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.

Is opioid-free general anesthesia for breast and gynecological surgery a viable option?

PURPOSE OF REVIEW: Opioid-free anesthesia (OFA) was introduced to avoid tolerance and hyperalgesia, allowing reduction in postoperative opioids. OFA focused initially on postoperative respiratory safety for patients undergoing ambulatory surgery and for obstructive sleep apnea syndrome patients otherwise requiring intensive care admission. What about using OFA in plastic and oncological breast surgery, in deep inferior epigastric perforators flap surgery, and in gynecological laparoscopy? RECENT FINDINGS: OFA requires the use of other drugs to block the unwanted reactions from surgical injury. This can be achieved with a single drug at a high dose or with a combination of different drugs at a lower dose, such as with alpha-2-agonists, ketamine, lidocaine, and magnesium, each working on a different target and therefore described as multitarget anesthesia. Three factors can explain OFA success: improved analgesia with less postoperative opioids, the near absence of postoperative nausea and vomiting if no opioid is needed postoperatively, and reduced inflammation enhancing the recovery after surgery. SUMMARY: Opioid-free general anesthesia is a viable option for breast and gynecological surgery and its use will only increase when anesthesiologists listen to their patients' experiences after undergoing surgery under general anesthesia.

A one-step conversion from gastric banding to laparoscopic Roux-en-Y gastric bypass is as safe as a two-step conversion: A comparative analysis of 885 patients.

AIMS: To achieve additional weight loss or to resolve band-related problems, a laparoscopic adjustable gastric banding (LAGB) can be converted to a laparoscopic Roux-en-Y gastric bypass (RYGB). There is limited data on the feasibility and safety of routinely performing a single-step conversion. We assessed the efficacy of this revisional approach in a large cohort of patients operated in a high-volume bariatric institution. METHODS: Between October 2004 and December 2015, a total of 885 patients who underwent LAGB removal with RYGB were identified from a prospectively collected database. In all cases, a single-stage conversion procedure was planned. The feasibility of this approach and peri-operative outcomes of these patients were evaluated and analyzed. RESULTS: A single-step approach was successfully achieved in 738 (83.4%) of the 885 patients. During the study period, there was a significant increase in performing the conversion from LAGB to RYGB single-staged. No mortality or anastomotic leakage was observed in both groups. Only 45 patients (5.1%) had a 30-d complication: most commonly hemorrhage (N = 20/45), with no significant difference between the groups. CONCLUSION: Converting a LAGB to RYGB can be performed with a very low morbidity and zero-mortality in a high-volume revisional bariatric center. With increasing experience and full standardization of the conversion, the vast majority of operations can be performed as a single-stage procedure. Only a migrated band remains a formal contraindication for a one-step approach.

Perioperative opioids aggravate obstructive breathing in sleep apnea syndrome: mechanisms and alternative anesthesia strategies.

PURPOSE OF REVIEW: Opioids induce and increase the severity of most sleep-disordered breathing in all patients, but especially in morbidly obese patients. Discussed herein are the direct impact and mechanisms of opioids on inducing and exacerbating obstructive sleep apnea syndrome in normal and morbidly obese patients. RECENT FINDINGS: Respiratory depression is a larger problem than obstructive sleep apnea syndrome during the first night after an opioid anesthesia because of the reduced amount of deep sleep and rapid-eye-movement sleep. Acute tolerance to the analgesic effects of opioids can be observed after one anesthetic opioid dose, although tolerance to the side-effects of opioids develops more slowly. Therefore, it makes sense to avoid all opioids intraoperatively. A recently developed multimodal nonopioid anesthesia method may prevent development of acute tolerance and facilitate postoperative pain management with less opioids and sleep-disordered breathing. SUMMARY: A multimodal nonopioid anesthesia method avoids the necessity for intraoperative opioids, reduces the need for postoperative opioid use, and improves analgesia with less narcotic.

Visualising improved peritoneal perfusion at lower intra-abdominal pressure by fluorescent imaging during laparoscopic surgery: A randomised controlled study.

