Effect of incremental PEEP titration on postoperative pulmonary complications in patients undergoing emergency laparotomy: a randomized controlled trial.

Postoperative pulmonary complications (PPC) has a significant negative impact and are associated with increased length of hospital stay and cost of care. Emergency surgery is a well-established risk factor for PPC. Previous studies reported that personalized positive end-expiratory pressure (PEEP) might reduce postoperative atelectasis and postoperative pulmonary complications. N = 168 adult patients undergoing major emergency laparotomy under general anesthesia were recruited in this study. A minimum driving pressure based incremental PEEP titration was compared to a fixed PEEP of 5 cmH2O. The primary outcome was PPC up to postoperative day 7. The mean (standard deviation) of the recruited patients was 41.7(16.1)y, and 48.8% (82 of 168 patients) were female. The risk of PPC at postoperative day 7 was similar in both the study groups [Relative risk (RR) (95% Confidence interval, CI) 0.81 (0.58, 1.13); p = 0.25]. In addition, the incidence of intraoperative hypotension [p = 0.75], oxygen-free days at day 28 [p = 0.27], duration of postoperative hospital stay [p = 0.50], length of postoperative intensive care unit stay [p = 0.28], and in-hospital mortality [p = 0.38] were similar in two groups. Incidence of PPC was not reduced with the use of an individualized PEEP strategy based on lowest driving pressure. However, the incidence of hypotension and bradycardia was also not increased with titrated PEEP.Trial Registration: www.ctri.nic.in ; CTRI/2020/12/029765.

Epidemiological & clinical characteristics & early outcome of COVID-19 patients in a tertiary care teaching hospital in India: A preliminary analysis.

BACKGROUND & OBJECTIVES: In this study we describe the epidemiological data, comorbidities, clinical symptoms, severity of illness and early outcome of patients with coronavirus disease 2019 (COVID-19) from a tertiary care teaching hospital in New Delhi, India. METHODS: In this preliminary analysis of a prospective observational study, all adult patients admitted to the screening intensive care unit (ICU) of the institute who fulfilled the WHO case definition of COVID-19 and confirmed to have SARS-CoV-2 infection by reverse transcription-polymerase chain reaction were included. Demographics, clinical data and 24 h outcome were assessed. RESULTS: The preliminary analysis of 235 patients revealed that the mean age was 50.7±15.1 yr and 68.1 per cent were male. Fever (68.1%), cough (59.6%) and shortness of breath (71.9%) were the most common presenting symptoms. Hypertension (28.1%) and diabetes mellitus (23.3%) were the most common associated comorbid illnesses. Patients with mild, moderate, severe and critical illness were 18.3, 32.3, 31.1 and 18.3 per cent, respectively, at the time of ICU admission. The proportions (95% confidence interval) of patients requiring any form of oxygen therapy, oxygen therapy by high-flow nasal cannula and invasive mechanical ventilation were 77, 21.7 and 25.5 per cent, respectively, within 24 h of hospital admission. The 24 h ICU mortality was 8.5 per cent, and non-survivors had higher respiratory rate (P <0.01, n=198) and lower baseline oxyhaemoglobin saturation (P <0.001, n=198) at presentation and higher baseline serum lactate (P <0.01, n=122), total leucocyte count (P <0.001, n=186), absolute neutrophil count (P <0.001, n=132), prothrombin time (P <0.05, n=54) and INR (P <0.05, n=54) compared to survivors. INTERPRETATION & CONCLUSIONS: Nearly half of the patients presented with severe and critical disease and required high-flow nasal oxygen or invasive mechanical ventilation at admission. Severity of the presenting respiratory illness, haematological parameters and lactate rather than age or presence of comorbidity predicted early death within 24 h.

Penetrating extremity trauma.

Penetrating extremity trauma (PET) usually becomes less important when present along with multiple truncal injuries. The middle eastern wars documented the terrible mortality and morbidity resulting from PET. Even in civilian trauma, PET can lead to significant morbidity and mortality. There are now well-established principles in the evaluation and management of vascular, bony, soft tissue, and neurologic lesions that will lead to a reduction of the poor outcomes. This review will summarize some of these recent concepts.

Effect of positive end expiratory pressure on atelectasis in patients undergoing major upper abdominal surgery under general anaesthesia: A lung ultrasonography study.

