Lluís Gallart

Post-operative pulmonary complications: Understanding definitions and risk assessment

Post-operative pulmonary complications (PPCs) can have severe consequences and their incidence is high. In recent years, PPCs have been the subject of numerous studies and articles, which have provided a great deal of information that is beneficial but that can cause confusion on a practical level. This review focusses on three main points: (1) the definitions of PPCs, which are heterogeneous and often vary from one report to another, despite emerging consensus; (2) the risk as reflected in the pool of PPC predictors, with each study identifying some but leaving us with a myriad of combinations; and (3) the many PPC prediction scores proposed, each with its strengths and limitations. We attempt to clarify the practical and research implications of the current situation.

Erratum to “Post-operative pulmonary complications: Understanding definitions and risk assessment” [Best Pract Res Clin Anaesthesiol 29 (2015) 315–330]

The publisher regrets that the following items in this paper require correction. Page 317, in the Patient-related risk factors section, the fourth sentence on Advanced age should read: The components of frailty are weakness and decreased functional reserve, which are candidates to target for improvement through prehabilitation interventions [23e25]. Page 319e320, Table 3 contained several errors, namely two of the footnotes to the Gupta et al. [13] paper in the ASA rows should have read b (denoting Reference group, ASA 5), and in the column for Patient risk factor, the row for Pre-operative SpO2, should include the indication (%), and the first category should have read 90. So it should have appeared as per the amended Table 3 on the next page. Page 321, Table 4 contained an error in the Duration of surgery (h) section, namely that the middle category should have read >3 and <6. The revised Table 4 is shown hereafter.

Fracciones inspiratorias elevadas de O2 con el uso del dispositivo convencional de nebulización de fármacos

UNLABELLED Nebulised drugs are very useful in COPD exacerbations. The most frequently used propellant is compressed air, which is commonly administered together with nasal oxygen in those patients with respiratory failure. The purpose of this approach is to avoid the risks inherent in breathing high inspiratory oxygen fractions (FIO(2)). AIM To analyze the actual FIO(2) obtained with such a common method under experimental conditions. METHODS Volunteers breathed using different patterns (quiet breathing, panting and deep breathing), through either the nose or the mouth, with oxygen flows of 0 vs. 4l/min. Then, they repeated quiet breathing and panting patterns, with nebulization of saline propelled by compressed air (8l/min) and oxygen flows of 0, 2, 4, 6 and 8l/min. The F(I)O(2) was simultaneously determined both in retronasal (RN) and retropharyngeal (RF) areas. RESULTS During breathing without simultaneous nebulization and oxygen flow of 4l/min, FIO(2) reached mean values of 0.42-0.71 (RN) and 0.29-0.38 (RF) for the three ventilatory patterns analyzed. With nebulisations during quiet breathing, mean FIO(2) values were 0.39 (RN) and 0.27 (RF) for 2l/min O(2) flow, 0.47 (RN), 0.34 (RF) for 4l/min, 0.58 (RN), 0.38 (RF) for 6l/min, and 0.68 (RN) and 0.50 (RF) for 8l/min. Similar results were obtained with the panting pattern. CONCLUSION The FIO(2) obtained using the conventional nebulization system (propulsion with compressed air and simultaneous nasal oxygen therapy) are relatively high, and therefore, might involve risks for COPD patients during exacerbations.

Increased Inspiratory Oxygen Fractions (FIO 2 ) Using a Conventional Drug Delivery Nebuliser

Nebulised drugs are very useful in COPD exacerbations. The most frequently used propellant is compressed air, which is commonly administered together with nasal oxygen in those patients with respiratory failure. The purpose of this approach is to avoid the risks inherent in breathing high inspiratory oxygen fractions

Rectal, central venous, gastric and bladder pressures versus esophageal pressure for the measurement of cough strength: a prospective clinical comparison

