Reduction In Respiratory Complications Research Articles

Intraoperative Dexamethasone is associated with a lower risk of respiratory failure in Thoracic Surgery: Observational cohort study (SURTHODEX).

Postoperative complications, particularly respiratory complications, are of significant clinical concern in patients undergoing elective thoracic surgery. Dexamethasone (DXM), commonly administered to prevent postoperative nausea and vomiting (PONV), has potential anti-inflammatory effects that might be beneficial in reducing these complications. We aimed to investigate whether intraoperative DXM administration could mitigate the occurrence of respiratory complications following elective thoracic surgery. We conducted a single-center observational study, including patients who underwent elective thoracic surgery from 2012 to 2020. The primary outcome was the onset of acute respiratory failure within 7 days post-surgery. Secondary outcomes encompassed other postoperative complications, duration of hospital stay, and mortality within 30 days post-surgery. An overlap propensity score analysis was employed to estimate the treatment effect. We included 1,247 adult patients, 897 who received dexamethasone (DXM) and 350 who served as controls. Intraoperative dexamethasone administration was associated with a significant reduction in respiratory complications with an adjusted relative risk (RR) of 0.65 (95% CI: 0.43-0.97). There was also a significant decline in composite infectious criteria with an adjusted RR of 0.76 (95% CI: 0.63-0.93). Cardiac complications were also assessed as a composite criterion, and a significant reduction was observed (adjusted RR, 0.68; 95% CI, 0.51-0.9). However, there were no association with mechanical complications, mortality within 30 days (adjusted RR of 0.43, 95% CI: 0.17-1.09) or in the length of hospital stay (adjusted RR of 0.85, 95% CI: 0.71-1.02). Dexamethasone administration was associated with a reduction in postoperative respiratory complications. Further prospective studies are needed to confirm these findings.

COMPARISON BETWEEN BASKA MASK AND I-Gel INSERTION IN MINOR SURGERIESUNDER GENERAL ANAESTHESIA IN PATIENT AGED 18-50 Y:-A RANDOMIZEDINTERVENTIONAL STUDY

Objective: The supraglottic airway (SAD) is considered a viable alternative to endotracheal intubation, particularly in cases where SAD is not contraindicated. SAD plays a crucial role in difficult airway algorithms, offering unobstructed oxygenation and ventilation, as well as providing hemodynamic stability with minimal laryngopharyngeal morbidity. The LMA-classic, introduced by Archie Brain in 1983, was the first second-generation SAD used in clinical practice. Over time, numerous advancements have led to the development of improved second-generation SADs.
 Methods: This study aims to compare the efficacy and advantages of different supraglottic airway devices. Two types of second-generation SADs were evaluated:I-gel (Intersurgical, Wokingham, UK) and a novel device called Baska Mask, which belongs to the third generation of SADs. The evaluation criteria included ease of insertion, oropharyngeal sealing pressure, ability to drain gastric fluid, prevention of malposition, sealing pressure during controlled ventilation and spontaneous breathing, and reduction of respiratory complications.
 Results: The second-generation SADs, including the I-gel, are easy to insert and offer high oropharyngeal sealing pressure. They have a gastric channel to drain gastric fluid, reducing aspiration risk. The I-gel, a new latex-free SAD with a noninflatable cuff made of medical-grade thermoplastic elastomer, provides a superior seal, resulting in lower respiratory complications compared to earlier SADs. It ensures effective sealing during controlled ventilation and spontaneous breathing. The third-generation Baska Mask combines the advantages of second-generation LMAs and provides higher seal pressure during IPPV by apposing to the glottis, distinguishing it from non-inflatable cuff devices like the I-gel.
 Conclusion: Supraglottic airway devices, particularly second-generation SADs like I-gel, offer effective airway management alternatives to endotracheal intubation. These devices provide ease of insertion, high oropharyngeal sealing pressure, and the ability to drain gastric fluid, reducing the risk of complications. The third-generation device, Baska Mask, exhibits enhanced seal pressure during IPPV, making it a promising advancement in airway management.

Diabetes, Drug Treatment, and Mortality in COVID-19: A Multinational Retrospective Cohort Study.