Postoperative pulmonary complications vary in major upper abdominal surgery. The objective of this study was to assess the effect of positive end expiratory pressure on the incidence of atelectasis in patients undergoing major upper abdominal surgery under general anaesthesia using lung ultrasound. The patients were randomised into receiving either no positive end expiratory pressure (Group I) or positive end expiratory pressure of 5cm H2O (Group II). Lung ultrasound was performed at various time points - baseline, 10 minutes, 2 hours after induction, during closure of skin and 30 minutes post extubation. The lung aeration as assessed by Total Modified Lung Ultrasound Score was worse in the Group I as compared to the Group II at 2 hours post induction. Driving pressure in Group II was significantly reduced compared to Group I. Application of positive end expiratory pressure, as minimal as 5cm H2O, as a single intervention, helps in significantly reducing the Total Modified Lung Ultrasound Score after a duration of more than 2 hours and also attaining low driving pressures during intraoperative mechanical ventilation.

Effect of driving pressure-guided positive end-expiratory pressure (PEEP) titration on postoperative lung atelectasis in adult patients undergoing elective major abdominal surgery: A randomized controlled trial.

BACKGROUND: As respiratory system compliances are heterogenous, we hypothesized that individualized intraoperative positive end-expiratory pressure titration on the basis of lowest driving pressure can reduce postoperative atelectasis and improve intraoperative oxygenation and postoperative lung functions. METHODS: Eighty-two adult patients undergoing major abdominal surgery were recruited in this randomized trial. In the titrated positive end-expiratory pressure group, positive end-expiratory pressure was titrated incrementally until lowest driving pressure was achieved, and the same procedure was repeated in every 2 hours. In the fixed positive end-expiratory pressure group, a positive end-expiratory pressure of 5 cmH2O was used throughout the surgery. The primary objective of this study was lung ultrasound score noted at the completion of surgery and 5 minutes after extubation at 12 lung areas bilaterally. RESULTS: Mean (standard deviation) age of the recruited patients were 43.8 (17.3) years, and 50% of all patients (41 of 82) were women. Lung ultrasound aeration scores were significantly higher in the fixed positive end-expiratory pressure group both before and after extubation (median [interquartile range] 7 [5-8] vs 4 [2-6] before extubation and 8 [6-9] vs 5 [3-7] after extubation; P = .0004 and P = .0011, respectively). Incidence of postoperative pulmonary complications was significantly lower in the titrated positive end-expiratory pressure group (absolute risk difference [95% CI] 17.1% [32.5%-1.7%]; P = .034). The number of patients requiring postoperative supplemental oxygen therapy to maintain SpO2 >95%, the requirement of intraoperative rescue therapy, and the duration of hospital stay were similar in both of the groups. CONCLUSION: Intraoperative titrated positive end-expiratory pressure reduced postoperative lung atelectasis in adult patients undergoing major abdominal surgery. Further large clinical trials are required to know its effect on postoperative pulmonary complications.

Medications and patient safety in the trauma setting: a systematic review.

Background: Medication errors account for the most common adverse events and a significant cause of mortality in the USA. The Joint Commission has required medication reconciliation since 2006. We aimed to survey the literature and determine the challenges and effectiveness of medication reconciliation in the trauma patient population. Materials and methods: We conducted a systematic review of the literature to determine the effectiveness of medication reconciliation in trauma patients. English language articles were retrieved from PubMed/Medline, CINAHL, and Cochrane Review databases with search terms "trauma OR injury, AND medication reconciliation OR med rec OR med rek, AND effectiveness OR errors OR intervention OR improvements." Results: The search resulted in 82 articles. After screening for relevance and duplicates, the 43 remaining were further reviewed, and only four articles, which presented results on medication reconciliation in 3041 trauma patients, were included. Two were retrospective and two were prospective. Two showed only 4% accuracy at time of admission with 48% of medication reconciliations having at least one medication discrepancy. There were major differences across the studies prohibiting comparative statistical analysis. Conclusions: Trauma medication reconciliation is important because of the potential for adverse outcomes given the emergent nature of the illness. The few articles published at this time on medication reconciliation in trauma suggest poor accuracy. Numerous strategies have been implemented in general medicine to improve its accuracy, but these have not yet been studied in trauma. This topic is an important but unrecognized area of research in this field.