Abstract
BackgroundIn 2014, this group published an investigation of surgical patients from 2012 who had substantial rates of postoperative hypoxemia (POH) and perioperative pulmonary aspiration (POPA). Therefore, we investigated whether intraoperative reverse Trendelenburg positioning (RTP) decreases POH and POPA rates.MethodsConsecutive ASA I–IV surgical patients who had preoperative pulmonary stability requiring general anesthesia with endotracheal intubation were evaluated. Using pulse oximetry, hypoxemia was documented intraoperatively and during the 48 h following PACU discharge. POPA was the presence of a pulmonary infiltrate with hypoxemia. In early 2015, a multifaceted effort was undertaken to enhance anesthesiologist and operating nurse awareness of RTP to potentially decrease POH and POPA rates. Analyses included (1) combining 2012 and 2015 cohorts to assess risk conditions, (2) comparing post-campaign 2015 (increased RTP) and 2012 cohorts, and (3) comparing 2015 patients with audit-documented RTP during surgery to the other 2015 patients.ResultsCombining the 500 patients in 2012 with the 1000 in 2015 showed that POH had increased mortality (2.3%), compared to no POH (0.2%; p = 0.0004). POH had increased postoperative length of stay (LOS) (4.6 days), compared to no POH (2.0 days; p < 0.0001). POPA had increased mortality (7.7%) and LOS (8.8 days), compared to no POPA (0.4%; p = 0.0004; 2.3 days; p < 0.0001). Open aortic, cranial, laparotomy, and neck procedures had greater POH (41.3%) and LOS (4.0 days), compared to other procedures (16.3%; p < 0.0001; 2.2 days; p < 0.0001). Glycopyrrolate on induction had lower POH (17.4%) and LOS (1.9 days), compared to no glycopyrrolate (21.6%; p = 0.0849; 2.7 days; p < 0.0001). POH was lower (18.1%) in 2015, than in 2012 (25.6%; p = 0.0007). POPA was lower with RTP in 2015 (0.6%), than in 2012 (4.8%; p = 0.0088). For the 2015 patients, LOS was lower with audit-documented RTP (2.2 days), compared to other patients (2.7 days; p = 0.0246).ConclusionsThese findings are only hypothesis-generating. A randomized clinical trial is needed to confirm whether RTP has an inverse association with POH and POPA, and if RTP and glycopyrrolate are associated with improved outcomes.Trial registrationClinicalTrials.gov, NCT02984657
Highlights
In 2014, this group published an investigation of surgical patients from 2012 who had substantial rates of postoperative hypoxemia (POH) and perioperative pulmonary aspiration (POPA)
We provided evidence to suggest that the substantial rates of perioperative hypoxemia and perioperative pulmonary aspiration (POPA) may have been related to horizontal recumbency
A randomized clinical trial is needed to confirm (1) whether POH and POPA have an association with mortality and postoperative length of stay (LOS), (2) if reverse Trendelenburg positioning (RTP) has an inverse association with POH, POPA, and LOS, (3) whether glycopyrrolate administration on anesthesia induction is associated with a lower postoperative LOS and a reduction in POH, and (4) if our particular medical record abstraction process is credible
Summary
In 2014, this group published an investigation of surgical patients from 2012 who had substantial rates of postoperative hypoxemia (POH) and perioperative pulmonary aspiration (POPA). We provided evidence to suggest that the substantial rates of perioperative hypoxemia and perioperative pulmonary aspiration (POPA) may have been related to horizontal recumbency. Clinical evidence demonstrates that horizontal positioning in mechanically ventilated patients is a risk for pulmonary aspiration with lung inflammation (Kalinowski and Kirsch 2004; Smith and Ng 2003) and ventilatorassociated pneumonia (Ewig and Torres 2002; Torres et al 1992; Ferrer and Artigas 2002; Keenan et al 2002; Koeman et al 2001; Fernandez-Crehuet et al 1997; Drakulovic et al 1999; Kollef 1993).
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