Reduction In Pulmonary Complications Research Articles

Neuraxial Anesthesia and Analgesia During Cardiothoracic Surgery: A Narrative Review.

The purpose of this review is to synthesize and examine the literature on the use of neuraxial anesthesia and analgesia during cardiothoracic surgery. As cardiothoracic procedures often require systemic anticoagulation, neuraxial techniques are quite often underutilized due to the theoretical risk of epidural hematoma. In this review, we seek to examine the literature to review the indications and contraindications and to explore if neuraxial anesthesia and analgesia has a role in cardiothoracic surgery. Neuraxial techniques have multiple advantages during cardiothoracic surgery including coronary vasodilation, decreased sympathetic surge, and a decreased cortisol level leading to overall reduction in stress response. Multiple studies have shown an improvement in pain scores, reduction in pulmonary complications, faster extubation times, with minimal complications when neuraxial techniques are utilized in cardiothoracic surgeries. Given the numerous advantages and minimal complications of neuraxial techniques in cardiothoracic surgeries, we hope its utilization continues to increase. Moving forward, we hope additional studies continue to reaffirm the benefits of neuraxial anesthesia and analgesia for cardiothoracic surgeries to improve its utilization.

257. UPDATE OF THE INTRODUCTION OF MINIMALLY INVASIVE TRANSCERVICAL ESOPHAGECTOMY (MICE), CLINICAL OUTCOMES OF THE LEARNING CURVE COHORT

Abstract Background Surgical resection remains the cornerstone of curative treatment for patients with esophageal cancer. Transthoracic minimally invasive esophagectomies have reduced the occurrence of pulmonary complications, however it is still associated with significant morbidity. The Minimally Invasive transCervical Esophagectomy (MICE) is a novel surgical technique. To date this technique is not routinely performed in Western esophageal cancer patients. We aim to assess the safety and efficacy of the MICE procedure in Dutch patients with esophageal carcinoma. An update of the clinical outcomes of the learning curve cohort. Methods The MICE is a recently developed surgical technique in Japan. The procedure combines a laparoscopic transhiatal and single-port transcervical mediastinal dissection and aims to ensure a radical oncological resection with a reduction of pulmonary complications because a thoracotomy/scopy is avoided. Potential drawbacks may be an increased incidence of recurrent laryngeal nerve paresis (RLNP) and learning associated morbidity. A prospective pilot study was performed including consecutive patients undergoing MICE for esophageal cancer. Results Results will be updated up to August 2023, probably around 70 cases. A total of 50 patients were included in this study in Januari 2023 (male/female ratio 16:4, median age 71 years (IQR 52–85). Median operation time and blood loss was 350 minutes (IQR 326–360) and 100 mL (IQR 50–175). Conversion occurred in five patients (12%). Anastomotic leakage occurred in four patients (10%, 3 ECCG grade 1 and 1 ECCG grade 3). Pneumonia, pleural effusion and chyle leakage occurred in two (5%), five 12%) and two (5%) patients. Recurrent laryngeal nerve paralysis was seen in 22 patients (55%), at least 16 (73%) of which were only temporary. Median length-of-stay was 9 days (IQR 7–10). Conclusion MICE is a novel minimally invasive surgical technique which seems safe and effective to perform in Dutch patients with esophageal carcinoma. As expected, a higher incidence of RLNP was seen, but often only temporarily. Long-term safety and effectiveness will be prospectively evaluated in a larger population.

Do advances in technology translate to improved outcomes? Comparing robotic bariatric surgery outcomes over two-time intervals utilizing the MBSAQIP database.

