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postoperative respiratory failure

Etiology: risk factors - older age - low preoperative oxygen saturation, subsumes - smoking - preexisting pulmonary disease - COPD, obstructive sleep apnea [2] - obesity hypoventilation syndrome [1] - hypercapnia [1] - respiratory infection during the previous month - preoperative hemoglobin level <10 g/dL - chronic heart failure [2] - poor health or functional dependence [2] - low serum albumin [2] - renal failure [2] - upper abdominal or thoracic procedure - duration of surgery > 2-3 hours - emergency procedure - obesity hypoventilation syndrome - hypercapnia Laboratory: - preoperative arterial blood gas in at risk patients - pO2 - pCO2, hypercapnia is a risk factor - serum albumin - serum creatinine - complete blood count (CBC) Management: - preoperative prevention - preoperative inspiratory muscle training [4] - smoking cessation at least one month prior to surgery [4] - postoperative prevention - early mobility [2] - pain control [2] - chest physiotherapy [2] - more intensive alveolar recruitment strategy (moderate PEEP + recruiting maneuvers) with low tidal volumes for protective ventilation may reduce severity of pulmonary complications in patients with hypoxemia after cardiac surgery [3] - MKSAP suggests sleeping with head of bed elevated may be acceptable if patient desaturates when sleeping supine but is asymptomatic when awake & upright [2,6] - not beneficial - no benefit for postoperative incentive spirometry after CABG or abdominal surgery [4] - no benefit for incentive spirometry with or without deep breathing exercises [2] - continuous positive airway pressure (CPAP) after abdominal surgery does not prevent pneumonia, reintubation, or death [5] - no benefit for bronchoscopy to clear airway mucus vs other methods of chest physiotherapy for preventing postoperative atelectasis [2]

General

postoperative complication respiratory failure

References

  1. Kaw R, Bhateja P, Paz Y et al. Postoperative complications in patients with unrecognized obesity hypoventilation syndrome undergoing elective noncardiac surgery. Chest 2016 Jan; 149:84 PMID: 25996642 http://www.sciencedirect.com/science/article/pii/S0012369215001166
  2. Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16. 17, 18, 19 American College of Physicians, Philadelphia 2006, 2009, 2012, 2015, 2018, 2022.
  3. Leme AC, Hajjar LA, Volpe MS et al Effect of Intensive vs Moderate Alveolar Recruitment Strategies Added to Lung-Protective Ventilation on Postoperative Pulmonary Complications. A Randomized Clinical Trial. JAMA. Published online March 21, 2017 PMID: 28322416 http://jamanetwork.com/journals/jama/fullarticle/2612913
  4. Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019
  5. PRISM trial group. Postoperative continuous positive airway pressure to prevent pneumonia, re-intubation, and death after major abdominal surgery (PRISM): A multicentre, open-label, randomised, phase 3 trial. Lancet Respir Med 2021 Nov; 9:1221. PMID: 34153272 https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(21)00089-8/fulltext
  6. Chung F, Memtsoudis SG, Ramachandran SK, et al. Society of Anesthesia and Sleep Medicine guidelines on preoperative screening and assessment of adult patients with obstructive sleep apnea. Anesth Analg. 2016;123:452-73. P PMID: 27442772