Patients with type 2 diabetes mellitus (T2DM) are at increased risk of severe coronavirus disease 2019 (COVID-19) outcomes possibly because of dysregulated inflammatory responses. Glucose-regulating medications, such as glucagon-like peptide 1 receptor (GLP-1R) agonists, dipeptidyl peptidase 4 (DPP-4) inhibitors, and pioglitazone, are known to have anti-inflammatory effects that may improve outcomes in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In a multinational retrospective cohort study, we used the TriNetX COVID-19 Research Network of 56 large health care organizations to examine these medications in relation to the incidence of hospital admissions, respiratory complications, and mortality within 28 days after a COVID-19 diagnosis. After matching for age, sex, race, ethnicity, BMI, and significant comorbidities, use of GLP-1R agonists and/or pioglitazone was associated with significant reductions in hospital admissions (GLP-1R: 15.7% vs. 23.5%, risk ratio [RR] 0.67 [95% CI 0.57–0.79; P < 0.001]; pioglitazone: 20.0% vs. 28.2%; RR 0.71 [95% CI 0.54–0.93; P = 0.01]). Use of GLP-1R agonists was also associated with reductions in respiratory complications (15.3% vs. 24.9%, RR 0.62 [95% CI 0.52–0.73]; P < 0.001) and incidence of mortality (1.9% vs. 3.3%, RR 0.58 [95% CI 0.35–0.97]; P = 0.04). Use of DPP-4 inhibitors was associated with a reduction in respiratory complications (24.0% vs. 29.2%, RR 0.82 [95% CI 0.74–0.90]; P < 0.001), and continued use of DPP-4 inhibitors after hospitalization was associated with a decrease in mortality compared with those who discontinued use (9% vs. 19%, RR 0.45 [95% CI 0.28–0.72]; P < 0.001). In conclusion, use of glucose-regulating medications, such as GLP-1R agonists, DPP-4 inhibitors, or pioglitazone, may improve COVID-19 outcomes for patients with T2DM; randomized clinical trials are needed to further investigate this possibility.

A Sensitive Matter: Performance of Contemporary Outcomes Measures in Detecting Complications in Complex Endovascular Aortic Repair

Agency for Healthcare Research and Quality Patient Safety Indicators are quality improvement indicators used to determine hospital performance and, increasingly, to rank surgical programs. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the Society for Vascular Surgery Vascular Quality Initiative (SVS-VQI) databases are also frequently used to compare outcomes, but definitions of complications vary between the systems, and the optimal system for tracking complications in complex endovascular repair remains unclear. Herein we assess the three outcomes tracking systems and their ability to capture complications in fenestrated endovascular (FEVAR) and open aortic aneurysm (OAR) repair at a large complex aortic program. Demographic and operative data for patients undergoing repair of juxta- or pararenal aortic aneurysms between 2004 and 2018 via both open and fenestrated endovascular (FEVAR) approaches at the Johns Hopkins Medical Institutions were compiled in a prospectively maintained retrospective database. Postoperative complications were defined according to the SVS-VQI, ACS-NSQIP and data dictionaries and were compared between surgical approaches as well as eras before and after the introduction of FEVAR. Complication rates between the classification systems were compared using proportion testing and strength of correlation between the systems was evaluated with Spearman’s rank test. Statistical analysis was performed with Stata version 15.1 (StataCorp, Cary, NC). Introduction of fenestrated technology was associated with a decrease in the overall number of complications (37.2% to 20.6%; P = .036). By classification systems, VQI identified the most complications (39.9% of the entire cohort and 25% of FEVAR cases), followed by NSQIP (29.0% and 33.3%, respectively) and PSI (4.1% and 5%, respectively). The two clinically focused databases were found to correlate well with a surgeon-designed classification system as well as each other (Spearman ρ ≥ 0.735) but not with PSI (ρ < 0.23). Proportion testing demonstrated the rate of complications identified by PSI to be significantly less than either VQI or NSQIP (P < .001). Specifically, PSI did not effectively identify renal complications (1.4% vs 9% by NSQIP and 27.3% by VQI definitions; P < .001). The introduction of FEVAR is associated with an overall reduction in complications in this study, mostly owing to a reduction in respiratory complications. The clinically relevant VQI and NSQIP databases show good concordance in capturing complications; however, PSI did not correlate with either and captured significantly fewer complications. This highlights the value of high scrutiny classification systems to track endovascular complications and suggests that PSI are insufficient to rank complex aortic programs with high levels of FEVAR use.

LO93: A single center randomized control trial of intravenous lidocaine for the management of traumatic rib fractures

