Lung Protective Strategy Research Articles

The use of protective mechanical ventilation during extracorporeal membrane oxygenation for the treatment of acute respiratory failure.

Acute respiratory failure (ARF) strikes an estimated two million people in the United States each year, with care exceeding US$50 billion. The hallmark of ARF is a heterogeneous injury, with normal tissue intermingled with a large volume of low compliance and collapsed tissue. Mechanical ventilation is necessary to oxygenate and ventilate patients with ARF, but if set inappropriately, it can cause an unintended ventilator-induced lung injury (VILI). The mechanism of VILI is believed to be overdistension of the remaining normal tissue known as the 'baby' lung, causing volutrauma, repetitive collapse and reopening of lung tissue with each breath, causing atelectrauma, and inflammation secondary to this mechanical damage, causing biotrauma. To avoid VILI, extracorporeal membrane oxygenation (ECMO) can temporally replace the pulmonary function of gas exchange without requiring high tidal volumes (VT) or airway pressures. In theory, the lower VT and airway pressure will minimize all three VILI mechanisms, allowing the lung to 'rest' and heal in the collapsed state. The optimal method of mechanical ventilation for the patient on ECMO is unknown. The ARDSNetwork Acute Respiratory Management Approach (ARMA) is a Rest Lung Approach (RLA) that attempts to reduce the excessive stress and strain on the remaining normal lung tissue and buys time for the lung to heal in the collapsed state. Theoretically, excessive tissue stress and strain can also be avoided if the lung is fully open, as long as the alveolar re-collapse is prevented during expiration, an approach known as the Open Lung Approach (OLA). A third lung-protective strategy is the Stabilize Lung Approach (SLA), in which the lung is initially stabilized and gradually reopened over time. This review will analyze the physiologic efficacy and pathophysiologic potential of the above lung-protective approaches.

Anti-Inflammatory Potency of Human Wharton's Jelly Mesenchymal Stem Cell-Derived Exosomes on L2 Cell Line Induced by Lipopolysaccharides.

At present, therapeutic interventions to treat acute lung injury (ALI) remain largely limited to lung-protective strategies, as no real molecular-driven therapeutic intervention has yet become available. The administration of bacterial lipopolysaccharides (LPS) is known as an inflammatory activator, representing a frequently used model of ALI. This study investigated the biological function of normoxic (21% O2 ) vs. hypoxic conditions (5% O2 ) obtained from human Wharton's Jelly mesenchymal stem cells (hWJ-MSCs) and discovered that exosomes have the ability to suppress inflammatory responses by specifically targeting TNF-α, IL-1β, IL-6. and identify the toll-like receptor 4 (TLR4) NF-κβ gene expression. Primer culture hWJ-MSCs characterization with trilineage differentiation and CD markers was conducted. To obtain exosomes, hWJ-MSCs were stimulated with two different oxygen levels: 21% (nor-exo) and 5% (hypo-exo). Then, the L2 cell line was induced with LPS 1 µg/mL. Inflamed-L2 was treated with nor-exo, hypo-exo, and dexamethasone as a positive control. The RNA extracted from treated L2 cells was utilized to examine the gene expression profiles of TLR4 and NF-κβ, and the medium was used to measure tumor necrosis factor α (TNF-α), interleukin (IL)-1β, and IL-6 levels using ELISA. Lastly, proteomic analysis of the exosome using LC/MS-MS was conducted. Nor-exo and hypo-exo can be characterized and can produce higher yields exosomes under hypoxic conditions. The expression of TLR4 and NF-κβ genes and the proinflammatory levels such as IL-6, IL-1β, and TNF-α levels in nor-exo and hypo-exo treatments decreased. Nor-exo and hypo-exo derived from hWJ-MSCs were proven to have anti-inflammatory activities.