BACKGROUND: Laparoscopy is the gold standard for many surgical procedures and is embraced as minimally invasive surgery in the enhanced recovery after surgery programme. Lowering intra-abdominal pressure during laparoscopy may decrease the degree of surgical injury and further enhance patient outcomes. This study aims to assess the effect of low pressure pneumoperitoneum on peritoneal perfusion during laparoscopic surgery. MATERIALS AND METHODS: We performed a prospective randomized intervention study in 30 adults undergoing colorectal robot assisted laparoscopic surgery at a secondary care medical center in the Netherlands between June and December 2018. A 3 min video recording of the parietal peritoneum was made with the Da Vinci® Firefly mode following intravenous injection of 0.2 mg/kg indocyanine green at a pneumoperitoneum pressure of 8, 12 or 16 mmHg. Observers were blinded for the level of intra-abdominal pressure that was used. Fluorescent intensity in [-] over time was extracted from each video in MATLAB. Time to reach maximal fluorescent intensity (TMFI) and maximum fluorescent intensity (MFI) were compared among groups. The study was registered at clinicaltrials.gov (NCT03928171). RESULTS: Mean TMFI was shorter at low pressure (8 mmHg) than standard pressure (12 and 16 mmHg): 44 ± 12 versus 58 ± 18 s (p = 0.032), respectively. Mean MFI was higher at 8 mmHg than 12 and 16 mmHg (222 ± 25 versus 188 ± 54, p = 0.033). Regression analysis identified intra-abdominal pressure, mean arterial pressure and female gender as significant predictors of peritoneal perfusion. CONCLUSION: Low pressure pneumoperitoneum was associated with improved perfusion of the parietal peritoneum. Current available evidence supported feasibility and enhanced postoperative recovery. Future investigations should focus on optimizing factors that facilitate lower intra-abdominal pressure and explore effects on other clinically relevant patient outcomes such as anastomotic leakage and immune homeostasis.

Anaesthetic Factors Affecting Outcome After Bariatric Surgery, a Retrospective Levelled Regression Analysis.

BACKGROUND: Deep neuromuscular block (NMB) and opioid-free anaesthesia (OFA) improve surgical workspace and reduce post-operative opioid consumption, but its impact on perioperative outcomes is unknown. This observational study compared complications and healthcare resource utilization after bariatric surgery, with or without continuous deep NMB or OFA. METHODS: We included all 9246 patients who underwent laparoscopic bariatric surgery at our institution from January 2009 to February 2017. Continuous clinical deep NMB was defined as receiving a continuous infusion of rocuronium with a dose of > 1 mg/kg IBW for each hour or sugammadex > 2 mg/kg total body weight at the time of reversal. We analysed the effect of continuous clinical deep NMB and OFA and covariates on 1 month post-operative complications using the Clavien-Dindo (CD) classification (grades II-V) and healthcare utilization (hospital length of stay [LOS], rates of reoperations within 1 week, high-dependency care unit admissions, and readmissions within 1 month). Covariates included experience of the attending anaesthesiologist, patient age, sex, body mass index, American Society of Anesthesiologists physical status score, obstructive sleep apnoea syndrome, diabetes, hypertension, surgery type, surgical team experience, and neostigmine use. RESULTS: OFA, continuous deep NMB, surgical and anaesthesia team experience, younger age, and surgery type were associated with fewer complications. OFA was associated with lower healthcare resource utilization. Reduced LOS was also associated with younger age, surgical team experience, and surgery type, but not continuous deep NMB. CONCLUSION: Continuous deep NMB and OFA were associated with fewer complications after bariatric surgery.

Perioperative Care of Patients With Obstructive Sleep Apnea Undergoing Upper Airway Surgery: A Review and Consensus Recommendations.

IMPORTANCE: To date, no consensus exists regarding optimal perioperative care of patients with obstructive sleep apnea (OSA) undergoing upper airway (UA) surgery. These patients are at risk related to anesthesia and postoperative analgesia, among other risks associated with difficult airway control, and may require intensified perioperative management. OBJECTIVE: To provide a consensus-based guideline by reviewing available literature and collecting expert opinion during an international consensus meeting with experts from relevant speciliaties. EVIDENCE REVIEW: In a consensus meeting conducted on April 4, 2018, a total of 47 questions covering preoperative, intraoperative, and postoperative care were formulated by 12 international experts with extensive clinical experience in the field of UA surgery for OSA. Systematic literature searches were performed by an independent information specialist and 6 researchers according to the Oxford and GRADE systems, and 164 articles published on or before December 31, 2011, were included in the analysis. Two moderators chaired the meeting according to the Amsterdam Delphi Method, including iteration of literature conclusions, expert discussion, and voting rounds. Consensus was reached when there was 70% or more agreement among experts. FINDINGS: Of 47 questions, 35 led to a recommendation or statement. The remaining 12 questions provided no additional information and were excluded in the judgment of experts. Consensus was reached for 32 recommendations. For 1 question there was less than 70% agreement among experts; therefore, consensus was not achieved. Highlights of these recommendations include (1) postoperative bleeding is a complication described for all types of UA surgery; (2) OSA is a relative risk factor for difficult mask ventilation and intubation, and plans for difficult airway management should be considered and implemented; (3) safe perioperative care should be provided, with aspects such as OSA severity, adherent use of positive airway pressure, type of surgery, and comorbidities taken into account; (4) although there is no direct evidence to date, in patients undergoing UA surgery, preoperative treatment with positive airway pressure may reduce the risk of postoperative airway complications; and (5) alternative pain management options perioperatively to reduce opioid use should be considered. CONCLUSIONS AND RELEVANCE: This consensus contains 35 recommendations and statements on the perioperative care of patients with OSA undergoing UA surgery and may be used as a guideline in daily practice.

