What are the optimum components in a care bundle aimed at reducing post-operative pulmonary complications in high-risk patients?

Popc-Cb Investigators ,Sophie V Griffiths,Daniel H Conway,Ben C Creagh-Brown,Michael P W Grocott,Michael Sander,Ib Jammer

doi:10.1186/s13741-018-0084-9

Abstract

BackgroundPost-operative pulmonary complications (POPC) are common, predictable and associated with increased morbidity and mortality, independent of pre-operative risk. Interventions to reduce the incidence of POPC have been studied individually, but the use of a care bundle has not been widely investigated. The purpose of our work was to use Delphi consensus methodology and an independently chosen expert panel to formulate a care bundle for patients identified as being at high of POPC, as preparation towards an evaluation of its effectiveness at reducing POPC.MethodsWe performed a survey of members of the ESICM POIC section to inform a Delphi consensus and to share their opinions on a care bundle to reduce POPC, the POPC-CB. We formed a team of 36 experts to participate in and complete an email-based Delphi consensus over three rounds, leading to the formulation of the POPC-CB.ResultsThe survey had 362 respondents and informed the design of the Delphi consensus. The Delphi consensus resulted in a proposed POPC-CB that incorporates components before surgery-supervised exercise programmes and inspiratory muscle training, during surgery, low tidal volume ventilation with individualised PEEP (positive end-expiratory pressure), use of routine monitoring to avoid hyperoxia and efforts made to limit neuromuscular blockade, and post-operatively, deep breathing exercises and elevation of the head of the bed.ConclusionA care bundle has been suggested for evaluation in surgical patients at high risk of POPC. Evaluation of feasibility of both implementation and effectiveness is now indicated.

Highlights

Post-operative pulmonary complications (POPC) are common, predictable and associated with increased morbidity and mortality, independent of pre-operative risk
We performed a survey of members of the European Society of Intensive Care Medicine (ESICM) Perioperative Intensive Care (POIC) section, both to identify ‘expert volunteers’ for the Delphi and to gain an appreciation of clinical opinion regarding the potential components of a POPC-care bundle (CB)
From a survey sent to the 6623 members of the POIC group of ESICM, there were 362 responses which helped establish the potential of POPC risk assessments and possible interventions in a POPC-CB for patients screened at moderate to high risk

Summary

Introduction

Post-operative pulmonary complications (POPC) are common, predictable and associated with increased morbidity and mortality, independent of pre-operative risk. Post-operative pulmonary complications (POPC) are defined as ‘a pulmonary abnormality that produces identifiable disease or dysfunction that is clinically significant and adversely affects the clinical course’ (Restrepo and Braverman 2015). They are common, with a reported incidence ranging from 2–40%, and adverse outcomes include mortality, with studies reporting that 1 in 5 patients with POPC will die within 30 days of surgery, and the average hospital stay is lengthened by 8 days (Restrepo and Braverman 2015). Reduction in the rate of POPC starts with the recognition of moderate- and high-risk patients through the use of validated tools such as ARISCAT (Assess Respiratory rIsk in Surgical patients in CATalonia) (Canet et al 2010; Canet et al 2015)

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