Evidence-Based Care of Staircase Recruitment Maneuver in a Patient with Severe Acute Respiratory Distress Syndrome

<p>急性呼吸窘迫症是致死率很高的急症，嚴重呼吸困難會造成病人有瀕死的危象。筆者於2020 年11月照顧一位67歲男性因急性呼吸衰竭插管治療，對於肺保護通氣策略之效果不佳，甚至使用體外膜氧合維生系統仍嚴重低血氧，引發筆者想解決此醫療困境之動機。運用實證步驟探討階梯式肺再擴張術增加氧合能力之成效，以PICO詮釋臨床問題，P為急性呼吸窘迫症（Acute respiratory distress syndrome, ARDS）、I為階梯式肺再擴張術（Staircase recruitment maneuver, SRM）、C為常規照護（Usual care）、O為氧合能力（PaO2/FiO2 ratio, PFR），檢索Cochrane Library、PubMed、CINAHL和華藝線上圖書館等資料庫，最終納入五篇符合篩選標準之隨機對照試驗研究，經系統性回顧後再進行統合分析，共有1,229 位病人之資料進行統合分析，發現SRM可改善PFR增加氧合，其綜合效量為55.63（95%CI [44.92, 66.33]）。依據研究結果應用於個案，住院第二天在壓力控制模式下執行一次SRM，當驅動壓力15 cmH2O，呼氣末正壓從10 cmH2O開始調升，每40秒增加5 cmH2O，並追蹤個案之動脈血氧，其PFR由174上升至318 mmHg，最終成功脫離呼吸器。因此，建議使用呼吸器之ARDS病人，若肺保護通氣策略下仍有嚴重低血氧時，可以考慮執行SRM來增加病人的氧合，進而讓病人能盡早脫離呼吸器。</p> <p> </p><p>Acute Respiratory Distress Syndrome is a highly fatal emergency. Severe dyspnea could lead to a re-spiratory crisis. The author provided care for a 67-year-old man who was intubated due to acute respi-ratory failure in November 2020. The ventilation strategies for lung protection strategies (LPS) were not as effective as expected. Even when using the extracorporeal membrane oxygenation (ECMO) life support system, hypoxemia still presented and deteriorated rapidly. This incident gave the author the motivation to solve this medical dilemma. An evidence-based approach was adopted to assess the ef-fectiveness of the staircase recruitment maneuver for oxygenation. The clinical treatment using PICO interpretations are as follows P: Acute respiratory distress syndrome (ARDS), I: Staircase recruitment maneuver (SRM), C: Usual care, O: PaO2/FiO2 ratio (PFR). Databases such as Cochrane Library, PubMed, CINAHL, and Airiti Library were searched. Five randomized controlled trial studies that met the screening criteria were included, and a meta-analysis was conducted after a systematic review. A total of 1,229 patients were analyzed in the meta-analysis, which showed that SRM can improve PFR and increase oxygenation. The effect size was 55.63 (95% CI [44.92, 66.33]). According to the re-search results applied to this case, SRM was performed in pressure control mode on the second day of hospitalization. When the driving pressure was set at 15cmH2O, the positive end-expiratory pressure (PEEP) was titrated from 10cmH2O, increasing by 5cmH2O every 40 seconds. Tracing the patient’s arterial blood oxygenation, the PFR increased from 174 to 318 mmHg, and the patient was successful-ly weaned from the ventilator. Therefore, ventilators are recommended for ARDS patients with severe hypoxemia under LPS. SRM maybe considered to improve the patient’s oxygenation, allowing for ear-ly weaning from the ventilator.</p> <p> </p>

Lung-protective strategy during one-lung ventilation: current and future approaches to quantify the role of positive end-expiratory pressure.

Lung-protective strategy during one-lung ventilation: current and future approaches to quantify the role of positive end-expiratory pressure.