This study aims to compare outcomes and utilization of robotics in bariatric procedures across two-time intervals, chosen because they correspond to drastic changes in technology utilization-namely, a new platform and a new stapling device. Outcomes of robotic Roux-en-Y gastric bypass (rRYGB) and robotic sleeve gastrectomy (rSG) across this changing landscape have not been well studied, despite increasing popularity. The MBSAQIP database was analyzed over early (2015-2016) and late (2019-2020) time intervals. Patients who underwent rSG and rRYGB were identified, and the cohorts were matched for 26 preoperative characteristics using Propensity Score Matching Analysis. We then compared 30-day outcomes and bariatric-specific complications between the early and late time frames for rSG and rRYGB. 49,442 rSG were identified: 13,526 cases in the early time frame and 35,916 in the late time frame. The matched cohorts were 13,526 for the two groups. 30-day outcomes showed that in the late time frame, rSG was associated with lower rates of pulmonary complications (0.1% vs 0.3%, p < 0.001), readmissions (2.5% vs 3.6%, p < 0.001), interventions (0.6% vs 1.4%, p < 0.001), reoperations (0.7% vs 1.0%, p = 0.024), length of stay (1.36 ± 1.01days vs 1.76 ± 1.79days, p < 0.001), operative time (92.47 ± 41.70min vs102.76 ± 45.67min p < 0.001), staple line leaks (0.2% vs 0.4%, p = 0.001) and strictures (0.0% vs 0.2%, p < 0.001). Similarly, 21,933 rRYGB were found: 6,514 cases were identified in the early time frame and 15,419 in the late time frame. The matched cohorts were 6,513 for the two groups. 30-day outcomes revealed that the late time fame rRYGB was associated with lower rates of pulmonary complications (0.1% vs 0.3%, p = 0.012), readmissions (6.3% vs 7.2%, p = 0.050), interventions (2.0% vs 3.1%, p < 0.001), length of stay (1.69 ± 1.46days vs 2.13 ± 2.12days p < 0.001), postoperative bleeding (0.4% vs 0.7%, p = 0.001), stricture (0.4% vs 0.8%, p < 0.001) and anastomotic ulcer (0.2% vs 0.4%, p = 0.013). Compared to early robotic bariatric surgery outcomes, a significant reduction in pulmonary complications, readmissions, reoperations, interventions and length of stay were seen in 2019-20 after rSG and rRYGB. Potential contributing factors include increased surgical experience and advances in the robotic platform. A significant recent reduction in staple line leaks with faster operative times associated with rSG suggests that stapling technology has had a positive impact on patient outcomes.

609. MINIMALLY INVASIVE CERVICAL ESOPHAGECTOMY (MICE): FIRST RESULTS OF A DUTCH PILOT STUDY

Abstract Surgical resection remains the cornerstone of curative treatment for patients with esophageal cancer. Transthoracic minimally invasive esophagectomies have reduced the occurrence of pulmonary complications, however it is still associated with significant morbidity. The Minimally Invasive Cervical Esophagectomy (MICE) is a novel surgical technique. To date this technique is not routinely performed in European esophageal cancer patients. We aim to assess the safety and efficacy of the MICE procedure in Dutch patients with esophageal carcinoma. The MICE is a recently developed surgical technique in Japan. The procedure combines a laparoscopic transhiatal and single-port transcervical mediastinal dissection and aims to ensure a radical oncological resection with a reduction of pulmonary complications because a thoracotomy/scopy is avoided. A prospective pilot study was performed including consecutive patients undergoing MICE for esophageal cancer. Twenty patients were included. The male/female ratio was 16:4 with a median age of 71 years (IQR 52-85). Median operation time and blood loss was 350 minutes (IQR 326-360) and 100 ml (IQR 50-175). Conversion occurred in five patients (20%). Recurrent laryngeal nerve paralysis was seen in seven patients (35%), at least six of which were temporary. Anastomotic leakage occurred in three patients (15%, 2 ECCG grade 1 and 1 ECCG grade 3). Pneumonia, chyle leakage and hemothorax all occurred once in different patients (Clavien-Dindo grade 2, 4 and 3a, respectively). The median length-of-stay was 10 days (IQR 7-10). MICE is a novel minimally invasive surgical technique which seems safe and effective to perform in Dutch patients with esophageal carcinoma. As expected, a higher incidence of RLNP was seen, in most cases only temporarily. Long-term safety and effectiveness will be prospectively evaluated in a larger population.

Th Effect of Nursing Intervention on the Reduction of Pulmonary Complications after Thoracotomy

Th Effect of Nursing Intervention on the Reduction of Pulmonary Complications after Thoracotomy

Ventilatory weaning strategies for predicting extubation success in children following cardiac surgery for congenital heart disease: a protocol for a systematic review and meta-analysis

IntroductionCongenital heart disease (CHD) comprises the anatomic malformations that jeopardise the structure and function of the heart. It can be extremely complex and serious, corresponding to 30% of all deaths...

