Effects of Normocapnia and Mild Hypercapnia on the Optic Nerve Sheath Diameter and Regional Cerebral Oxygen Saturation in Patients Undergoing Gynecological Laparoscopy with Total Intravenous Anesthesia

Effect of positioning and expiratory rib-cage compression on atelectasis in a patient who required prolonged mechanical ventilation: a case report

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