Perioperative analgesic profile of dexmedetomidine infusions in morbidly obese undergoing bariatric surgery: a meta-analysis and trial sequential analysis.

BACKGROUND: Opioid-sparing analgesia for bariatric surgery in morbidly obese can potentially prevent catastrophic airway complications. Our meta-analysis attempts to consolidate the evidence on dexmedetomidine evaluating its analgesic and safety profile. METHODS: Trails comparing perioperative dexmedetomidine infusion to conventional analgesic regimens for bariatric surgery were searched. Comparisons were made for 24-hour and postanesthesia care unit (PACU) morphine consumed, PACU pain scores, postoperative nausea and vomiting pain scores, and heartrate. Meta-regression was performed for length of stay to evaluate various analgesic control subgroups. RESULTS: Six trials were included in the final analysis. Dexmedetomidine infusion (reported in 5 intraoperative subgroups and 2 postoperative subgroups) decreased 24-hour morphine by 18.13±6.11 mg (random effects: P<.001, I2 = 95.48%). Despite the small number of included studies, the sample size for avoiding a false positive result was adequate as the trial sequential analysis found the present sample size (362) to be well past the required "sample size" (n = 312) for 85% power. Meta-regression for infusion dose on morphine consumption difference found a predictability of 49% (coefficient = 39.93, random-effects, Tau2 = 396.08), and predictability of the model improved to 68% on inclusion of time of initiation of infusion. The dexmedetomidine group had lower PACU morphine consumption (by 6.91±1.19, I2 = 34.37%), lower pain scores (scale of 0-10±2.27, I2 = 88.14%), lower postoperative nausea and vomiting incidence (odds ratio =±0.26, I2 = 0%), and lower heart rate (73.25 versus. 83.50) (mean difference =±10.15 I2 = 94.04%). No adverse events were reported across trials. CONCLUSION: Perioperative dexmedetomidine infusion in obese patients undergoing bariatric surgery is a promising and safe alternative. Both intraoperative or postoperative infusions lead to significant opioid sparing in early and extend postoperative recovery phase. Morbidly obese patients receiving perioperative dexmedetomidine infusions have overall better pain control and lower incidence of postoperative nausea-vomiting. All the aforementioned merits come with a stable hemodynamic profile and without any reported major adverse events.

Deep Neuromuscular Blockade Improves Laparoscopic Surgical Conditions: A Randomized, Controlled Study.

INTRODUCTION: Sustained deep neuromuscular blockade (NMB) during laparoscopic surgery may facilitate optimal surgical conditions. This exploratory study assessed whether deep NMB improves surgical conditions and, in doing so, allows use of lower insufflation pressures during laparoscopic cholecystectomy. We further assessed whether use of low insufflation pressure improves patient pain scores after surgery. METHODS: This randomized, controlled, blinded study (NCT01728584) compared use of deep (1-2 post-tetanic-counts) or moderate (train-of-four ratio 10%) NMB, and lower (8 mmHg) or higher (12 mmHg; 'standard') insufflation pressure in a 2 × 2 factorial design. Primary endpoint was surgeon's overall satisfaction with surgical conditions, rated at end of surgery using an 11-point numerical scale. Post-operative pain scores were also evaluated. Data were analyzed using analysis of covariance. RESULTS: Of 127 randomized patients, 120 had evaluable data for the primary endpoint. Surgeon's score of overall satisfaction with surgical conditions was significantly higher with deep versus moderate NMB indicated by a least-square mean difference of 1.1 points (95% confidence interval 0.1-2.0; P = 0.026). Furthermore, strong evidence of an effect was observed for standard versus low pressure: least-square mean difference of 3.0 points (95% confidence interval 2.1-4.0; P < 0.001). No significant difference was observed in average pain scores within 24 h post-surgery for low versus standard pressure [0.17 (95% confidence interval -0.67 to +0.33); P = 0.494]. CONCLUSIONS: Although associated with significantly improved surgical conditions, deep NMB alone was insufficient to promote use of low insufflation pressure during laparoscopic cholecystectomy. Furthermore, low insufflation pressure did not result in reduced pain, compared with standard pressure. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov identifier, NCT01728584. FUNDING: Merck Sharp and Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA.