Regional Anaesthesia for Lower Extremity Amputation is Associated with Reduced Post-operative Complications Compared with General Anaesthesia

Primary and secondary lower extremity amputation, performed for patients with lower extremity arterial disease, is associated with increased post-operative morbidity. The aim of the study was to assess the impact of regional anaesthesia vs. general anaesthesia on post-operative pulmonary complications. A retrospective analysis of 45 492 patients undergoing lower extremity amputation between 2005 and 2018 was conducted using data from the American College of Surgeons National Safety Quality Improvement Program database. Multivariable logistic regression was carried out to assess differences in primary outcome of post-operative pulmonary complications (pneumonia or respiratory failure requiring re-intubation) within 48 hours and 30 days after surgery between patients receiving regional (RA) or general anaesthesia (GA). Secondary outcomes included post-operative blood transfusion, septic shock, re-operation, and post-operative death within 30 days. Of 45 492 patients, 40 026 (88.0%) received GA and 5 466 (12.0%) RA. Patients who received GA had higher odds of developing pulmonary complications at 48 hours (2.1% vs. 1.4%; adjusted odds ratio [aOR] 1.39, 95% confidence interval [CI] 1.09 - 1.78; p= .007) and within 30 days (6.3% vs. 5.9%; aOR 1.15, 95% CI 1.09 - 1.78; p= .039). The odds of blood transfusions (aOR 1.11, 95% CI 1.02 - 1.21; p= .017), septic shock (aOR 1.29, 95% CI 1.03 - 1.60; p= .025) and re-operation (OR 1.26, 95% CI 1.03 - 1.53; p= .023) were also higher for patients who received GA vs. patients who received RA. No difference in mortality rate was observed between patients who received GA and those who received RA (5.7% vs. 7.1%; odds ratio 0.95, 95% CI 0.84 - 1.07). A statistically significant reduction in pulmonary complications was observed in patients who received RA for lower extremity amputation compared with GA.

Enhanced Post-Operative Recovery with Continuous Peripheral Nerve Block After Lower Extremity Amputation

Despite progress in perioperative care standards, there has not been a significant risk reduction in morbidity and mortality rates of lower extremity amputations, an intermediate risk surgery performed on high risk patients. The single-shot peripheral nerve block has shown equivocal impact on postoperative course following lower extremity amputation. Hence, we assessed the potential of preemptive use of continuous catheter-based peripheral nerve block in lower extremity amputations for reduction in pulmonary complications, acute post-operative pain scores, and opioid use in post-operative period. A retrospective review of a quality improvement project initiated in 2018 was conducted to compare outcomes amongst general anesthesia in combination with a catheter-based peripheral nerve block (catheter group) and general anesthesia alone in patients receiving lower extremity amputation. The rate of postoperative pulmonary complications was identified as a primary endpoint. The secondary outcomes assessed were acute post-operative pain scores and opioid consumption up to 48 hours. Our analysis was adjusted for potential confounding variables inclusive of demographics, medical comorbidities, type of surgical procedure and smoking status. Ninety-six patients were included in the study (61 in the general anesthesia group, 35 in the catheter group). After adjusting for baseline demographics, comorbidities, surgical technique and smoking status, the odds of postoperative pulmonary complications were significantly lower with catheter-based peripheral nerve block in comparison to general anesthesia alone, OR 0.11 [95% CI, 0.01- 0.88] (P = 0.048). The decrease in acute pain scores was also observed in the catheter group when compared to general anesthesia alone, OR 0.72 [95% CI, 0.56 - 0.93] (P = 0.012). Similarly, the opioid consumption was also lower in the catheter group in comparison to general anesthesia alone, OR 0.97 [95% CI, 0.95 - 0.99] (P = 0.025). Preemptive use of continuous peripheral nerve block in patients undergoing lower extremity amputation reduces the incidence of pulmonary complications, acute postoperative pain scores and narcotic use in post-operative period.