Introduction: Traumatic rib fractures (RF) are a common occurrence with 10% incidence in all trauma patients and are associated with significant morbidity and mortality. Adequate analgesia is paramount for preventing pulmonary complications and reducing morbidity and mortality. There is evidence of intravenous (IV) lidocaine's effectiveness and safety in the post-operative thoracic and abdominal surgical patient and we hypothesize that it may be ideal in trauma patients with RF. We evaluated IV lidocaine's analgesic efficacy in this population. Methods: A single-centre, double-blind, randomized control trial comparing a 72-96 hour IV lidocaine infusion plus standard analgesics to placebo infusion plus standard analgesics. Participants were adult trauma patients diagnosed with two or more RFs requiring hospital admission. A total of 36 patients were enrolled over 5 months in 2019. The study was powered to detect a 20% reduction in pain scores, which is determined to be clinically significant. Results: The primary outcome was mean pain score at rest and with movement, as measured on the Visual Analog Scale (VAS). There were consistent trends toward reduced VAS pain scores at rest and with movement in the lidocaine group as compared to placebo group with mean scores of 3.49 [SD 2.02 95% CI] and 7.08 [SD 1.71 95% CI] in the lidocaine group and 3.83 [SD 1.93 95% CI] and 8.03 [SD 1.44 95% CI] in the placebo group, at rest (p value 0.624) and with movement (p value 0.110), respectively . Secondary outcomes were patient satisfaction as measured on the VAS which demonstrated a score of 7.79 [SD 1.82 95% CI] in the lidocaine group and 6.63 [SD 1.77 95% CI] (p = 112) in the placebo group, and total morphine equivalents (ME) used (including breakthrough doses) that demonstrated a trend towards a reduction in the lidocaine group with 210.9 mg [SD 180.0 95% CI] compared to the placebo with total ME used of 309.9 mg [SD 221.8 95% CI]. Other secondary outcomes were protocol adherence, incidence of respiratory failure, hospital and ICU length of stay, mortality, incidence of lidocaine toxicity, and treatment regimens (non-opioid analgesics). Conclusion: These results demonstrate a trend towards lidocaine's analgesic benefit during rest and the critical times of patient movement and mobility, which has been demonstrated to be paramount in the reduction of respiratory complications from rib fractures. The results also tend towards a reduction in morphine equivalents, although the trial was not powered to demonstrate this

Abdominal Functional Electrical Stimulation to Augment Respiratory Function in Spinal Cord Injury.

Background: Functional electrical stimulation (FES) is the application of electrical pulses to a nerve to achieve a functional muscle contraction. Surface electrical stimulation of the nerves that innervate the abdominal muscles, termed abdominal FES, can cause the abdominal muscles to contract, even when paralysed after spinal cord injury. As the abdominal muscles are the major expiratory muscles, and commonly partially or completely paralysed in tetraplegia, abdominal FES offers a promising method of improving respiratory function for this patient group. Objective: The aim of the article is to provide readers with a better understanding of how abdominal FES can be used to improve the health of the spinal cord-injured population. Methods: A narrative review of the abdominal FES literature was performed. Results: Abdominal FES can achieve an immediate effective cough in patients with tetraplegia, while the repeated application over 6 weeks of abdominal FES can improve unassisted respiratory function. Ventilator duration and tracheostomy cannulation time can also be reduced with repeated abdominal FES. Conclusion: Abdominal FES is a noninvasive method to achieve functional improvements in cough and respiratory function in acute and chronically injured people with tetraplegia. Potential practical outcomes of this include reduced ventilation duration, assisted tracheostomy decannulation, and a reduction in respiratory complications. All of these outcomes can contribute to reduced morbidity and mortality, improved quality of life, and significant potential cost savings for local health care providers.

Heart beats: not to be beaten.

Heart beats: not to be beaten.

Haemodynamics in a patient with Fontan physiology undergoing laparoscopic cholecystectomy.

Laparoscopic surgery in patients with Fontan circulation is a haemodynamic challenge; venous return may be compromised by insufflation of carbon dioxide into the abdomen (increasing intra-abdominal pressure), the use of reverse Trendelenburg position and positive pressure ventilation. Combined with an increase in pulmonary vascular resistance due to hypercarbia, cardiac output may be reduced. However, for non-haemodynamic reasons, laparoscopic surgery has advantages over open surgery: less postoperative pain, shorter hospital stay, a reduction in postoperative wound infections and a reduction of respiratory complications. In this case report, we present a patient with Fontan circulation who underwent uneventful laparoscopic cholecystectomy.

Intraoperative Extracorporeal Membrane Oxygenation as an Alternative to Cardiopulmonary Bypass in Lung Transplantation

Purpose Extracorporeal membrane oxygenation (ECMO) may be used for intraoperative support as an alternative to cardiopulmonary bypass (CPB) during lung transplantation. We sought to evaluate its efficacy. Methods and Materials We reviewed lung transplants with intraoperative support (CPB or ECMO) from 8/09-11/12. Patients were stratified into groups by type of support. Postoperative ECMO utilization, graft and overall survival were compared along with blood product utilization and complications. For comparisons, a 2:1 propensity matched cohort of CPB:ECMO was analyzed. Results 169 patients underwent lung transplantation with mechanical support during the study period (17 ECMO and 152 CPB). Demographic were similar in both groups with higher mean Lung Allocation Score (LAS; 83 vs 56) in the ECMO group. Patients transplanted on ECMO in the overall groups were extubated earlier (0.8 vs 4.8 days; p=0.11) and had significantly decreased rates of respiratory failure post transplantation (29% vs 6%; p=0.04) with similar trends in the propensity matched cohort. There were no differences in postoperative ECMO utilization between groups. A trend toward improved overall survival was seen with ECMO at 1 year (100% vs 77%) and 3 years (100% vs 66%; p=0.13). Graft survival was significantly improved in the ECMO group (p=0.05). [ figure 1 ] Conclusions Intraoperative ECMO support for primary lung transplantation is comparable to CPB and is associated with earlier extubation, significant reduction in respiratory complications, a trend toward lower transfusion requirement and improved overall survival. Graft survival was significantly improved with the use of ECMO. Further longitudinal data is necessary.

