Explore the vast range of titles available.

The perioperative use and relevance of protective ventilation in surgical patients is being increasingly recognized. Obesity poses particular challenges to adequate mechanical ventilation in addition to surgical constraints, primarily by restricted lung mechanics due to excessive adiposity, frequent respiratory comorbidities (i.e. sleep apnea, asthma), and concerns of postoperative respiratory depression and other pulmonary complications. The number of surgical patients with obesity is increasing, and facing these challenges is common in the operating rooms and critical care units worldwide. In this review we summarize the existing literature which supports the following recommendations for the perioperative ventilation in obese patients: (1) the use of protective ventilation with low tidal volumes (approximately 8 mL/kg, calculated based on predicted -not actual- body weight) to avoid volutrauma; (2) a focus on lung recruitment by utilizing PEEP (8–15 cmH 2 O) in addition to recruitment maneuvers during the intraoperative period, as well as incentivized deep breathing and noninvasive ventilation early in the postoperative period, to avoid atelectasis, hypoxemia and atelectrauma; and (3) a judicious oxygen use (ideally less than 0.8) to avoid hypoxemia but also possible reabsorption atelectasis. Obesity poses an additional challenge for achieving adequate protective ventilation during one-lung ventilation, but different lung isolation techniques have been adequately performed in obese patients by experienced providers. Postoperative efforts should be directed to avoid hypoventilation, atelectasis and hypoxemia. Further studies are needed to better define optimum protective ventilation strategies and analyze their impact on the perioperative outcomes of surgical patients with obesity.

Background It is uncertain whether the association of the intraoperative driving pressure (ΔP) with postoperative pulmonary complications (PPCs) depends on the surgical approach during abdominal surgery. Our primary objective was to determine and compare the association of time–weighted average ΔP (ΔP TW ) with PPCs. We also tested the association of ΔP TW with intraoperative adverse events. Methods Posthoc retrospective propensity score–weighted cohort analysis of patients undergoing open or closed abdominal surgery in the ‘Local ASsessment of Ventilatory management during General Anaesthesia for Surgery’ (LAS VEGAS) study, that included patients in 146 hospitals across 29 countries. The primary endpoint was a composite of PPCs. The secondary endpoint was a composite of intraoperative adverse events. Results The analysis included 1128 and 906 patients undergoing open or closed abdominal surgery, respectively. The PPC rate was 5%. ΔP was lower in open abdominal surgery patients, but ΔP TW was not different between groups. The association of ΔP TW with PPCs was significant in both groups and had a higher risk ratio in closed compared to open abdominal surgery patients (1.11 [95%CI 1.10 to 1.20], P  <  0.001 versus 1.05 [95%CI 1.05 to 1.05], P  <  0.001; risk difference 0.05 [95%CI 0.04 to 0.06], P  <  0.001). The association of ΔP TW with intraoperative adverse events was also significant in both groups but had higher odds ratio in closed compared to open abdominal surgery patients (1.13 [95%CI 1.12– to 1.14], P  <  0.001 versus 1.07 [95%CI 1.05 to 1.10], P  <  0.001; risk difference 0.05 [95%CI 0.030.07], P  <  0.001). Conclusions ΔP is associated with PPC and intraoperative adverse events in abdominal surgery, both in open and closed abdominal surgery. Trial registration LAS VEGAS was registered at clinicaltrials.gov (trial identifier NCT01601223 ).