A Lower Tidal Volume Regimen during One-lung Ventilation for Lung Resection Surgery Is Not Associated with Reduced Postoperative Pulmonary Complications

Protective ventilation may improve outcomes after major surgery. However, in the context of one-lung ventilation, such a strategy is incompletely defined. The authors hypothesized that a putative one-lung protective ventilation regimen would be independently associated with decreased odds of pulmonary complications after thoracic surgery. The authors merged Society of Thoracic Surgeons Database and Multicenter Perioperative Outcomes Group intraoperative data for lung resection procedures using one-lung ventilation across five institutions from 2012 to 2016. They defined one-lung protective ventilation as the combination of both median tidal volume 5 ml/kg or lower predicted body weight and positive end-expiratory pressure 5 cm H2O or greater. The primary outcome was a composite of 30-day major postoperative pulmonary complications. A total of 3,232 cases were available for analysis. Tidal volumes decreased modestly during the study period (6.7 to 6.0 ml/kg; P < 0.001), and positive end-expiratory pressure increased from 4 to 5 cm H2O (P < 0.001). Despite increasing adoption of a "protective ventilation" strategy (5.7% in 2012 vs. 17.9% in 2016), the prevalence of pulmonary complications did not change significantly (11.4 to 15.7%; P = 0.147). In a propensity score matched cohort (381 matched pairs), protective ventilation (mean tidal volume 6.4 vs. 4.4 ml/kg) was not associated with a reduction in pulmonary complications (adjusted odds ratio, 0.86; 95% CI, 0.56 to 1.32). In an unmatched cohort, the authors were unable to define a specific alternative combination of positive end-expiratory pressure and tidal volume that was associated with decreased risk of pulmonary complications. In this multicenter retrospective observational analysis of patients undergoing one-lung ventilation during thoracic surgery, the authors did not detect an independent association between a low tidal volume lung-protective ventilation regimen and a composite of postoperative pulmonary complications.

Liposomal Bupivacaine Intercostal Block Is Important for Reduction of Pulmonary Complications

We have previously demonstrated that Enhanced Recovery After Surgery protocols are associated with a reduction in pulmonary complications. As a component of enhanced recovery pathways, intercostal nerve blocks with liposomal bupivacaine are increasingly utilized, but the extent to which this element may contribute to such outcomes has not been evaluated. Patients undergoing lung resection for stage I to III non-small cell lung cancer at a single institution from 2006 to 2017 were examined for major postoperative pulmonary morbidity, defined as pneumonia, acute respiratory distress syndrome, respiratory arrest, reintubation, bronchoscopy, or need for discharge with oxygen. Pharmacy records were queried for administration of liposomal bupivacaine via posterior intercostal nerve block. Patients treated with and without liposomal bupivacaine were compared in a logistic regression to determine the impact on pulmonary morbidity. A total of 2865 patients were identified, including 860 (30%) who were treated with liposomal bupivacaine via posterior intercostal block. Pulmonary morbidity occurred in 455 (16%). Adoption of liposomal bupivacaine analgesia occurred over several years, beginning in 2012 to full adoption by 2017. Liposomal bupivacaine management was associated with a reduction in pulmonary complications, as compared with nonuse (odds ratio, 0.63; P= .006). Additional factors associated with the occurrence of pulmonary morbidity were age, body mass index, smoking, spirometry values, and operative blood loss. As a component of an active enhanced recovery program, liposomal bupivacaine is associated with a reduction in major pulmonary complications, and utilization should be evaluated on a hospital-by-hospital basis.

A Simple Protocol to Stratify Pulmonary Risk Reduces Complications After Total Joint Arthroplasty