BackgroundCough pressure, an expression of expiratory muscle strength, is usually measured with esophageal or gastric balloons, but these invasive catheters can be uncomfortable for the patient or their placement impractical. Because pressure in the thorax and abdomen are expected to be similar during a cough, we hypothesized that measurement at other thoracic or abdominal locations might also be similar as well as useful in clinical scenarios. This study aimed to compare cough pressures measured at thoracic and abdominal sites that could serve as alternatives to esophageal pressures (Pes).MethodsNine patients scheduled for laparotomy were asked to cough as forcefully as possible from total lung capacity in supine position. Three cough maneuvers were performed while Pes (the gold standard) as well as gastric, central venous, bladder and rectal pressures (Pga, Pcv, Pbl, and Prec, respectively) were measured simultaneously. The intraclass correlation coefficient (ICC) was used to evaluate the repeatability of the measurements in each patient at each site and evaluate agreement between alternative sites (Pga, Pcv, Pbl, and Prec) and Pes. Bland–Altman plots were used to compare Pes and the measurements at the other sites.ResultsMedian (first quartile, third quartile) maximum pressures were as follows: Pes 112 (89,148), Pga 105 (92,156), Pcv 102 (91,149), Pbl 118 (93,157), and Prec 103 (88,150) cmH2O. The ICCs showed excellent within-site repeatability of the measurements (p < 0.001) and excellent agreement between alternative sites and Pes (p < 0.004). The Bland–Altman plots showed minimal differences between Pes, Pga, Pcv, and Prec. However, Pbl was higher than the other pressures in most patients, and the difference between Pes and Pbl was slightly larger.ConclusionsCough pressure can be measured in the esophagus, stomach, superior vena cava or rectum, since their values are similar. It can also be measured in the bladder, although the value will be slightly higher. These results potentially facilitate the assessment of dynamic expiratory muscle strength with fewer invasive catheter placements in most hospitalized patients, thus providing an option that will be particularly useful in those undergoing thoracic or abdominal surgery.Trial registrationNCT02957045 registered at November 7, 2016. Retrospectively registered.

Can Postoperative Pulmonary Complications Be Objectively Evaluated

Thoracic surgery is frequently accompanied by postoperative pulmonary complications (PPCs). PPCs may be mild, moderate, or severe complications and increase the length of stay in hospital and even mortality. Notably, the chance of developing PPCs may be associated with specific intraoperative risk factors, as identified in retrospective, observational prospective, single- and multiple-center studies. Such factors may be combined and weighed in scores that might be useful to predict the risk of developing PPCs. Some of those scores allow identifying subpopulations with especially high risk of adverse postoperative pulmonary events, but they may differ in their performance. Despite those differences, PPCs after thoracic surgery can be predicted with acceptable sensitivity and specificity and may be useful for selecting high-risk groups, planning interventions, and allocating resources.

Hallazgo de un bronquio traqueal derecho durante fibrobroncoscopia intraoperatoria

pulmonares derechas por toracotomia. Al realizar la comprobacion del tubo de doble luz mediante fibrobroncoscopio se observaron tres ramificaciones bronquiales, que crearon confusion al observador. Tras retirar el tubo se observo la estructura traqueal tipica en semiluna, y se vieron tres ramificaciones donde deberia haber 2 (bronquios derecho e izquierdo), debido a la presencia de un bronquio traqueal derecho (Figura 1). El bronquio traqueal es una anomalia congenita originada en la traquea o bronquios principales, con una prevalencia de 0,1-2%, principalmente derecho. Suele ser un hallazgo casual y asintomatico, pero su existencia debe sospecharse ante neumonias persistentes, atelectasias, y bullas en lobulos superiores. Debe conocerse su existencia para evitar errores de interpretacion durante la broncoscopia, como sucedio en este caso.

Diagnóstico de síndrome de HELLP por visualización hepática intraoperatoria

con cefalea intensa, obnubilacion, diplopia, dolor epigastrico y edemas. Se procedio a cesarea emergente con anestesia general. El dolor epigastrico hizo sospechar lesion hepatica por sindrome de HELLP, por lo que se realizo un examen visual intraoperatorio del higado, que mostro piqueteado hemorragico en su cara inferior (Fig. 1). Posteriormente se confirmo el diagnostico de sindrome de HELLP (hemolisis, enzimas hepaticas elevadas y plaquetopenia), ademas presentaba necrosis tubular aguda que requirio hemodialisis, asi como AVC isquemico. La preeclampsia grave con sindrome de HELLP es una complicacion infrecuente pero grave, cuyo pronostico depende del diagnostico precoz y la terapeutica adecuada. En nuestro caso la exploracion visual del higado permitio la sospecha del sindrome y la actuacion precoz. Esta maniobra no es habitual durante la cesarea y podria tener cierta yatrogenia, por lo que solo deberia efectuarse en caso de sospecha de sindrome de HELLP.