Background The benefits of lung-protective ventilation (LPV) with a low tidal volume (6 mL/kg of ideal body weight [IBW]), limited plateau pressure (< 28–30 cm H 2 O), and appropriate positive end-expiratory pressure (PEEP) in patients with acute respiratory distress syndrome have become apparent and it is now widely adopted in intensive care units. Recently evidence for LPV in general anaesthesia has been accumulated, but it is not yet generally applied by anaesthesiologists in the operating room. Methods This study investigated the perception about intraoperative LPV among 82 anaesthesiologists through a questionnaire survey and identified the differences in ventilator settings according to recognition of lung-protective ventilation. Furthermore, we investigated the changes in the trend for using this form of ventilation during general anaesthesia in the past 10 years. Results Anaesthesiologists who had received training in LPV were more knowledgeable about this approach. Anaesthesiologists with knowledge of the concept behind LPV strategies applied a lower tidal volume (median (IQR [range]), 8.2 (8.0–9.2 [7.1–10.3]) vs. 9.2 (9.1–10.1 [7.6–10.1]) mL/kg; p  = 0.033) and used PEEP more frequently (69/72 [95.8%] vs. 5/8 [62.5%]; p  = 0.012; odds ratio, 13.8 [2.19–86.9]) for laparoscopic surgery than did those without such knowledge. Anaesthesiologists who were able to answer a question related to LPV correctly (respondents who chose ‘height’ to a multiple choice question asking what variables should be considered most important in the initial setting of tidal volume) applied a lower tidal volume in cases of laparoscopic surgery and obese patients. There was an increase in the number of patients receiving LPV (V T  < 10 mL/kgIBW and PEEP ≥5 cm H 2 O) between 2004 and 2014 (0/818 [0.0%] vs. 280/818 [34.2%]; p  <  0.001). Conclusions Our study suggests that the knowledge of LPV is directly related to its implementation, and can explain the increase in LPV use in general anaesthesia. Further studies should assess the impact of using intraoperative LPV on clinical outcomes and should determine the efficacy of education on intraoperative LPV implementation.

Background The impact of anesthetic equipment on clinical practice parameters associated with development of acute respiratory distress syndrome (ARDS) has not been extensively studied. We hypothesized a change in anesthesia machines would be associated with parameters associated with lower rates of ARDS. Methods We performed a retrospective cohort study on a subset of data used to evaluate intraoperative ventilation. Patients included adults receiving a non-cardiac, non-thoracic, non-transplant, non-trauma, general anesthetic between 2/1/05, and 3/31/09 at the University of Michigan. Existing anesthesia machines (Narkomed IIb, Drager) were exchanged for new equipment (Aisys, General Electric). The initial subset compared the characteristics of patients anesthetized between 12/1/06 and 1/31/07 (pre) with those between 4/1/07 and 5/30/07 (post). An extended subset examined cases two years pre and post exchange. Using the standard predicted body weight (PBW), we calculated and compared the tidal volume (total Vt and mL/kg PBW) as well as positive end-expiratory pressure (PEEP), peak inspiratory pressure (PIP), Delta P (PIP-PEEP), and FiO2. Results A total of 1,414 patients were included in the 2-month pre group and 1,635 patients included in the post group. Comparison of ventilation characteristics found statistically significant differences in median (pre v post): PIP (26 ± 6 v 21 ± 6 cmH2O,p < .001), Delta P (24 ± 6 v 19 ± 6 cmH2O, p < .001), Vt (588 ± 139 v 562 ± 121 ml, p < 0.001; 9.3 ± 2.2 v 9.0 ± 1.9 ml/kg predicted body weight, p < .001), FiO2 (0.57 ± 0.17 v 0.52 ± 0.18, p < .001). Groups did not differ in age, ASA category, PBW, or BMI. The two year subgroup had similar parameters. Risk adjustment resulted in minimal differences in the analysis. New anesthesia machines were associated with a non-statistically significant reduction in postoperative ARDS. Conclusions In this study, a change in ventilator management was associated with an anesthesia machine exchange. The smaller Vt and lower PIP noted in the post group may imply a lower risk of volutrauma and barotrauma, which may be significant in at-risk populations. However, there was not a statistically significant reduction in the incidence of post-operative ARDS.