BackgroundPulmonary complications after total joint arthroplasty are a burden to patients and the healthcare system. The aim of this study is to demonstrate the effectiveness of a pulmonary screening questionnaire and intervention protocol developed at our institution to prevent pulmonary complications. MethodsBetween 2010 and 2015, 7658 consecutive total joint arthroplasty patients at our institution were reviewed. Based on our pre-operative pulmonary risk assessment tool, 1625 patients were flagged as high pulmonary risk. Patients were determined to be high risk if they were a current or former heavy smoker with an abnormal spirometry, had a positive obstructive sleep apnea screening, required continuous positive airway pressure/bi-level positive airway pressure use, had a history of significant pulmonary disease, had an oxygen saturation <90%, or had body mass index >40. A standardized monitoring protocol and interventions including smoking cessation, treatment and optimization of primary pulmonary conditions, peri-operative inhaler use, spinal anesthesia, aspiration precautions, elevated head of bed >20° resting and >45° while eating, maintaining oxygen saturation ≥92%, early use of incentive spirometer, avoidance of narcotics and early respiratory therapy consult were initiated for all high risk patients. ResultsOnly 7 of 7658 (0.091%) patients suffered pulmonary complications after initiating our intervention protocol. These included 3 aspiration pneumonias, 1 asthma exacerbation, 1 chronic obstructive pulmonary disease exacerbation, 1 continuous positive airway pressure intolerance in a patient with obstructive sleep apnea, and 1 requirement of bi-level positive airway pressure. The pulmonary risk questionnaire accurately identified all patients who had pulmonary complications. The overall pulmonary complication rate at our institution decreased from 5.7% to 0.09% after implementing our screening questionnaire and intervention protocol (P < .0001). ConclusionOur results demonstrate a more than 63-fold reduction in pulmonary complications at our institution. Our screening questionnaire and intervention protocol is an effective way of identifying and preventing pulmonary complications.

Patient blood management in cardiac surgery: Results

Abstract Objective The main objective of the study was to evaluate the effect of implementing a blood-saving programme in patients undergoing elective cardiac surgery with an analysis of the transfusion rate and complications. Materials and methods A single-centre, observational, retrospective, comparative study which included 604 consecutive patients older than 15 years old undergoing elective cardiac surgery. Two groups of patients were created according to whether or not they were included in a blood-saving protocol, and analysed between December 2012 and July 2013 (293 patients, prep group) and April 2015 to May 2016 (311 patients, posp group). Results The overall blood product transfusion rate was reduced in the posp group (89.5 vs. 67.6%; p Conclusions The implementation of a blood-saving programme in the cardiac surgery area has favourable consequences, such as a saving in blood product and a reduction of pulmonary complications, although without decreasing the mortality rate.

Programa de ahorro de sangre en cirugía cardiaca: resultados

ObjectiveThe main objective of the study was to evaluate the effect of implementing a blood-saving programme in patients undergoing elective cardiac surgery with an analysis of the transfusion rate and complications. Materials and methodsA single-centre, observational, retrospective, comparative study which included 604 consecutive patients older than 15 years old undergoing elective cardiac surgery. Two groups of patients were created according to whether or not they were included in a blood-saving protocol, and analysed between December 2012 and July 2013 (293 patients, prep group) and April 2015 to May 2016 (311 patients, posp group). ResultsThe overall blood product transfusion rate was reduced in the posp group (89.5 vs. 67.6%; P<0.001), as well as individually: red blood cell concentrates (83.6%; P<0.001), fresh frozen plasma (36.2 vs. 21.2%; P<0.001), platelets (40.8 vs. 32.7; P<0.001). By contrast, fibrinogen use increased from 16.4 to 49% (P<0.001). Postoperative complications were similar in both groups, except for pulmonary complications (57.8 vs. 43.1%; P<0.001). Length of hospital stay was similar in both groups except in the Critical Care Unit with longer stay for the prep group (5.81±8.00 vs. 4.18±4.38; P=0.002). Mortality did not change. ConclusionsThe implementation of a blood-saving programme in the cardiac surgery area has favourable consequences, such as a saving in blood product and a reduction of pulmonary complications, although without decreasing the mortality rate.

Heated humidified high-flow nasal cannula oxygen after thoracic surgery — A randomized prospective clinical pilot trial

BackgroundThoracic surgery patients are at high-risk for adverse pulmonary outcomes. Heated humidified high-flow nasal cannula oxygen (HHFNC O2) may decrease such events. We hypothesized that patients randomized to prophylactic HHFNC O2 would develop fewer pulmonary complications compared to conventional O2 therapy. Methods and patientsFifty-one patients were randomized to HHFNC O2 vs. conventional O2. The primary outcome was a composite of postoperative pulmonary complications. Secondary outcomes included oxygenation and length of stay. Continuous variables were compared with t-test or Mann-Whitney-U test, categorical variables with Fisher's Exact test. ResultsThere were no differences in postoperative pulmonary complications based on intention to treat [two in HHFNC O2 (n=25), two in control (n=26), p=0.680], and after exclusion of patients who discontinued HHFNC O2 early [one in HHFNC O2 (n=18), two in control (n=26), p=0.638]. Discomfort from HHFNC O2 occurred in 11/25 (44%); 7/25 (28%) discontinued treatment. ConclusionsPulmonary complications were rare after thoracic surgery. Although HHFNC O2 did not convey significant benefits, these results need to be interpreted with caution, as our study was likely underpowered to detect a reduction in pulmonary complications. High rates of patient-reported discomfort with HHFNC O2 need to be considered in clinical practice and future trials.

