Perioperative anaesthetic management of patients with or at risk of acute distress respiratory syndrome undergoing emergency surgery

Abstract

Patients undergoing emergency surgery may present with the acute respiratory distress syndrome (ARDS) or develop this syndrome postoperatively. The incidence of ARDS in the postoperative period is relatively low, but the impact of ARDS on patient outcomes and healthcare costs is relevant [1]. The development of ARDS as a postoperative pulmonary complication (PPC) is associated with prolonged hospitalisation, longer duration of mechanical ventilation, increased intensive care unit length of stay and high morbidity and mortality [2]. In order to mitigate the risk of ARDS after surgery, the anaesthetic management and protective mechanical ventilation strategies play an important role. In particular, a careful integration of general anaesthesia with neuraxial or locoregional techniques might promote faster recovery and reduce opioid consumption. In addition, the use of low tidal volume, minimising plateau pressure and titrating a low-moderate PEEP level based on the patient’s need can improve outcome and reduce intraoperative adverse events. Moreover, perioperative management of ARDS patients includes specific anaesthesia and ventilator settings, hemodynamic monitoring, moderately restrictive fluid administration and pain control. The aim of this review is to provide an overview and evidence- and opinion-based recommendations concerning the management of patients at risk of and with ARDS who undergo emergency surgical procedures.

Severe Acute Respiratory Syndrome Coronavirus-2 Cardiovascular Complications: Implications for Cardiothoracic Anesthesiology

“…These recommendations include lung-protective ventilation (LPV) strategies (discussed in the following), restrictive fluid management, judicious use of blood products, minimization of opioids, and the use of neuromuscular blocking drugs to help with patient-ventilator asynchrony and high peak airway pressures (Fig 1). 99,100 For patients with persistent hypoxia, advanced therapies may be needed. Prone positioning should be considered in moderate-to-severe ARDS.…”

“…The most important recommendation is to maintain a tidal volume 6to-8 mL/kg of predicted body weight. 100,104 For patients with definitive ARDS, a tidal volume of 4-to-6 mL/kg predicted body weight is recommended. 99 Positive end-expiratory pressure is beneficial, but the exact amount is not agreed on.…”

“…In general, starting with a low level (ie, 5 cmH 2 O) and gradually increasing the amount in an individualized fashion to improve oxygenation is recommended. 99,100,104 Maintaining plateau pressures as low as possible also is important, with a goal of 27to-30 cmH 2 O. Recruitment maneuvers generally should be used only as a rescue therapy when other interventions have failed.…”

“…Recruitment maneuvers generally should be used only as a rescue therapy when other interventions have failed. 99,100 The end goal of these interventions is to maintain an oxygen saturation of 88% to 90%. 99…”