Chapter 43 - Respiratory complications Flashcards
Risk factors for postop pulmonary complication
TABLE 43.1
Smoking cessation in this weeks range worsens postop pulmonary complication
4-8 weeks increased sputum production not clear not reproducible still should quit
Reasons to do pre-op PFT
1) identify if open surgery outweigh benefit 2) identify patients where percutaneous better 3) identify patients that would benefit from aggressive periop management
Rate of pre-op CXR to identify abnormality rate of it affecting perioperative management
1.3% 0.1%
Canet Prediction of post-op pulmonary complications
TABLE 43.2
Rate of VAP in intubated patients
9-27%
Early tracheotomy benefit
Less stay in ICU no improvement in mortality or VAP
Rate of atelectasis
Collapse or closure of alveoli Affects dependent portion of lung 90% of anesthetized patient
Bronchospasm key points
1) increased tone in bronchial smooth muscles 2) narrowing of bronchi 3) histamine, muscarinic, allergic
Acute management of bronchospasm
1) beta-2 agonist 2) iv steroids 3) iv epinephrine
hospital acquired pneumonia definition
1) pneumonia after > 48 hr hospital admission
Ventilation associated pneumonia VAP definition
HAP that develop > 48 hr after intubation
Healthcare-associated pneumonia
1) hospitalization > 2 days in acute care facility within 90 days of admission 2) resident of nursing home or long-term care facility at time of infection 3) HD within 30 days 4) patient who received IV treatment or wound care within 30 days 5) patient family member of a known patient with multidrug resistant pathogen
Etiology of VAP
1) bacterial colonization 2) aspiration of contaminated secretion of lower airway
Ortanism of VAP
1) staphlococcus aureus (MRSA 54-82%) 2) pseudomonas 3) enterobacter 4) acinetobacter 5) klebsiella
VAP score
TABLE 43.3 > 6 is VAP
VAP with MRSA treatment
Vancomycin or linezolid
Duration of antibiotic therapy for VAP
8 days
PaO2 in hypoxemic resp failure
< 60 mmHg
Berlin definition of ARDS
TABLE 43.4
Pathogenesis of ARDS
1) dysregulated inflammation 2) inappropriate accumulation of leukocytes and platelets 3) uncontrolled activation of coagulation pathway 4) altered permeability of alveolar endothelial and epithelial barriers
Stages of ARDS
1) Acute/exudative phase: rapid onset resp failure and arterial hypoxemia - refractory to supplemental O2 (consolidation, atelectasis, alveolar filling) 2) Fibrosing alveolitis: persistent hypoxemia, increased alveolar dead space, compromised pulm comopliance
Transfusion-related acute lung injury TRALI
1) suspected if resp failure within 6 hours of transfusion 2) bilateral chest infiltrate 3) PaO2:FIO2 < 300 4) no pulm edema
Mortality of TRALI
5-10%
Management strategies for respiratory failure
1) high flow nasal oxygen: up to 60 L/min 2) noninfasive positive pressure ventilation (CPAP): Increase functional residual capacity, improve lung compliance, optimize gas exchange
Complications with NPPV
1) nasal bridge ulceration 2) gastric distension
Lung protective mechanical ventilation strategies
1) low tidal volume 6 ml/kg 2) permissive hypercapnia 3) elevated PEEP 4) pressure-limited ventilator modes
high-frequency oscillatory ventilation for ARDS
not considered routine may harm
PEEP in ARDS
high peep has no mortality benefit than low peep
diuretic or HD in ARDS
no proven benefit
Cisatracurium in ARDS
useful if PaO2:FIO2 < 150 mmHg
prone positioning for ARDS
has a mortality benefit
ECMO in ards
rescue strategy but more evidence needed
