Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations.

Postoperative pulmonary complications (PPCs) occur frequently and are associated with substantial morbidity and mortality. Evidence suggests that reduction of PPCs can be accomplished by using lung-protective ventilation strategies intraoperatively, but a consensus on perioperative management has not been established. We sought to determine recommendations for lung protection for the surgical patient at an international consensus development conference. Seven experts produced 24 questions concerning preoperative assessment and intraoperative mechanical ventilation for patients at risk of developing PPCs. Six researchers assessed the literature using questions as a framework for their review. The modified Delphi method was utilised by a team of experts to produce recommendations and statements from study questions. An expert consensus was reached for 22 recommendations and four statements. The following are the highlights: (i) a dedicated score should be used for preoperative pulmonary risk evaluation; and (ii) an individualised mechanical ventilation may improve the mechanics of breathing and respiratory function, and prevent PPCs. The ventilator should initially be set to a tidal volume of 6-8 ml kg-1 predicted body weight and positive end-expiratory pressure (PEEP) 5 cm H2O. PEEP should be individualised thereafter. When recruitment manoeuvres are performed, the lowest effective pressure and shortest effective time or fewest number of breaths should be used.

Certified Registered Nurse Anesthetists' Adherence to an Intraoperative Lung Protective Ventilation Protocol.

The clinical application of intraoperative mechanical ventilation is highly variable and often determined by providers' attitudes and preferences, rather than evidence. Ventilation strategies using high tidal volumes (VT) with little to no positive end-expiratory pressure (PEEP) are associated with lung injury, increasing the risk of postoperative pulmonary complications. Literature demonstrates that applying lung protective ventilation (LPV) strategies intraoperatively, including low VT, individualized PEEP, and alveolar recruitment maneuvers, can reduce the risk of postoperative pulmonary complications. This multicenter quality improvement project aimed to develop and implement an LPV protocol to increase nurse anesthetists' knowledge and adherence to LPV strategies in adults undergoing laparoscopic cholecystectomy. The anesthesia providers were educated about LPV strategies and their intraoperative application to individualize ventilation settings based on patient comorbidities and body habitus. Adherence was determined by collecting ventilator data and evaluating the data using logistic regression. The overall protocol adherence significantly increased (P=.01). Additionally, there was a significant improvement in adherence to each individual component of the protocol (all P<.05) except for VT. Decreasing the oxygen concentration administered during maintenance and emergence was the most commonly adopted practice (P<.0001). This project demonstrates that education and a standardized protocol can increase the use of intraoperative LPV strategies.