Prevention of respiratory complications of the surgical patient: actionable plan for continued process improvement.
OBJECTIVE
Postoperative respiratory complications (PRCs) increase hospitalization time, 30-day mortality and costs by up to $35 000. These outcomes measures have gained prominence as bundled payments have become more common.


RESULTS
Results of recent quantitative effectiveness studies and clinical trials provide a framework that helps develop center-specific treatment guidelines, tailored to minimize the risk of PRCs. The implementation of those protocols should be guided by a local, respected, and visible facilitator who leads proper implementation while inviting center-specific input from surgeons, anesthesiologists, and other perioperative stakeholders.


CONCLUSIONS
Preoperatively, patients should be risk-stratified for PRCs to individualize intraoperative choices and postoperative pathways. Laparoscopic compared with open surgery improves respiratory outcomes. High-risk patients should be treated by experienced providers based on locally developed bundle-interventions to optimize intraoperative treatment and ICU bed utilization. Intraoperatively, lung-protective ventilation (procedure-specific positive end-expiratory pressure utilization, and low driving pressure) and moderately restrictive fluid therapy should be used. To achieve surgical relaxation, high-dose neuromuscular blocking agents (and reversal agents) as well as high-dose opioids should be avoided; inhaled anesthetics improve surgical conditions while protecting the lungs. Patients should be extubated in reverse Trendelenburg position. Postoperatively, continuous positive airway pressure helps prevent airway collapse and protocolized, early mobilization improves cognitive and respiratory function.
aDepartment of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA bKlinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Germany.
Katarina J
KJ
Ruscic
Stephanie D
SD
Grabitz
Maíra I
MI
Rudolph
Matthias
M
Eikermann
D000402:Airway Obstruction / Q000517:prevention & control*; D000758:Anesthesia / Q000009:adverse effects* / Q000379:methods; D018685:Anesthetics, Inhalation / Q000008:administration & dosage / Q000009:adverse effects; D045422:Continuous Positive Airway Pressure; D006801:Humans; D015994:Incidence; D007362:Intensive Care Units / Q000706:statistics & numerical data; D007430:Intraoperative Care / Q000379:methods; D007902:Length of Stay; D008171:Lung Diseases / Q000453:epidemiology / Q000517:prevention & control*; D009466:Neuromuscular Blocking Agents / Q000008:administration & dosage / Q000009:adverse effects; D011183:Postoperative Complications / Q000453:epidemiology / Q000517:prevention & control*; D011184:Postoperative Period; D017410:Practice Guidelines as Topic; D011300:Preoperative Care / Q000379:methods; D012137:Respiratory System / Q000187:drug effects / Q000503:physiopathology; D018570:Risk Assessment; D012307:Risk Factors; D055948:Sarcopenia / Q000150:complications / Q000175:diagnosis; D020181:Sleep Apnea, Obstructive / Q000150:complications / Q000175:diagnosis; D013514:Surgical Procedures, Operative / Q000009:adverse effects* / Q000379:methods
D018685:Anesthetics, Inhalation; D009466:Neuromuscular Blocking Agents