Management of anesthesia in endovascular interventions

Cardiovascular diseases are one of the leading causes of morbidity and mortality in Germany. In these patients, the high-risk profile necessitates an interdisciplinary and multimodal approach to treatment. Endovascular interventions and vascular surgery have become established as an important element of this strategy in the past; however, the different anatomical localizations of pathological vascular alterations make it necessary to use awide spectrum of procedural options and methods; therefore, the requirements for management of anesthesia are variable and necessitate adifferentiated approach. Endovascular procedures can be carried out with the patient under general or regional anesthesia (RA); however, in the currently available literature there is no evidence for an advantage of RA over general anesthesia regarding morbidity and mortality, although a reduction in pulmonary complications could be found for some endovascular interventions. Epidural and spinal RA procedures should be carefully considered with respect to the risk-benefit ratio and consideration of the recent guidelines on anesthesia against the background of the current study situation and the regular use of therapy with anticoagulants. The following article elucidates the specific characteristics of anesthesia management as exemplified by some selected endovascular interventions.

Active versus passive humidification for self-ventilating tracheostomy and laryngectomy patients: A systematic review of the literature

Objective To determine whether active or passive humidification methods are more effective in preventing pulmonary complications in self-ventilating neck breather patients. Design Systematic Review adhering to PRISMA guidance (checklist sourced from www.equator-network.org/). Setting Review of current published relevant literature at a tertiary department of Otolaryngology and Head & Neck Surgery. Participants We included all separate studies and comparison studies of active and passive humidification techniques in adult and paediatric neck breather patients. Main Outcome Measures The primary outcome is the reduction in pulmonary complications. Secondary outcomes include patient compliance; carer and user satisfaction. Results and Conclusions Seven studies were included in this review: two RCTs (133 patients), one randomised controlled cross-over trial (29 patients), three randomised prospective studies (171 patients), and one retrospective study (73 patients). Only one study was conducted on paediatric neck breathers. The overall quality of the studies was low. Five studies were at a high risk of bias. Of the remaining two studies, one study had a low risk of bias and the other had an unclear risk. Despite limited subject evidence, results show that passive methods of humidification (mainly HME) is the preferred choice of humidification in the spontaneously breathing neck breather patients group mainly due to the reduction in pulmonary complaints, and better patient compliance.

Active versus passive humidification for self‐ventilating tracheostomy and laryngectomy patients: a systematic review of the literature

To determine whether active or passive humidification methods are more effective in preventing pulmonary complications in self-ventilating neck breather patients. Systematic Review adhering to PRISMA guidance (checklist sourced from www.equator-network.org/). Review of current published relevant literature at a tertiary department of Otolaryngology and Head & Neck Surgery. We included all separate studies and comparison studies of active and passive humidification techniques in adult and paediatric neck breather patients. The primary outcome is the reduction in pulmonary complications. Secondary outcomes include patient compliance; carer and user satisfaction. Seven studies were included in this review: two RCTs (133 patients), one randomised controlled cross-over trial (29 patients), three randomised prospective studies (171 patients), and one retrospective study (73 patients). Only one study was conducted on paediatric neck breathers. The overall quality of the studies was low. Five studies were at a high risk of bias. Of the remaining two studies, one study had a low risk of bias and the other had an unclear risk. Despite limited subject evidence, results show that passive methods of humidification (mainly HME) is the preferred choice of humidification in the spontaneously breathing neck breather patients group mainly due to the reduction in pulmonary complaints, and better patient compliance.

Reduction of pulmonary complications and hospital length of stay with a clinical care pathway after head and neck reconstruction.

