Annales françaises d'anesthèsie et de rèanimation
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Ann Fr Anesth Reanim · Jul 2014
ReviewIntraoperative management of heart-lung interactions: "From hypothetical prediction to improved titration"
Extensive literature describes the suitability of dynamic parameters to predict responsiveness in fluid. However, based on heart-lung interactions, these parameters can have serious limitations, including the use of protective lung ventilation. ⋯ In this context, the attending physician could, alternatively, titrate the need of fluids with a small fluid challenge, which remains unaffected by low tidal volume, the presence of arrhythmia, or the presence of spontaneous ventilation. When intraoperative prediction of fluid responsiveness is required in mechanically ventilated patients, "improved" titration should be preferred to a hypothetical prediction.
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After surgery, hypoxemia and/or acute respiratory failure (ARF) mainly develop following abdominal and/or thoracic surgery. Anesthesia, postoperative pain and surgery will induce respiratory modifications: hypoxemia, pulmonary volumes decrease and atelectasis associated to a restrictif syndrome and a diaphragm dysfunction. Maintenance of adequate oxygenation in the postoperative period is of major importance, especially when pulmonary complications such as ARF occur. ⋯ Rationale for postoperative NIV use is the same as the post-extubation NIV use plus the specificities due to the respiratory modifications induced by the surgery and anesthesia. Postoperative NIV improves gas exchange, decreases work of breathing and reduces atelectasis. The aims of this article are (1) to review the main respiratory modifications induced by surgery and anesthesia which justify postoperative NIV use (2) to offer some recommendations to apply safely postoperative NIV and (3) to present the main results obtained with preventive and curative NIV in a surgical context.
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The preoperative respiratory evaluation aims at predicting the occurrence of postoperative respiratory complications (PORC), such as: atelectasis, pulmonary infection (bronchitis and pneumonia), acute ventilatory distress, pleural effusion, prolonged mechanical ventilation, exacerbation of chronic respiratory disease and bronchospasm. The incidence of (PORC) all surgeries combined is 6.8%. Individual surgical and anesthetic factors are impacting on the occurrence of PORC. ⋯ PFT may however be useful to confirm an improvement in the clinical condition of the patient related to the preoperative preparation. Specialized EFR, including standardized testing efforts are sometimes required in the case of lung reduction surgery. These specialized explorations can predict lung function and post-interventional pulmonary oxygenation and ensure that these are viable.
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One of the key challenges in perioperative care is to reduce postoperative morbidity and mortality. Patients who develop postoperative morbidity but survive to leave hospital have often reduced functional independence and long-term survival. Mechanical ventilation provides a specific example that may help us to shift thinking from treatment to prevention of postoperative complications. ⋯ Stimulated by previous findings in patients with acute respiratory distress syndrome, the use of lower tidal volume ventilation is becoming increasingly more common in the operating room. However, lowering tidal volume, though important, is only part of the overall multifaceted approach of lung protective mechanical ventilation. In this review, we aimed at providing the most recent and relevant clinical evidence regarding the use of mechanical ventilation in patients undergoing abdominal surgery.