An international RAND/UCLA expert panel to determine the optimal diagnosis and management of burn inhalation injury

BackgroundBurn inhalation injury (BII) is a major cause of burn-related mortality and morbidity. Despite published practice guidelines, no consensus exists for the best strategies regarding diagnosis and management of BII. A modified DELPHI study using the RAND/UCLA (University of California, Los Angeles) Appropriateness Method (RAM) systematically analysed the opinions of an expert panel. Expert opinion was combined with available evidence to determine what constitutes appropriate and inappropriate judgement in the diagnosis and management of BII.MethodsA 15-person multidisciplinary panel comprised anaesthetists, intensivists and plastic surgeons involved in the clinical management of major burn patients adopted a modified Delphi approach using the RAM method. They rated the appropriateness of statements describing diagnostic and management options for BII on a Likert scale. A modified final survey comprising 140 statements was completed, subdivided into history and physical examination (20), investigations (39), airway management (5), systemic toxicity (23), invasive mechanical ventilation (29) and pharmacotherapy (24). Median appropriateness ratings and the disagreement index (DI) were calculated to classify statements as appropriate, uncertain, or inappropriate.ResultsOf 140 statements, 74 were rated as appropriate, 40 as uncertain and 26 as inappropriate. Initial intubation with ≥ 8.0 mm endotracheal tubes, lung protective ventilatory strategies, initial bronchoscopic lavage, serial bronchoscopic lavage for severe BII, nebulised heparin and salbutamol administration for moderate-severe BII and N-acetylcysteine for moderate BII were rated appropriate. Non-protective ventilatory strategies, high-frequency oscillatory ventilation, high-frequency percussive ventilation, prophylactic systemic antibiotics and corticosteroids were rated inappropriate. Experts disagreed (DI ≥ 1) on six statements, classified uncertain: the use of flexible fiberoptic bronchoscopy to guide fluid requirements (DI = 1.52), intubation with endotracheal tubes of internal diameter < 8.0 mm (DI = 1.19), use of airway pressure release ventilation modality (DI = 1.19) and nebulised 5000IU heparin, N-acetylcysteine and salbutamol for mild BII (DI = 1.52, 1.70, 1.36, respectively).ConclusionsBurns experts mostly agreed on appropriate and inappropriate diagnostic and management criteria of BII as in published guidance. Uncertainty exists as to the optimal diagnosis and management of differing grades of severity of BII. Future research should investigate the accuracy of bronchoscopic grading of BII, the value of bronchial lavage in differing severity groups and the effectiveness of nebulised therapies in different severities of BII.Graphical

Identifying High-Risk Patients for Severe Pulmonary Complications after Cardiosurgical Procedures as a Target Group for Further Assessment of Lung-Protective Strategies

ObjectiveIt remains unclear if intraoperative lung-protective strategies can reduce the rate of respiratory complications after heart surgery, partly because low-risk patients have been studied in the past. We established a screening model to easily identify a high-risk group for severe pulmonary complications (i.e., pneumonia or ARDS) that may be the ideal target population for the assessment of potential benefits of such measures. DesignRetrospective observational trial. SettingDepartments of cardiac surgery and cardiac anesthesia of university hospital. Participants: Consecutive patients undergoing heart surgery on cardiopulmonary bypass (CPB) and subsequent treatment at a dedicated cardiosurgical ICU between January 2019 and March 2021. InterventionsNone Measurements and main resultsOf 2572 patients undergoing surgery, 84 patients (3.3%) developed pneumonia/ARDS that significantly impacted outcome (i.e., longer ventilatory support (66 vs. 11%), higher reintubation rate (39 vs. 3%), prolonged length of ICU (33±36 vs. 4±10 days) and hospital stay (10±15 vs. 6±7 days), and higher in-hospital (43 vs. 9%) as well as 30-day (7 vs. 3%) mortality). Our screening model for severe pulmonary complications includes LVEF < 52%, EuroSCOREII > 5.9, CPB time > 123 minutes, left ventricular assist device or aortic repair surgery, and bronchodilatory therapy. A cut-off for the predicted risk of 2.5 % showed optimal sensivity and specificity with an AUC of 0.82. ConclusionWe suggest that future research on intraoperative lung protective measures should focus on this high-risk population and primarily aiming at mitigation of severe forms of postoperative pulmonary dysfunction associated with poor outcome and increased resource consumption.

