Intraoperative protective mechanical ventilation and risk of postoperative respiratory complications: hospital based registry study

Ladha, Karim; Melo, Marcos F. Vidal; McLean, Duncan; Wanderer, Jonathan P.; Grabitz, Stephanie D.; Kurth, Tobias; Eikermann, Matthias

doi:10.1136/bmj.h3646

Cited by 241 publications

(269 citation statements)

References 40 publications

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“…We used patient data from all sources to form one de-identified database, as previously reported by our group. [23][24][25] Patient involvement No patients were involved in setting the research question or the outcome measures, nor were they involved in developing plans for recruitment, design, or implementation of the study. No patients were asked advice on interpretation or writing up of results.…”

Section: Methods Study Populationmentioning

confidence: 99%

Migraine and risk of perioperative ischemic stroke and hospital readmission: hospital based registry study

Timm

Houle

Grabitz

et al. 2017

BMJ

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Objective To evaluate whether patients with migraine are at increased risk of perioperative ischemic stroke and whether this may lead to an increased hospital readmission rate.Design Prospective hospital registry study.Setting Massachusetts General Hospital and two satellite campuses between January 2007 and August 2014.Participants 124 558 surgical patients (mean age 52.6 years; 54.5% women).Main outcome measures The primary outcome was perioperative ischemic stroke occurring within 30 days after surgery in patients with and without migraine and migraine aura. The secondary outcome was hospital readmission within 30 days of surgery. Exploratory outcomes included post-discharge stroke and strata of neuroanatomical stroke location.Results 10 179 (8.2%) patients had any migraine diagnosis, of whom 1278 (12.6%) had migraine with aura and 8901 (87.4%) had migraine without aura. 771 (0.6%) perioperative ischemic strokes occurred within 30 days of surgery. Patients with migraine were at increased risk of perioperative ischemic stroke (adjusted odds ratio 1.75, 95% confidence interval 1.39 to 2.21) compared with patients without migraine. The risk was higher in patients with migraine with aura (adjusted odds ratio 2.61, 1.59 to 4.29) than in those with migraine without aura (1.62, 1.26 to 2.09). The predicted absolute risk is 2.4 (2.1 to 2.8) perioperative ischemic strokes for every 1000 surgical patients. This increases to 4.3 (3.2 to 5.3) for every 1000 patients with any migraine diagnosis, 3.9 (2.9 to 5.0) for migraine without aura, and 6.3 (3.2 to 9.5) for migraine with aura.Patients with migraine had a higher rate of readmission to hospital within 30 days of discharge (adjusted odds ratio 1.31, 1.22 to 1.41).Conclusions Surgical patients with a history of migraine are at increased risk of perioperative ischemic stroke and have an increased 30 day hospital readmission rate. Migraine should be considered in the risk assessment for perioperative ischemic stroke.

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Section: Methods Study Populationmentioning

confidence: 99%

Migraine and risk of perioperative ischemic stroke and hospital readmission: hospital based registry study

Timm

Houle

Grabitz

et al. 2017

BMJ

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“…Severgnini et al 36 compared the use of a traditional ventilation strategy (V T ϭ 9 mL/kg PBW and no PEEP) with a lung-protective strategy (V T ϭ 7 mL/kg PBW with PEEP ϭ 10 cm H 2 O and recruitment maneuvers) in 56 subjects scheduled to undergo elective open abdominal surgery lasting Ͼ2 h and found that subjects in the lung-protective group had better pulmonary function tests up to day 5, fewer alterations in chest radiographs up to day 3, better oxygenation, and a lower clinical pulmonary infection score. Ladha et al 37 performed a large (69,265 subjects) hospital-based registry study in 3 Massachusetts hospitals from January 2007 to August 2014. They compared subjects who received protective mechanical ventilation (V T Ͻ10 mL/kg PBW, PEEP Ն5 cm H 2 O, and plateau pressure Ͻ30 cm H 2 O) with subjects who received non-protective mechanical ventilation in terms of postoperative respiratory complications during non-cardiac surgery.…”

Section: Ventilation Of Surgical Patientsmentioning

confidence: 99%

Should A Tidal Volume of 6 mL/kg Be Used in All Patients?