Pulmonary complications are common after major head and neck oncologic surgery with microsurgical reconstruction and are associated with increased mortality and morbidity. Clinical care pathways are evidence-based tools that reduce unnecessary practice variation and ultimately improve patient outcomes. In this study, the authors evaluate the effectiveness of a comprehensive care pathway on reducing postoperative pulmonary complications and hospital length of stay in patients undergoing major head and neck carcinoma resection with free flap reconstruction. Fifty-five consecutive patients treated according to a prescribed postoperative clinical care pathway were compared to a historical cohort of patients treated before the implementation of the pathway. The incidence of pulmonary complications, hospital length of stay, and free flap survival were compared between the control and intervention groups. Patients on the clinical care pathway had 32.5 percent fewer pulmonary complications (p < 0.0001) and 7.4 days' shorter hospital length of stay (p = 0.0007) than patients not on the postoperative pathway. There was no significant difference in the rate of flap reoperation. A multidisciplinary, comprehensive, clinical care pathway for patients undergoing major head and neck surgery with microsurgical reconstruction is effective in reducing postoperative pulmonary complications and hospital length of stay. The postoperative pathway is safe in this patient population and should be considered for adoption into clinical practice. Therapeutic, III.

Preoperative inspiratory muscle training to prevent postoperative pulmonary complications in patients undergoing esophageal resection (PREPARE study): study protocol for a randomized controlled trial.

BackgroundEsophageal resection is associated with a high incidence of postoperative pneumonia. Respiratory complications account for almost half of the readmissions to the critical care unit. Postoperative complications can result in prolonged hospital stay and consequently increase healthcare costs. In cardiac surgery a preoperative inspiratory muscle training program has shown to prevent postoperative pneumonia and reduce length of hospital stay. While in some surgical centers inspiratory muscle training is already used in the preoperative phase in patients undergoing esophageal resection, the added value of this intervention on the reduction of pulmonary complications has not yet been investigated in large surgical populations other than cardiac surgery in a randomized and controlled study design.Methods/DesignThe effect of a preoperative inspiratory muscle training program on the incidence of postoperative pneumonia in patients undergoing esophageal resection will be studied in a single blind multicenter randomized controlled trial (the PREPARE study). In total 248 patients (age >18 years) undergoing esophageal resection for esophageal cancer will be included in this study. They are randomized to either usual care or usual care with an additional inspiratory muscle training intervention according to a high-intensity protocol which is performed with a tapered flow resistive inspiratory loading device. Patients have to complete 30 dynamic inspiratory efforts twice daily for 7 days a week until surgery with a minimum of 2 weeks. The starting training load will be aimed to be 60% of maximal inspiratory pressure and will be increased based on the rate of perceived exertion.The main study endpoint is the incidence of postoperative pneumonia. Secondary objectives are to evaluate the effect of preoperative inspiratory muscle training on length of hospital stay, duration of mechanical ventilation, incidence of other postoperative (pulmonary) complications, quality of life, and on postoperative respiratory muscle function and lung function.DiscussionThe PREPARE study is the first multicenter randomized controlled trial to evaluate the hypothesis that preoperative inspiratory muscle training leads to decreased pulmonary complications in patients undergoing esophageal resection.Trial registrationNCT01893008.

OS EFEITOS DAS TÉCNICAS DE RECRUTAMENTO ALVEOLAR: REVISÃO SISTEMÁTICA

Alveolar recruitment is indicated in patients with hypoxemia moderate to severe. Introduce an systematic review about the alveolar recruitment maneuver effects,the use i n relation to gas exchange upgrading , to the respi ratory mechanics and the reduction of pulmonary complications and this way collaborating the literature. Systematic rev iew, retrospective and descriptive. Available in the databases LILIACS and SCIELLO, between the years 2005 and 2012, in Brazilian language. Were found 11 articles in the literature according to the Inclusion and exclusion criteria. Can conclude that with this systematic review the alveolar recruitmen t maneuver showed efficacious in the most of studie s bringing a lot of benefits in the post and pre-operative, however this not results in permanent benefits in the gas e xchange, needing to execute more times,and also is a viable strategy to prevent pulmonary complications. Key-words: Physiotherapy; Physiotherapy modality; Alveolar re cruitment. Hospital physiotherapy. Positive Pressure Respiration