Congenital diaphragmatic hernia: quality improvement using a maximal lung protection strategy and early surgery-improved survival.

MLP with early surgery significantly improved survival and additional adverse outcomes of neonates with CDH. Prospective randomized studies are necessary to confirm the findings of the current study. • Ventilator-induced lung injury was reported as the main cause of mortality in neonates with congenital diaphragmatic hernia (CDH). • Conventional ventilation is recommended by the European CDH consortium as the first-line ventilation modality;timing of surgery is controversial. • A maximal lung protection strategy based on 15-Hz high-frequency oscillatory ventilation with low distending pressures as initial modality and early surgery significantly reduced mortality and other outcomes.

PROTECTIVE MECHANISM OF ALLEVIATING LUNG INJURY BY INHIBITING NF-κB PATHWAY

This review is to summarize the reports published in the past 10 years on the protective mechanism of 74 different intervention methods on lung injury through restraining nuclear factor kappa-B (NF-[Formula: see text]B) signaling pathway. We summarized the experimental studies on animal lung injury models of NF-[Formula: see text]B, MAPK/NF-[Formula: see text]B, PI3K/Akt/NF-[Formula: see text]B, TLR4/NF-[Formula: see text]B, NF-[Formula: see text]B/NALP3, NF-[Formula: see text]B/NLRP3 and other NF-[Formula: see text]B-related signal pathways. Lung injury leads to high mortality worldwide. Many potential mechanisms for the treatment and prevention of lung injury are still unclear. In addition to the use of lung protection strategies, currently, there are no effective drugs for lung injury treatment. Preemptive NF-[Formula: see text]B inhibition protects cells from damage, but inhibition at the decomposition stage delays tissue repair. Therefore, we think there is a need to conduct further studies that can provide more insights for future treatment and prevention of lung injury.

The forgotten tale of spontaneous plateau pressure

This article highlights the significance of measuring plateau pressure in spontaneously breathing patients as it provides valuable information about PMI (Pmusc Index), which serves as a surrogate for the patient's efforts during mechanical ventilation. The PMI value obtained from the difference between the end-inspiratory occlusion plateau pressure and the airway pressure before the occlusion (PEEP + PS) enables clinicians to estimate the patient's inspiratory effort accurately. The accurate measurement of patient efforts is crucial in optimizing pressure support during lung protective weaning strategies. By titrating pressure support based on PMI values, clinicians can provide personalized care to patients, reducing the risk of ventilator-induced lung injury and enhancing the likelihood of successful weaning. Keywords: PMI, Pmus, Plateau pressure

Sensory interventions to relieve dyspnoea in critically ill mechanically ventilated patients.

In critically ill patients receiving mechanical ventilation, dyspnoea is frequent, severe and associated with an increased risk of neuropsychological sequelae. We evaluated the efficacy of sensory interventions targeting the brain rather than the respiratory system to relieve dyspnoea in mechanically ventilated patients. Patients receiving mechanical ventilation for ≥48 h and reporting dyspnoea (unidimensional dyspnoea visual analogue scale (Dyspnoea-VAS)) first underwent increased pressure support and then, in random order, auditory stimulation (relaxing music versus pink noise) and air flux stimulation (facial versus lower limb). Treatment responses were assessed using Dyspnoea-VAS, the Multidimensional Dyspnea Profile and measures of the neural drive to breathe (airway occlusion pressure (P 0.1) and electromyography of inspiratory muscles). We included 46 patients (tracheotomy or intubation n=37; noninvasive ventilation n=9). Increasing pressure support decreased Dyspnoea-VAS by median 40 mm (p<0.001). Exposure to music decreased Dyspnoea-VAS compared with exposure to pink noise by median 40 mm (p<0.001). Exposure to facial air flux decreased Dyspnoea-VAS compared with limb air flux by median 30 mm (p<0.001). Increasing pressure support, but not music exposure and facial air flux, reduced P 0.1 by median 3.3 cmH2O (p<0.001). In mechanically ventilated patients, sensory interventions can modulate the processing of respiratory signals by the brain irrespective of the intensity of the neural drive to breathe. It should therefore be possible to alleviate dyspnoea without resorting to pharmacological interventions or having to infringe the constraints of mechanical ventilation lung protection strategies by increasing ventilatory support.

