RCoA and BJA Webinar - Perioperative pulmonary complications

The RCoA and British Journal of Anaesthesia are pleased to announce a series of webinars available to our members on how to optimise your reading of the medical literature.

Episode 5 -  Perioperative pulmonary complications 

    Chairs: Professor Hugh Hemmings, Editor in Chief, British Journal of Anaesthesia  

    Speakers:

    • Prediction and Prevention
      Professor Rupert Pearse, Consultant in Intensive Care Medicine and Clinical Director for Research and Development, Queen Mary University of London and Barts Health NHS Trust
    • Are neuromuscular blocking drugs to blame?
      Professor Jennifer Hunter MBE, Emeritus Professor of Anaesthesia, Senior Research Fellow, University of Liverpool
    • COVID-19 pneumonia: ARDS or not?
      Professor Paolo Pelosi, Professor in Anesthesiology and Intensive Care Medicine, University of Genoa

     

    Webinar recorded on 2 March 2021

    Questions and Answers

    tidal volume  7-10 ml (kg PBW) -lowest is better expecially during laparoscopic surgery 

    PEEP 5 cmH2O, no Recruitment maneuvre

    Pplat below 17 cmH2O - below 22 cmH2O in obese patients

    driving pressure below 13 cmH2O - below 18 cmH2O in obese patients

    if SatO2 below 92% - increase FiO2 up to 70-90%

    if SatO2 below 92% persists - perform RM by ventilator (stepwise) - and increase PEEP avoiding increase in driving pressure

    reference Br J Anaesth 123 (6) - 898-913, 2019

    (Answered by Professor Paolo Pelosi)

    Several scores have been proposed - then different interetation is needed as discussed by Rupert - personally I found ARISCAT (preoperative) score as well as LAS VEGAS (preopertaive and intraoperative) very helpful

    (Answered by Professor Paolo Pelosi)

    RM should not be used routinely in patients during anesthesia including obese patients - it should be used only when oxygenation (and or compliance)  is progressively decreasing - use RM by ventilator - stepwise - do not use manual RM

    (Answered by Professor Paolo Pelosi)

    references

    • Young CC et al. Br J Anaesth 123 (6), 898-913, 2019
    • The AVATAR Investigators – Br J Anaesth. 2021 Feb;126(2):533-543.
    • Ball L et al. Br J Anaesth. 2018 Oct;121(4):899-908
    • The LAS VEGAS Investigators - Eur J Anaesthesiol 2017; 34:492–507
    • Mazzinari G et al. J Appl Physiol (1985). 2020 Dec 24. (Online ahead of print)
    • Mazzinari G et al. Anesthesiology. 2020 Apr;132(4):667-677.
    • Neto AS et al. Lancet Respir Med. 2016 Apr;4(4):272-80.
    • Pereira SM et al. Anesthesiology. 2018 Dec;129(6):1070-10
    • PROVEnet  investigators JAMA. 2019 Jun 18;321(23):2292-2305 
    • PROVEnet investigators. Lancet. 2014 9;384(9942):495-503
    • Serpa-Neto A. et al. Anesthesiology. 2015 Jul;123(1):66-78
    • Karalapillai D et al. JAMA. 2020;324(9):848-858
    • Mazo V. et al. Anesthesiology. 2014 Aug;121(2):219-31

    Always monitor quantitative NMB and then you use the lowest dose of NMBA necessary whatever the technique.

    (Answered by Professor Jennie Hunter)

    Use Acceleromyography until TOFR = 1.0  

    (Answered by Professor Jennie Hunter)

    Anaphylaxis can occur with very small doses of any drug. So titrating SGX dose very rarely prevents it.                                  

    (Answered by Professor Jennie Hunter)

    In renal patients, I prefer cisatracurium, monitoring block and giving neostigmine when the TOFR is > 0.2.

    (Answered by Professor Jennie Hunter)

    You must have established the beginning of recovery TOFR > 0.2 and you must monitor until TOFR > 0.9

    Question:

    Sugammadex allergy - there’s more evidence for this now. I worry about increased use in Sugammadex with the message that it may reduce POPC. Having a strategy for NMB management with careful use of neostigmine has an important place in overall safe anaesthetic management. Always use quantitative NMB monitoring. 

    Answer: 

    I agree with a lot of this comment. But if you use Neostigmine you must monitor NMB and only give it when recovery has commenced to TOFR 0.2 and you must monitor to full recovery.

     (Answered by Professor Jennie Hunter)                                                                                     

    I agree, we must always be on the alert for anaphylaxis, but the evidence that SGX is higher risk that antibiotics is not robust.

    (Answered by Professor Jennie Hunter)