Interestingly, sleep apnea is much more common in pregnant than nonpregnant women and persists into the early post-partum period. Post-partum airway obstruction is a major cause of anesthesia-related maternal death . Consistent with findings in OSA, upper body elevation to 45 degrees increases the cross-sectional area of the upper airway as measured by acoustical pharyngometry and mitigates sleep apnea as measured by polysomnography in women 48 h after delivery [49▪]. It is prudent to extubate patients at risk of extubation failure in the reverse Trendelenburg position to decrease airway collapse after removal of the endotracheal tube .
Furthermore, proper monitoring in the PACU can decrease the number of ICU transfers and improves patients’ outcomes by detecting early signs of respiratory complications . Of note, it is important to use objective criteria to determine whether or not a patient needs to be admitted to an ICU. A recent study demonstrates that admission to the ICU rather than ward admission is associated with adverse outcomes in healthier patients [44▪]. Admission to the ICU strains the health system by increasing resource utilization and costs of hospital care. Furthermore, patients surviving an ICU stay subsequently demonstrate a higher risk of 5-year mortality .
Sarcopenia, frailty, and muscle strength are independent predictors of adverse discharge disposition and reintubation in surgical ICU patients [19▪▪,50▪▪,51]. Postoperatively, early mobilization improves functional independence. Our data demonstrate that early, goal-directed mobilization shortens patients’ length of stay in the SICU and improves functional mobility at hospital discharge [53▪▪]. Postoperative factors that can be modulated to decrease PRCs are described in Table 1 .
Guideline-driven clinical decision pathways are efficiently encapsulated by algorithms. Those algorithms and performance improvement measures developed by multidisciplinary teams on a local hospital or departmental level are likely to be the most successful .
In general, the following steps are followed: plans are created to implement improvement throughout the system and effectiveness is continually monitored and changes are made as needed. As clinicians, there is often divergence between what we know from reading current literature and what we practice. This ‘knowing-doing gap’ is what implementation science seeks to overcome. We have recently shown that proper implementation of a clinical algorithm improves important patient outcomes. Of utter importance is the selection of a locally respected ‘facilitator’ who makes sure that all voices are heard and that plans made on the basis of algorithms are properly implemented [53▪▪]. In this way, a nuanced subject matter can be made into algorithmic, usable hospital bundles by a local multidisciplinary team (Fig. 3).
More than a 10-fold increase in mortality risk is incurred by severe PRCs leading to reintubation and unplanned ICU admission [5▪]. Thus, preoperative risk stratification to identify patients at increased risk of PRCs and subsequent tailoring of an anesthetic plan with respiratory optimization is warranted. Surgery type affects PRCs, and laparoscopic surgery improves respiratory outcomes. Intraoperative use of appropriately restrained fluid management, increased utilization of inhaled anesthetics (while not allowing hypotension), judicious and careful titration of NMBAs with appropriately monitored reversal, minimization of opioids, and lung-protective ventilation should be used. Postoperatively, patients at high risk of PRCs should be extubated in the reverse Trendelenburg position. Obese patients and those with OSA should be treated with an ‘OSA hospital bundle’ [22▪,52,58]. PACU discharge disposition should incorporate patient risk stratification for PRCs as a key element of respiratory safety. Local guidelines need to be developed to optimize patients’ triage. Early, goal-directed mobilization should be implemented. The creation of local algorithms and hospital bundles will facilitate implementation of these suggested evidence-based practices to improve patient outcomes.
Papers of particular interest, published within the annual period of review, have been highlighted as:
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Abstract evaluating the independent impact of postoperative reintubation, pneumonia, pulmonary edema, respiratory failure, postoperative desaturation, and atelectasis on patient-centered adverse outcomes.
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Observational cohort study highlighting the independent and additive association of AKI, sepsis, and acute respiratory failure on patient mortality.
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Retrospective cohort study demonstrating the utility of sarcopenia assessment to predict postoperative respiratory complications (PRCs). Sarcopenia was assessed using metrics such as low muscle mass and low physical function.
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A prospective, observational cohort study revealing that sarcopenia diagnosed by bedside ultrasound can predict adverse discharge disposition (discharge to a nursing home or in-house mortality) as well as frailty in the surgical ICU setting. As novice operators were able to accurately perform the measurements, this modality could be utilized as a novel predictive biomarker.
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Review that emphasizes implementation of a clinical algorithm to provide optimal care of surgical patients with obstructive sleep apnea.
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Prospectively designed observational outcomes study showing an association of decreased rates of pulmonary edema, respiratory failure, pneumonia, and reintubation with the use of lung protective mechanical ventilation [defined as a positive end-expiratory pressure (PEEP) of 5 cmH2O and plateau pressure of 16 cmH2O or less].
26▪▪. de Jong MAC, Ladha KS, Melo MFV, et al. Differential effects of intraoperative positive end-expiratory pressure (PEEP) on respiratory outcome in major abdominal surgery versus craniotomy. Ann Surg 2016; 264:362–369.
Observational study suggesting that PEEP at least 5 cmH2O should be used during major abdominal surgery as this range of settings decreased the risk of PRCs. In craniotomy patients, PEEP did not have the same protective benefit.
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Prospective, crossover, nonrandomized interventional study in medical and surgical ICUs showing that a recruitment maneuver followed by PEEP titration (in the range of ∼12 cmH2O) can improve respiratory mechanics in morbidly obese patients.
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Prospectively designed outcomes study demonstrating the dose-dependent protective effect of inhalational anesthetics (volatile anesthetics and nitrous oxide) on development of PRCs.
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Prospectively designed observational outcomes study showing a dose-dependent increased risk of PRCs associated with the use of neuromuscular blocking agents as well as neostigmine, but suggests elimination of that risk with proper use of neostigmine reversal using neuromuscular transmission monitoring.
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A randomized, controlled study showing that sugammadex reduces residual neuromuscular blockade and shortens the time from drug administration to operating room discharge.
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Retrospective, multi-institutional outcomes study showing that laparoscopic liver resection is associated with decreased postoperative pulmonary complications compared with open major hepatectomy.
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Abstract presentation of an outcomes study showing that appropriate, well selected postoperative discharge to an ICU vs. floor admission improves multiple patient outcomes, including PRCs.
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Randomized, crossover study demonstrating the beneficial effects of elevated upper body position on sleep-disordered breathing and upper airway cross-sectional area in early-post-partum women.
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Multicentric, international, randomized controlled trial showing beneficial effects of early, goal-directed mobilization, and the importance of closed-loop communication in surgical ICU patients.
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