Recent advances in predicting, preventing, and managing postoperative delirium.

Postoperative delirium (POD) is a major public health problem associated with poor patient outcomes such as increased hospital lengths of stay, loss of functional independence, and higher mortality. Depending on the study, the reported incidence ranges from 5% to 65%, with the highest incidence in hip and cardiac surgery. Anesthesiologists should be familiar with the predisposing and precipitating factors of POD, particularly screening for preoperative cognitive impairment and frailty syndrome. Screening tools, for example, the Mini-Mental State Exam, Mini-Cog, 4 A's test for delirium screening, and Montreal Cognitive Assessment, can be used to assess for cognitive impairment and the Clinical Frailty Scale to assess for frailty syndrome. The Hospital Elder Life Program is the standard prevention protocol that is tried and tested in reducing the incidence of POD. Prehabilitation, lung protective strategies, pharmacologic agents such as ramelteon, a melatonin receptor agonist, glucocorticoids, dexmedetomidine, and non-pharmacologic agents, such as noise reduction strategies and the encouragement of nocturnal sleep, have all led to a decrease in the incidence of POD and are being studied for their efficacy. However, the data are inconclusive to date. Intraoperatively, preventing hypotension and blood pressure swings, ensuring adequate pain control and anesthetic depth, and using age-adjusted minimum alveolar concentration (MAC) titration reduce the incidence of POD. The incidence of POD using regional or general anesthesia is similar. In this narrative review, we will discuss the current understanding of the predictors, pathophysiology, prevention, and management of POD and identify areas of further research.

First Stabilize and then Gradually Recruit: A Paradigm Shift in Protective Mechanical Ventilation for Acute Lung Injury.

Acute respiratory distress syndrome (ARDS) is associated with a heterogeneous pattern of injury throughout the lung parenchyma that alters regional alveolar opening and collapse time constants. Such heterogeneity leads to atelectasis and repetitive alveolar collapse and expansion (RACE). The net effect is a progressive loss of lung volume with secondary ventilator-induced lung injury (VILI). Previous concepts of ARDS pathophysiology envisioned a two-compartment system: a small amount of normally aerated lung tissue in the non-dependent regions (termed "baby lung"); and a collapsed and edematous tissue in dependent regions. Based on such compartmentalization, two protective ventilation strategies have been developed: (1) a "protective lung approach" (PLA), designed to reduce overdistension in the remaining aerated compartment using a low tidal volume; and (2) an "open lung approach" (OLA), which first attempts to open the collapsed lung tissue over a short time frame (seconds or minutes) with an initial recruitment maneuver, and then stabilize newly recruited tissue using titrated positive end-expiratory pressure (PEEP). A more recent understanding of ARDS pathophysiology identifies regional alveolar instability and collapse (i.e., hidden micro-atelectasis) in both lung compartments as a primary VILI mechanism. Based on this understanding, we propose an alternative strategy to ventilating the injured lung, which we term a "stabilize lung approach" (SLA). The SLA is designed to immediately stabilize the lung and reduce RACE while gradually reopening collapsed tissue over hours or days. At the core of SLA is time-controlled adaptive ventilation (TCAV), a method to adjust the parameters of the airway pressure release ventilation (APRV) modality. Since the acutely injured lung at any given airway pressure requires more time for alveolar recruitment and less time for alveolar collapse, SLA adjusts inspiratory and expiratory durations and inflation pressure levels. The TCAV method SLA reverses the open first and stabilize second OLA method by: (i) immediately stabilizing lung tissue using a very brief exhalation time (≤0.5 s), so that alveoli simply do not have sufficient time to collapse. The exhalation duration is personalized and adaptive to individual respiratory mechanical properties (i.e., elastic recoil); and (ii) gradually recruiting collapsed lung tissue using an inflate and brake ratchet combined with an extended inspiratory duration (4-6 s) method. Translational animal studies, clinical statistical analysis, and case reports support the use of TCAV as an efficacious lung protective strategy.

