RCoA and BJA Webinar - Perioperative pulmonary complications

The RCoA and British Journal of Anaesthesia are pleased to announce a series of webinars available to our members on how to optimise your reading of the medical literature.

Episode 5 - Perioperative pulmonary complications

Chairs: Professor Hugh Hemmings, Editor in Chief, British Journal of Anaesthesia

Speakers:

Prediction and Prevention
Professor Rupert Pearse, Consultant in Intensive Care Medicine and Clinical Director for Research and Development, Queen Mary University of London and Barts Health NHS Trust
Are neuromuscular blocking drugs to blame?
Professor Jennifer Hunter MBE, Emeritus Professor of Anaesthesia, Senior Research Fellow, University of Liverpool
COVID-19 pneumonia: ARDS or not?
Professor Paolo Pelosi, Professor in Anesthesiology and Intensive Care Medicine, University of Genoa

Webinar recorded on 2 March 2021

Questions and Answers

Can we do anything differently in ventilating patients under anaesthesia to prevent post op. pulmonary complications?

tidal volume 7-10 ml (kg PBW) -lowest is better expecially during laparoscopic surgery

PEEP 5 cmH2O, no Recruitment maneuvre

Pplat below 17 cmH2O - below 22 cmH2O in obese patients

driving pressure below 13 cmH2O - below 18 cmH2O in obese patients

if SatO2 below 92% - increase FiO2 up to 70-90%

if SatO2 below 92% persists - perform RM by ventilator (stepwise) - and increase PEEP avoiding increase in driving pressure

reference Br J Anaesth 123 (6) - 898-913, 2019

(Answered by Professor Paolo Pelosi)

is there a dependable practical method for prediction of high risk patients particulary in abdominal surgeries?

Several scores have been proposed - then different interetation is needed as discussed by Rupert - personally I found ARISCAT (preoperative) score as well as LAS VEGAS (preopertaive and intraoperative) very helpful

(Answered by Professor Paolo Pelosi)

There is evidence recruitment maneouvres intraoperatively help, are there any studies looking at regular recruitment maneouvres post op (ie using incentive spiroemtry) helps and have the studies looking at intraop ventilation strategies adjusted for this?

RM should not be used routinely in patients during anesthesia including obese patients - it should be used only when oxygenation (and or compliance) is progressively decreasing - use RM by ventilator - stepwise - do not use manual RM

(Answered by Professor Paolo Pelosi)

references

Young CC et al. Br J Anaesth 123 (6), 898-913, 2019
The AVATAR Investigators – Br J Anaesth. 2021 Feb;126(2):533-543.
Ball L et al. Br J Anaesth. 2018 Oct;121(4):899-908
The LAS VEGAS Investigators - Eur J Anaesthesiol 2017; 34:492–507
Mazzinari G et al. J Appl Physiol (1985). 2020 Dec 24. (Online ahead of print)
Mazzinari G et al. Anesthesiology. 2020 Apr;132(4):667-677.
Neto AS et al. Lancet Respir Med. 2016 Apr;4(4):272-80.
Pereira SM et al. Anesthesiology. 2018 Dec;129(6):1070-10
PROVEnet investigators JAMA. 2019 Jun 18;321(23):2292-2305
PROVEnet investigators. Lancet. 2014 9;384(9942):495-503
Serpa-Neto A. et al. Anesthesiology. 2015 Jul;123(1):66-78
Karalapillai D et al. JAMA. 2020;324(9):848-858
Mazo V. et al. Anesthesiology. 2014 Aug;121(2):219-31

Is is preferable to reduce muscle relaxant dose, With TIVA Remi and Propofol, I’ve reduced muscle relaxant use!

Always monitor quantitative NMB and then you use the lowest dose of NMBA necessary whatever the technique.

(Answered by Professor Jennie Hunter)

Is there a dependable practical method for prediction of high risk patients particulary in abdominal surgeries

Use Acceleromyography until TOFR = 1.0

(Answered by Professor Jennie Hunter)

With the emerging incidence of sugammadex anaphylaxis/anaphylactoid reactions would suggest any benefit to titration of sugammadex aiming for a ratio >0.9 as opposed to a standard mg/kg dose.

Anaphylaxis can occur with very small doses of any drug. So titrating SGX dose very rarely prevents it.

(Answered by Professor Jennie Hunter)

Sugammadex and renal failure patient what do you advise, traditionally we used to use atracurium yet, there is growing trend to use roc. due to COVID

In renal patients, I prefer cisatracurium, monitoring block and giving neostigmine when the TOFR is > 0.2.

(Answered by Professor Jennie Hunter)

What would be the preferable strategy to follow if I have the only option neostigmine?

You must have established the beginning of recovery TOFR > 0.2 and you must monitor until TOFR > 0.9

Sugammadex allergy - there’s more evidence for this now. I worry about increased use in Sugammadex with the message that it may reduce POPC - Question continued in box

Question:

Sugammadex allergy - there’s more evidence for this now. I worry about increased use in Sugammadex with the message that it may reduce POPC. Having a strategy for NMB management with careful use of neostigmine has an important place in overall safe anaesthetic management. Always use quantitative NMB monitoring.

Answer:

I agree with a lot of this comment. But if you use Neostigmine you must monitor NMB and only give it when recovery has commenced to TOFR 0.2 and you must monitor to full recovery.

(Answered by Professor Jennie Hunter)

Agree with Prof Hunter. But, Incidence is higher than antibiotic anaphylaxis. So, it might be low overall, but not that low to not pay attention in my opinion.

I agree, we must always be on the alert for anaphylaxis, but the evidence that SGX is higher risk that antibiotics is not robust.

(Answered by Professor Jennie Hunter)