2016

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It has been shown that mechanical ventilation by itself can cause lung injury and affect outcomes. Ventilator-induced lung injury is associated with high tidal volumes in lungs afflicted with ARDS. However, the question is: Do high tidal volumes have this same effect in normal lungs or lungs that have respiratory compromise stemming from something other than ARDS? Many clinicians believe that a tidal volume strategy of 6 mL/kg predicted body weight should be standard practice in all patients receiving mechanical ventilation. There is a growing body of evidence related to this issue, and this is the debate that will be tackled in this paper from both pro and con perspectives. Key words: tidal volume; predicted body weight; mechanical ventilation; lung-protective ventilation; time constant; ARDS; stress; strain; hypercapnia. [Respir Care 2016;61(6):774 -790 . © 2016 Daedalus Enterprises] IntroductionIt is well known that the use of mechanical ventilation has the potential to aggravate pulmonary injury, but emerging evidence indicates that it may also precipitate lung injury in patients with no previous injury. Lung-protective ventilation has evolved over the past couple of decades to the point that it has become standard of care for patients with ARDS. The use of lower tidal volume (V T ) 4 -8 mL/kg predicted body weight (PBW) is part of this lung-protective strategy for mechanical ventilation (mechanical ventilation) along with limiting the plateau pressure to a maximum of 30 cm H 2 O and prudent use of PEEP to prevent atelectasis. Since we now know that the use of lower V T strategies (more specifically 6 mL/kg PBW) helps to limit the pulmonary damage during ARDS, the question now is: Should we be using this strategy in all mechanically ventilated patients? Anatomically speaking, it makes sense to, since the normal physiologic V T for humans is approximately 6 mL/kg PBW. 1 There is a growing body of evidence that points toward the use of lower V T values leading to improved outcomes in patients suffering from other forms and degrees of respiratory failure. The aim of this paper is to examine the evidence relating to the use of lower V T values in conditions other than ARDS in which mechanical ventilation is required. This will be done with viewpoints from both the pro and con positions. Early StudiesThere is a plethora of preclinical evidence from animal studies supporting the fact that the use of high V T values can directly cause injury to normal lungs. Animal studies have shown that high V T ventilation increases levels of pro-inflammatory mediators, leads to pulmonary edema, and causes increased alveolar-capillary permeability and structural abnormalities. [2][3][4][5][6][7][8] With the emergence of these animal data, clinicians began to question the traditional use of V T values in the range of 10 -15 mL/kg PBW in humans. Several small human studies were reported in the mid-to late 1990s that produced conflicting results. 9-11 These studies were hampered by several factors, including higher than predicte...

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“…11–13 Recent studies have reported contradictory results regarding the association between PEEP and the risk of postoperative respiratory complications. 14–17 …”

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confidence: 99%

Differential Effects of Intraoperative Positive End-expiratory Pressure (PEEP) on Respiratory Outcome in Major Abdominal Surgery Versus Craniotomy

et al. 2016

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Objectives In this study, we examined whether (1) positive end-expiratory pressure (PEEP) has a protective effect on the risk of major postoperative respiratory complications in a cohort of patients undergoing major abdominal surgeries and craniotomies, and (2) the effect of PEEP is differed by surgery type. Background Protective mechanical ventilation with lower tidal volumes and PEEP reduces compounded postoperative complications after abdominal surgery. However, data regarding the use of intraoperative PEEP is conflicting. Methods In this observational study, we included 5915 major abdominal surgery patients and 5063 craniotomy patients. Analysis was performed using multivariable logistic regression. The primary outcome was a composite of major postoperative respiratory complications (respiratory failure, reintubation, pulmonary edema, and pneumonia) within 3 days of surgery. Results Within the entire study population (major abdominal surgeries and craniotomies), we found an association between application of PEEP ≥5cmH2O and a decreased risk of postoperative respiratory complications compared with PEEP <5cmH2O. Application of PEEP >5cmH2O was associated with a significant lower odds of respiratory complications in patients undergoing major abdominal surgery (odds ratio 0.53, 95% confidence interval 0.39 – 0.72), effects that translated to deceased hospital length of stay [median hospital length of stay : 6 days (4–9 days), incidence rate ratios for each additional day: 0.91 (0.84 - 0.98)], whereas PEEP >5cmH2O was not significantly associated with reduced odds of respiratory complications or hospital length of stay in patients undergoing craniotomy. Conclusions The protective effects of PEEP are procedure specific with meaningful effects observed in patients undergoing major abdominal surgery. Our data suggest that default mechanical ventilator settings should include PEEP of 5–10cmH2O during major abdominal surgery.

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Intraoperative protective mechanical ventilation and risk of postoperative respiratory complications: hospital based registry study

Abstract: ObjeCtiveTo evaluate the effects of intraoperative protective ventilation on major postoperative respiratory complications and to define safe intraoperative mechanical ventilator settings that do not translate into an increased risk of postoperative respiratory complications.

Cited by 241 publications

References 40 publications

Migraine and risk of perioperative ischemic stroke and hospital readmission: hospital based registry study

Migraine and risk of perioperative ischemic stroke and hospital readmission: hospital based registry study

Should A Tidal Volume of 6 mL/kg Be Used in All Patients?

Differential Effects of Intraoperative Positive End-expiratory Pressure (PEEP) on Respiratory Outcome in Major Abdominal Surgery Versus Craniotomy

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