Required biological time for lung maturation and duration of invasive ventilation: a Korean cohort study of very low birth weight infants.

We investigated the duration of invasive ventilation among very low birth weight (VLBW) infants to evaluate the current minimum time required for lung maturation to breathe without ventilator assistance after preterm birth. A total of 14,658 VLBW infants born at ≤32+6 weeks between 2013 and 2020 were enrolled. Clinical data were collected from the Korean Neonatal Network, a national prospective cohort registry of VLBW infants from 70 neonatal intensive care units. Differences in the duration of invasive ventilation according to gestational age and birth weight were investigated. Recent trends and changes in assisted ventilation duration and associated perinatal factors between 2017-20 and 2013-16 were compared. Risk factors related to the duration of assisted ventilation were also identified. The overall duration of invasive ventilation was 16.3 days and the estimated minimum time required corresponded to 30+4 weeks of gestation. The median duration of invasive ventilation was 28.0, 13.0, 3.0, and 1.0 days at <26, 26-27, 28-29, and 30-32 weeks of gestation, respectively. In each gestational age group, the estimated minimum weaning points from the assisted ventilator were 29+5, 30+2, 30+2, and 31+5 weeks of gestation. The duration of non-invasive ventilation (17.9 vs. 22.5 days) and the incidence of bronchopulmonary dysplasia (28.1% vs. 31.9%) increased in 2017-20 (n = 7,221) than in 2013-16 (n = 7,437). In contrast, the duration of invasive ventilation and overall survival rate did not change during the periods 2017-20 and 2013-16. Surfactant treatment and air leaks were associated with increased duration of invasive ventilation (inverse hazard ratio 1.50, 95% CI, 1.04-2.15; inverse hazard ratio 1.62, 95% CI, 1.29-2.04). We expressed the incidence proportion of ventilator weaning according to the invasive ventilation duration using Kaplan-Meier survival curves. The slope of the curve slowly decreased as gestational age and birth weight were low and risk factors were present. This population-based data on invasive ventilation duration among VLBW infants suggest the present limitation of postnatal lung maturation under specific perinatal conditions after preterm birth. Furthermore, this study provides detailed references for designing and/or assessing earlier ventilator weaning protocols and lung protection strategies by comparing populations or neonatal networks.

Factors Associated With Prolonged Ventilation in Patients Receiving Prone Positioning Protocol With Muscle Relaxants for Severe COVID-19 Pneumonia.

