Best practice & research. Clinical anaesthesiology
-
Best Pract Res Clin Anaesthesiol · Jun 2010
ReviewInfluence of non-ventilatory options on postoperative outcome.
Perioperative patient handling should urgently be updated according to current evidence and, if none is available, at least according to physiological knowledge. To prevent pulmonary aspiration, preoperative fasting for 2 h (clear fluids) and 6 h (solid food) and abdication of 20 min for smoking is sufficient. Beta-blockage requires an indication. ⋯ This strategy has been shown to positively influence organ function, homeostasis, morbidity, need for hospitalisation and convalescence and, therefore, to reduce costs. Despite these promising results, general implementation of evidence-based measures leaves a lot to be desired. Further development of surgical minimally invasive techniques and ongoing evaluation of procedure-specific strategies is urgently warranted.
-
Best Pract Res Clin Anaesthesiol · Jun 2010
ReviewPrevention and reversal of lung collapse during the intra-operative period.
General anaesthesia induces ventilation/perfusion mismatch by lung collapse. Such lung collapse predisposes patients to preoperative complications since it can persist for several hours or days after surgery. Atelectasis can be partially prevented by using continuous positive airway pressure (CPAP) and/or by lowering FiO2 during anaesthesia induction. ⋯ The application of RMs during anaesthesia normalises lung function along the intraoperative period. There is physiological evidence that patients of all ages and any kind of surgery benefit from such an active intervention. The effect of RMs on patient outcome in the postoperative period is, however, not yet known.
-
Best Pract Res Clin Anaesthesiol · Jun 2010
ReviewPerioperative modifications of respiratory function.
Postoperative pulmonary complications contribute considerably to morbidity and mortality, especially after major thoracic or abdominal surgery. Clinically relevant pulmonary complications include the exacerbation of underlying chronic lung disease, bronchospasm, atelectasis, pneumonia and respiratory failure with prolonged mechanical ventilation. Risk factors for postoperative pulmonary complications include patient-related risk factors (e.g., chronic obstructive pulmonary disease (COPD), tobacco smoking and increasing age) as well as procedure-related risk factors (e.g., site of surgery, duration of surgery and general vs. regional anaesthesia). ⋯ Pulmonary function tests are not suitable as a general screen to assess risk of postoperative pulmonary complications. Strategies to reduce the risk of postoperative pulmonary complications include smoking cessation, inspiratory muscle training, optimising nutritional status and intra-operative strategies. Postoperative care should include lung expansion manoeuvres and adequate pain control.
-
Obesity is a metabolic disease that is on the increase all over the world. Up to 35% of the population in North America and 15-20% in Europe can be considered obese. Since these patients are characterised by several systemic physiopathological alterations, the perioperative management may present some problems, mainly related to their respiratory system. ⋯ The suggested perioperative ventilation management includes (a) awake and/or facilitated endotracheal intubation by using a video-laryngoscope; (b) tidal volume of 6-10 ml kg(-1) ideal body weight, increasing respiratory rate to maintain physiological PaCO2, while avoiding intrinsic positive end-expiratory pressure (PEEPi); and (c) a recruitment manoeuvre (35-55 cmH2O for 6 s) followed by the application of an end-expiratory pressure (PEEP) of 10 cmH2O. The recruitment manoeuvre should always be performed only when a volemic and haemodynamic stabilisation is reached after induction of anaesthesia. In the postoperative period, beach chair position, aggressive physiotherapy, noninvasive respiratory support and short-term recovery in intermediate critical care units with care of fluid management and pain may be useful to reduce pulmonary complications.
-
Best Pract Res Clin Anaesthesiol · Jun 2010
ReviewRole of spontaneous and assisted ventilation during general anaesthesia.
Spontaneous ventilation during general anaesthesia has been shown to favour atelectasis formation and decreased functional residual capacity. Therefore, general anaesthesia is commonly associated with endotracheal intubation and mechanical ventilation. Laryngeal lesions, residual curarisation, haemodynamics impairment, but most importantly, situation of cannot ventilate-cannot intubate may occur. ⋯ Spontaneous ventilation assisted by PSV with laryngeal mask may avoid all the complications of endotracheal intubation and mechanical ventilation. Therefore, PSV should be a valid alternative for all patients having general anaesthesia with the exception of some contraindication. A close monitoring of tidal volume and minute ventilation is also needed.