Minimally invasive esophagectomy: an overview

Minimally invasive approaches to esophageal resection have been shown to be feasible and safe, with outcomes similar to open esophagectomy. There are no controlled trials comparing the outcomes of minimally invasive esophagectomy (MIE) with open techniques, just a few comparative studies and many single institution series from which assessment of MIE and its present role have been made. The reported improvements from MIE approaches include reduced blood loss, time in intensive care and time in hospital. In comparative studies there is no clear reduction in respiratory complications, although larger series suggest there may be a benefit from MIE. Although MIE approaches report less lymph node retrieval compared with open extended lymphadenectomy, MIE cancer outcomes are comparable with open surgery. MIE will be a major component of the future esophageal surgeons’ armamentarium, but should continue to be carefully assessed. There is a role for multicentered studies to prospectively audit outcomes. Large numbers of patients would be required to perform randomized trials of MIE versus open resection.

Pro: Early endotracheal extubation is preferable to late extubation in patients following coronary artery surgery

Prolonged mechanical ventilation following CABG should not be uncritically considered "routine," and should only be used where indicated. A thorough physiologic and clinical evaluation with attention to hemodynamics, neurologic status, temperature and metabolism, hemostasis, and respiratory reserve should precede extubation. Continued post-operative ventilation is indicated in patients at high risk for complications, and it is possible to identify this subset preoperatively and upon arrival in the postoperative ICU. Early extubation (within 8 hours of arrival) should otherwise be the goal. The benefits of early extubation include improved cardiac function and patient comfort, reduction in respiratory complications, ease in management, and cost savings as the result of shortened length-of-stay in expensive postoperative units. More research is needed to clarify unanswered questions regarding ablating the stress response and avoiding myocardial ischemia.

Level of Consciousness on Arrival in the Recovery Room and the Development of Early Respiratory Morbidity

An audit review of 16,065 patients undergoing operative procedures under general anaesthesia was carried out to examine the relationship between early postoperative respiratory complications and the level of consciousness of patients on arrival in the recovery room. In patients aged over ten years, the incidence of respiratory complications was significantly (P less than 0.005) related to the level of consciousness independent of ASA grade or age. Since the level of consciousness of patients arriving in the recovery room could be modified by changes to anaesthetic practice it is concluded that a significant reduction in respiratory complications might be possible if anaesthetists used general anaesthetic techniques which returned patients awake to the recovery room.

Level of Consciousness on Arrival in the Recovery Room and the Development of Early Respiratory Morbidity

An audit review of 16,065 patients undergoing operative procedures under general anaesthesia was carried out to examine the relationship between early postoperative respiratory complications and the level of consciousness of patients on arrival in the recovery room. In patients aged over ten years, the incidence of respiratory complications was significantly (P less than 0.005) related to the level of consciousness independent of ASA grade or age. Since the level of consciousness of patients arriving in the recovery room could be modified by changes to anaesthetic practice it is concluded that a significant reduction in respiratory complications might be possible if anaesthetists used general anaesthetic techniques which returned patients awake to the recovery room.

Guidelines for Routine Respiratory Care of Patients with Spinal Cord Injury

Pulmonary compromise is a leading cause of morbidity in patients with spinal cord injury (SCI). Because these patients have such complex and massive needs, routine respiratory care is not always given the priority it deserves in a rehabilitation program. Our institution established a committee to formulate guidelines for the routine respiratory care of patients in our interdisciplinary Acute Spinal Cord Injury Program. The guidelines consisted of evaluation, treatment, and teaching interventions. The purposes of the guidelines were to increase staff awareness of the need for routine, prophylactic respiratory care of patients with SCI; to be an effective teaching tool for staff, thus resulting in a reduction of respiratory complications; and also to be a teaching tool for patients and their families so that routine respiratory care could be continued in the home. After using the guidelines for over a year, we believe that the quality of the respiratory care we provide our patients with SCI has improved. The respiratory care is more comprehensive, consistent, and coordinated among disciplines.