Prone positioning and neuromuscular blocking agents (NMBAs) are frequently used to treat severe respiratory failure from COVID-19 pneumonia. Prone positioning has shown to improve mortality, whereas NMBAs are used to prevent ventilator asynchrony and reduce patient self-inflicted lung injury. However, despite the use of lung-protective strategies, high death rates in this patient population have been reported. We retrospectively examined the factors affecting prolonged mechanical ventilation in subjects receiving prone positioning plus muscle relaxants. The medical records of 170 patients were reviewed. Subjects were divided into 2 groups according to ventilator-free days (VFDs) at day 28. Whereas subjects with VFDs < 18 d were defined as prolonged mechanical ventilation, subjects with VFDs ≥18 d were defined as short-term mechanical ventilation. Subjects' baseline status, status at ICU admission, therapy before ICU admission, and treatment in the ICU were studied. Under the proning protocol for COVID-19, the mortality rate in our facility was 11.2%. The prognosis may be improved by avoiding lung injury in the early stages of mechanical ventilation. According to multifactorial logistic regression analysis, persistent SARS-CoV-2 viral shedding in blood (P = .03), higher daily corticosteroid use before ICU admission (P = .007), delayed recovery of lymphocyte count (P < .001), and higher maximal fibrinogen degradation products (P = .039) were associated with prolonged mechanical ventilation. A significant relationship was found between daily corticosteroid use before admission and VFDs by squared regression analysis (y = -0.00008522x2 + 0.01338x + 12.8; x: daily corticosteroids dosage before admission [prednisolone mg/d]; y: VFDs/28 d, R2 = 0.047, P = .02). The peak point of the regression curve was 13.4 d at 78.5 mg/d of the equivalent prednisolone dose, which corresponded to the longest VFDs. Persistent SARS-CoV-2 viral shedding in blood, high corticosteroid dose from the onset of symptoms to ICU admission, slow recovery of lymphocyte counts, and high levels of fibrinogen degradation products after admission were associated with prolonged mechanical ventilation in subjects with severe COVID-19 pneumonia.

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Intraoperative Factors Modifying the Risk of Postoperative Pulmonary Complications After Living Donor Liver Transplantation.

The relationship between intraoperative anesthetic management and postoperative pulmonary complications (PPCs) after liver transplantation is not fully understood. We aimed to determine the intraoperative contributors to PPC. The retrospectively collected cohort included 605 patients who underwent living donor liver transplantation. PPCs comprised respiratory failure, respiratory infection, pulmonary edema, atelectasis (at least moderate degree), pneumothorax, and pleural effusion (at least moderate degree). The presence and type of PPC were evaluated by 2 pulmonary physicians. Logistic regression analysis was performed to determine the association between perioperative variables and PPC risk. Of the 605 patients, 318 patients (52.6%) developed 486 PPCs. Multivariable analysis demonstrated that PPC risk decreased with low tidal volume ventilation (odds ratio [OR] 0.62 [0.41-0.94], P = 0.023) and increased with greater driving pressure at the end of surgery (OR 1.08 [1.01-1.14], P = 0.018), prolonged hypotension (OR 1.85 [1.27-2.70], P = 0.001), and blood albumin level ≤3.0 g/dL at the end of surgery (OR 2.43 [1.51-3.92], P < 0.001). Survival probability at 3, 6, and 12 mo after transplantation was 91.2%, 89.6%, and 86.5%, respectively, in patients with PPCs and 98.3%, 96.5%, and 93.4%, respectively, in patients without PPCs (hazard ratio 2.2 [1.3-3.6], P = 0.004). Graft survival probability at 3, 6, and 12 mo after transplantation was 89.3%, 87.1%, and 84.3%, respectively, in patients with PPCs and 97.6%, 95.8%, and 92.7%, respectively, in patients without PPCs (hazard ratio 2.3 [1.4-3.7], P = 0.001). We found that tidal volume, driving pressure, hypotension, and albumin level during living donor liver transplantation were significantly associated with PPC risk. These data may help determine patients at risk of PPC or develop an intraoperative lung-protective strategy for liver transplant recipients.