Test the hypothesis that the center of ventilation, a measure of ventro-dorsal atelectasis, is posterior during supraglottic ventilation indicating better dependent-lung ventilation. Secondarily, we tested the hypothesis that supraglottic ventilation improves oxygenation and carbon dioxide elimination. Supraglottic and subglottic jet ventilation are both used during laryngotracheal surgery. Supraglottic jet ventilation may better prevent atelectasis and provide superior ventilation. Randomized, cross-over trial. Operating rooms. Patients having elective micro-laryngotracheal surgery. Patients were sequentially ventilated for 5 min with one randomly selected type of jet ventilation before being switched to the alternative method. Regional ventilation distribution was estimated using electrical impedance tomography, with arterial oxygenation and carbon dioxide partial pressures being simultaneously evaluated. Thirty patients completed the study. There were no statistically significant or clinically meaningful differences in the center of ventilation with supraglottic and subglottic ventilation. However, ventilation with the supraglottic approach was about 4 % higher in the ventromedial lung region and about 4 % lower in the dorsal lung. Surprisingly, arterial blood oxygenation was considerably worse with supraglottic (173 [156, 199] mmHg) than subglottic ventilation (293 [244, 340] mmHg). Arterial carbon dioxide partial pressure was near 40 mmHg with each approach, although slightly lower with supraglottic jet ventilation. The center of ventilation distribution, a measure of atelectasis, was similar with supraglottic and subglottic jet ventilation. Subglottic jet ventilation improved the dorsal-dependent lung region and provided superior arterial oxygenation. Both techniques effectively eliminated carbon dioxide, with the supraglottic approach demonstrating slightly superior efficacy. •In a cross-over trial, we compared supraglottic and subglottic jet ventilation during open-airway laryngeal surgery.•Jet ventilation did not significantly shift the overall center of ventilation as determined by EIT.•Supraglottic jet ventilation worsened ventilation in dorsal lung regions compared to subglottic jet ventilation by 4 %.•Oxygenation was substantially better with subglottic than supraglottic jet ventilation.•Either type of jet ventilation appears suitable for open-airway laryngeal surgery.

The aim of this study was to investigate whether goal-directed treatment using artificial intelligence, compared to standard care, can reduce the frequency, duration, and severity of intraoperative hypotension in patients undergoing single lung ventilation, with a potential reduction of postoperative acute kidney injury (AKI). single center, single-blinded randomized controlled trial. University hospital operating room. 150 patients undergoing lung surgery with single lung ventilation were included. Patients were randomly assigned to two groups: the Intervention group, where a goal-directed therapy based on the Hypotension Prediction Index (HPI) was implemented; the Control group, without a specific hemodynamic protocol. The primary outcome measures include the frequency, duration of intraoperative hypotension, furthermore the Area under MAP 65 and the time-weighted average (TWA) of MAP of 65. Other outcome parameters are the incidence of AKI and myocardial injury after non-cardiac surgery (MINS). The number of hypotensive episodes was lower in the intervention group compared to the control group (0 [0–1] vs. 1 [0–2]; p = 0.01), the duration of hypotension was shorter in the intervention group (0 min [0–3.17] vs. 2.33 min [0–7.42]; p = 0.01). The area under the MAP of 65 (0 mmHg * min [0−12] vs. 10.67 mmHg * min [0–44.16]; p < 0.01) and the TWA of MAP of 65 (0 mmHg [0–0.08] vs. 0.07 mmHg [0–0.25]; p < 0.01) were lower in the intervention group. The incidence of postoperative AKI showed no differences between the groups (6.7 % vs.4.2 %; p = 0.72). There was a trend to lower incidence of MINS in the intervention group (17.1 % vs. 31.8 %; p = 0.07). A tendency towards reduced postoperative infection was seen in the intervention group (16.0 % vs. 26.8 %; p = 0.16). The implementation of a treatment algorithm based on HPI allowed us to decrease the duration and severity of hypotension in patients undergoing lung surgery. It did not result in a significant reduction in the incidence of AKI, however we observed a tendency towards lower incidence of MINS in the intervention group, along with a slight reduction in postoperative infections. •What is known?•Hypotension is associated with worse outcomes, especially acute kidney injury and myocardial injury.•The hypotension prediction index (HPI), along with an algorithm, can predict and prevent hypotension in general surgery.•What is new?•The HPI was not employed to investigate the clinical outcomes in patients undergoing lung surgery.•An algorithm utilizing the HPI can reduce hypotensive episodes during lung surgery and a slight reduction in myocardial injury and infections was observed.