Perioperative management of obstructive sleep apnea in bariatric surgery: a consensus guideline.

BACKGROUND: The frequency of metabolic and bariatric surgery (MBS) is increasing worldwide, with over 500,000 cases performed every year. Obstructive sleep apnea (OSA) is present in 35%-94% of MBS patients. Nevertheless, consensus regarding the perioperative management of OSA in MBS patients is not established. OBJECTIVES: To provide consensus based guidelines utilizing current literature and, when in the absence of supporting clinical data, expert opinion by organizing a consensus meeting of experts from relevant specialties. SETTING: The meeting was held in Amsterdam, the Netherlands. METHODS: A panel of 15 international experts identified 75 questions covering preoperative screening, treatment, postoperative monitoring, anesthetic care and follow-up. Six researchers reviewed the literature systematically. During this meeting, the "Amsterdam Delphi Method" was utilized including controlled acquisition of feedback, aggregation of responses and iteration. RESULTS: Recommendations or statements were provided for 58 questions. In the judgment of the experts, 17 questions provided no additional useful information and it was agreed to exclude them. With the exception of 3 recommendations (64%, 66%, and 66% respectively), consensus (>70%) was reached for 55 statements and recommendations. Several highlights: polysomnography is the gold standard for diagnosing OSA; continuous positive airway pressure is recommended for all patients with moderate and severe OSA; OSA patients should be continuously monitored with pulse oximetry in the early postoperative period; perioperative usage of sedatives and opioids should be minimized. CONCLUSION: This first international expert meeting provided 58 statements and recommendations for a clinical consensus guideline regarding the perioperative management of OSA patients undergoing MBS.

Sedation options for the morbidly obese intensive care unit patient: a concise survey and an agenda for development.

BACKGROUND: We offer some perspectives and commentary on the sedation of obese patients in the intensive care unit (ICU). DISCUSSION: Sedation in morbidly obese patients should conform to the same broad principles now current in ICU practice. These include a general presumption against benzodiazepines as first-line agents. Opioids should be avoided in any situation where spontaneous breathing is required. Remifentanil is the preferred agent where continuous stable opioid levels using an infusion are required, because of its lack of context-sensitive accumulation. Volatile anaesthetics may be an option for the same reason but there are no substantial, controlled demonstrations of effectiveness/safety in short-term use in the ICU setting. Propofol is a valuable resource in the morbidly obese patients but the duration of continuous sedation should not exceed 6 days, in order to avoid propofol infusion syndrome. Alpha-2 agonists offer a range of theoretically positive features for the sedation of morbidly obese patients, but at present there is a lack of pharmacokinetic data and a critical mass of high-grade clinical data. Dexmedetomidine has the attraction of not causing respiratory depression or obstructive breathing during sedation and its sympatholytic effects should help deliver stable blood pressure and heart rate. Ketamine has a poor tolerability profile in adults so its use in the ICU context is largely confined to paediatrics. CONCLUSION: None of the agents currently available is ideal for every situation encountered in the management of morbidly obese patients. This article identifies additional research needed to place sedation practice of obese patients on a more systematic footing.

Factors determining the smooth flow and the non-operative time in a one-induction room to one-operating room setting.

RATIONALE, AIMS AND OBJECTIVES: What factors determine the use of an anaesthesia preparation room and shorten non-operative time? METHODS: A logistic regression is applied to 18 751 surgery records from AZ Sint-Jan Brugge AV, Belgium, where each operating room has its own anaesthesia preparation room. Surgeries, in which the patient's induction has already started when the preceding patient's surgery has ended, belong to a first group where the preparation room is used as an induction room. Surgeries not fulfilling this property belong to a second group. A logistic regression model tries to predict the probability that a surgery will be classified into a specific group. Non-operative time is calculated as the time between end of the previous surgery and incision of the next surgery. A log-linear regression of this non-operative time is performed. RESULTS: It was found that switches in surgeons, being a non-elective surgery as well as the previous surgery being non-elective, increase the probability of being classified into the second group. Only a few surgery types, anaesthesiologists and operating rooms can be found exclusively in one of the two groups. Analysis of variance demonstrates that the first group has significantly lower non-operative times. Switches in surgeons, anaesthesiologists and longer scheduled durations of the previous surgery increases the non-operative time. A switch in both surgeon and anaesthesiologist strengthens this negative effect. Only a few operating rooms and surgery types influence the non-operative time. CONCLUSION: The use of the anaesthesia preparation room shortens the non-operative time and is determined by several human and structural factors.