Design of Fuzzy Logic-Based ARDS Berlin Definition for Ventilator Adjustments to Ensure Lung Protection

The studies done on lung protective strategies in medical ventilators have shown that tidal volume of 6-ml/ kg predicted body weight protects the lungs of a patient during the invasive ventilation for acute respiratory distress syndrome (ARDS) patients in intensive care unit. Corona virus disease 2019 has increased the need for mechanical ventilation, which are operated manually, in changing the settings on the mechanical ventilators. In this study, fuzzy logic method is used to develop a computer-aided decision-making to improve on the accuracy of the reasoning done during the ventilator setting adjustment, by adding the fuzzy reasoning concept into the ARDS Berlin definition. The ARDS positive end-expiratory pressure (PEEP) values were used in building the fuzzy rules of the fuzzy algorithm. From the experimental results, the algorithm mimics the recommended ARDS PEEP values with respect to the values of fraction of inspired oxygen (FiO2); the algorithm as well increases the respiratory rate and tidal volume for potential of Hydrogen (pH) less than 7.2; maintains the respiratory rate and tidal volume for pH between 7.2 and 7.4; decreases the respiratory rate; and maintains the tidal volume for pH greater than 7.4. The developed fuzzy system can therefore be applied as a physician–ventilator interface to guide the clinician/physician during the ventilation, so as, to reduce the human errors and ensure lung protection.

A Trial of Adding Lung Protective Strategies to Existing Enhanced Recovery After Surgery Protocols and Its Effect on Improving Postoperative Lung Function.

With this rising popularization of enhanced recovery after surgery (ERAS) protocols, it is important to ask if the current and developing pathways are fully comprehensive for the patient's perioperative experience. Many current pathways discuss aspects of care including fluid management, pain management, and anti-emetic medication regiments, but few delineate recommendations for lung protective strategies. The hypothesis was that intraoperative lung protective strategies would results in improved postoperative lung function. One hundred patients at the Medical University of South Carolina undergoing hepatobiliary and colorectal surgeries were randomized to receive intraoperative lung protective techniques or a standard intraoperative ventilation management. Three maximum vital capacity breaths were recorded preoperatively, and postoperatively 30 min, 1 h, and 2 h after anesthesia stop time. Average maximum capacity breaths from all four data collection interactions were analyzed between both study and control cohorts. There was no significant difference in the preoperative inspiratory capacity between the control and the ERAS group (2,043.3 ± 628.4 mL vs. 2,012.2 ± 895.2 mL; P = 0.84). Additional data analysis showed no statistically significant difference between ERAS and control groups: total average of the inspiratory capacity volumes (1,253.5 ± 593.7 mL vs. 1,390.4 ± 964.9 mL; P = 0.47), preoperative oxygen saturation (97.76±2.3% vs. 98.04±1.7%; P = 0.50), the postoperative oxygen saturation (98.51±1.4% vs. 96.83±14.2%; P = 0.40), and change in inspiratory capacity (95% confidence interval (CI) (-211.2 - 366.6); P = 0.60). No statistically significant difference in postoperative inspiratory capacities were seen after the implementation of intraoperative lung protective strategies. The addition of other indicators of postoperative lung function like pneumonia incidence or length of inpatient stay while receiving oxygen treatment could provide a fuller picture in future studies, but a higher power will be needed.

Perioperative anaesthetic management in post Fontan adult patient with kyphoscoliosis for transsphenoidal resection of pituitary tumour

Pituitary macroadenomas are most common suprasellar tumours in adult. Trans sphenoidal approach is commonly used for tumour resection. We report a case of forty four year old female who had undergone fontan palliation procedure at age of 19 years with pulmonary stenosis, thoracic khyphoscoliosis and pulmonary artery hypertension at present who presented for excision of tumor. Along with general concerns of pituitary patient was nebulised with bronchodilators, milrinone, encouraged spirometry, lung protection strategies were used for ventilation and hemodynamic stability maintained. Multi system involvement poses challenge to anaesthetists as it demands management and care of all the involved systems.

Comparison Of P/F Ratio In Ventilated ARDS Patients Using Driving Pressure Strategy And Conventional Lung-Protective Strategy Method In ICU H. Adam Malik Hospital Medan

Comparison Of P/F Ratio In Ventilated ARDS Patients Using Driving Pressure Strategy And Conventional Lung-Protective Strategy Method In ICU H. Adam Malik Hospital Medan