Background High flow nasal therapy (HFNT) is a technique in which humidified and heated gas is delivered to the airways through the nose via small nasal prongs at flows that are higher than the rates generally applied during conventional oxygen therapy. The delivered high flow rates combine mixtures of air and oxygen and enable different inspired oxygen fractions ranging from 0.21 to 1. HFNT is increasingly used in critically ill adult patients, especially hypoxemic patients in different clinical settings. Main body Noninvasive ventilation delivers positive pressure (end-expiratory and inspiratory pressures or continuous positive airway pressure) via different external interfaces. In contrast, HFNT produces different physiological effects that are only partially linked to the generation of expiratory positive airway pressure. HFNT and noninvasive ventilation (NIV) are interesting non-invasive supports in perioperative medicine. HFNT exhibits some advantages compared to NIV because HFNT is easier to apply and requires a lower nursing workload. Tolerance of HFNT remains a matter of intense debate, and it may be related to selected parameters. Patients receiving HFNT and their respiratory patterns should be closely monitored to avoid delays in intubation despite correct oxygenation parameters. Conclusion HFNT seems to be an interesting noninvasive support in perioperative medicine. The present review provides anesthesiologists with an overview of current evidence and practical advice on the application of HFNT in perioperative medicine in adult patients.

Uncertainty persists regarding the optimal mode of mechanical ventilation for laparoscopic perioperative periods. Electrical impedance tomography (EIT) is an effective tool for monitoring and guiding lung-protective ventilation. This study aimed to compare the effects of pressure-controlled ventilation-volume guaranteed (PCV-VG) and volume-controlled ventilation (VCV) on pulmonary ventilation during laparoscopic surgery. This trial was a randomized crossover study, with the laparoscopic perioperative period divided into five phases: pre-anesthesia induction (AWAKE), post-anesthesia induction (BEGIN), the first phase of surgery (MIDDLE-1), the second phase of surgery (MIDDLE-2), and pre-wakefulness (END). EIT data were recorded at each phase, and EIT parameters were calculated to quantify pulmonary ventilation performance in both spatial and temporal dimensions. During the surgical period, plateau pressure (Pplat) and driving pressure (ΔP) under PCV-VG were lower, while the oxygenation index (PaO2/FiO2) was higher compared to VCV. Furthermore, PCV-VG was associated with an increased center of ventilation (45.1 ± 3.7 vs. 41.7 ± 3.5, P < 0.05), a decrease in global inhomogeneity (GI) (0.85 ± 0.16 vs. 1.06 ± 0.30, P < 0.05), and a reduction in regional ventilation delay index (RVDI) (10.5 ± 4.5 vs. 15.9 ± 5.3, P < 0.05), when compared to VCV. The improvements in pulmonary ventilation were more pronounced with PCV-VG compared to VCV during the surgical period, compared to the non-surgical period. EIT parameters reveal significant differences in ventilation between VCV and PCV-VG during the laparoscopic perioperative period. PCV-VG improves ventilation inhomogeneity and mitigates ventilation delay caused by the Trendelenburg position and pneumoperitoneum during surgery. PCV-VG is more effective than VCV in optimizing intraoperative lung ventilation. ClinicalTrials.gov ChiCTR2400089365.

The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p<0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p<0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.

This study aimed to assess the feasibility and safety of early mobilisation in promoting enhanced recovery among patients with concurrent atrial fibrillation undergoing cardiac valve surgery. A total of 190 patients who underwent cardiac valve surgery with concurrent atrial fibrillation at a tertiary-grade A hospital in Changsha City between January and December 2022 were randomly allocated to either an intervention ( n  = 95) or a control group ( n  = 95). The control group received standard perioperative care, while the intervention group followed a care programme that integrated conventional and Enhanced Recovery After Surgery (ERAS) protocols. The study compared recovery progress, incidence of complications, and various other metrics between the two groups. The intervention group demonstrated statistically. significant differences ( p  < 0.01) compared to the control group in terms of time to first mobilisation, duration of intensive care unit (ICU) stay, mechanical ventilation duration, pain scores, 6-minute walking distances, occurrence of arrhythmias, ICU re-admission, pulmonary infection rates, sternal incision infection rates, length of hospital stay, hospitalisation expenses, and adverse event rates. Summarily, patients in the intervention group exhibited more favourable outcomes across these metrics than those in the control group. Implementing an ERAS protocol-based early mobilisation strategy is a safe and viable approach for patients undergoing cardiac valve surgery with concurrent atrial fibrillation, facilitating their expedited recovery.