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      Low intraoperative tidal volume ventilation with minimal PEEP is associated with increased mortality

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          Abstract

          Background

          Anaesthetists have traditionally ventilated patients’ lungs with tidal volumes (TVs) between 10 and 15 ml kg −1 of ideal body weight (IBW), without the use of PEEP. Over the past decade, influenced by the results of the Acute Respiratory Distress Syndrome Network trial, many anaesthetists have begun using lower TVs during surgery. It is unclear whether the benefits of low TV ventilation can be extended into the perioperative period.

          Methods

          We reviewed the records of 29 343 patients who underwent general anaesthesia with mechanical ventilation between January 1, 2008 and December 31, 2011. We calculated TV kg −1 IBW, PEEP, peak inspiratory pressure (PIP), and dynamic compliance. Cox regression analysis with propensity score matching was performed to examine the association between TV and 30-day mortality.

          Results

          Median TV was 8.6 [7.7–9.6] ml kg −1 IBW with minimal PEEP [4.0 (2.2–5.0) cm H 2O]. A significant reduction in TV occurred over the study period, from 9 ml kg −1 IBW in 2008 to 8.3 ml kg −1 IBW in 2011 ( P=0.01). Low TV 6–8 ml kg −1 IBW was associated with a significant increase in 30-day mortality vs TV 8–10 ml kg −1 IBW: hazard ratio (HR) 1.6 [95% confidence interval (CI) [1.25–2.08], P=0.0002]. The association remained significant after matching: HR 1.63 [95% CI (1.22–2.18), P<0.001]. There was only a weak correlation between TV kg −1 IBW and dynamic compliance ( r=−0.006, P=0.31) and a weak-to-moderate correlation between TV kg −1 IBW and PIP ( r=0.32 P<0.0001).

          Conclusions

          Use of low intraoperative TV with minimal PEEP is associated with an increased risk of 30-day mortality.

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          Most cited references35

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          Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network.

          Traditional approaches to mechanical ventilation use tidal volumes of 10 to 15 ml per kilogram of body weight and may cause stretch-induced lung injury in patients with acute lung injury and the acute respiratory distress syndrome. We therefore conducted a trial to determine whether ventilation with lower tidal volumes would improve the clinical outcomes in these patients. Patients with acute lung injury and the acute respiratory distress syndrome were enrolled in a multicenter, randomized trial. The trial compared traditional ventilation treatment, which involved an initial tidal volume of 12 ml per kilogram of predicted body weight and an airway pressure measured after a 0.5-second pause at the end of inspiration (plateau pressure) of 50 cm of water or less, with ventilation with a lower tidal volume, which involved an initial tidal volume of 6 ml per kilogram of predicted body weight and a plateau pressure of 30 cm of water or less. The primary outcomes were death before a patient was discharged home and was breathing without assistance and the number of days without ventilator use from day 1 to day 28. The trial was stopped after the enrollment of 861 patients because mortality was lower in the group treated with lower tidal volumes than in the group treated with traditional tidal volumes (31.0 percent vs. 39.8 percent, P=0.007), and the number of days without ventilator use during the first 28 days after randomization was greater in this group (mean [+/-SD], 12+/-11 vs. 10+/-11; P=0.007). The mean tidal volumes on days 1 to 3 were 6.2+/-0.8 and 11.8+/-0.8 ml per kilogram of predicted body weight (P<0.001), respectively, and the mean plateau pressures were 25+/-6 and 33+/-8 cm of water (P<0.001), respectively. In patients with acute lung injury and the acute respiratory distress syndrome, mechanical ventilation with a lower tidal volume than is traditionally used results in decreased mortality and increases the number of days without ventilator use.
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            Dose-response analyses using restricted cubic spline functions in public health research.

            Taking into account a continuous exposure in regression models by using categorization, when non-linear dose-response associations are expected, have been widely criticized. As one alternative, restricted cubic spline (RCS) functions are powerful tools (i) to characterize a dose-response association between a continuous exposure and an outcome, (ii) to visually and/or statistically check the assumption of linearity of the association, and (iii) to minimize residual confounding when adjusting for a continuous exposure. Because their implementation with SAS® software is limited, we developed and present here an SAS macro that (i) creates an RCS function of continuous exposures, (ii) displays graphs showing the dose-response association with 95 per cent confidence interval between one main continuous exposure and an outcome when performing linear, logistic, or Cox models, as well as linear and logistic-generalized estimating equations, and (iii) provides statistical tests for overall and non-linear associations. We illustrate the SAS macro using the third National Health and Nutrition Examination Survey data to investigate adjusted dose-response associations (with different models) between calcium intake and bone mineral density (linear regression), folate intake and hyperhomocysteinemia (logistic regression), and serum high-density lipoprotein cholesterol and cardiovascular mortality (Cox model). 2010 John Wiley & Sons, Ltd.
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              Prediction of postoperative pulmonary complications in a population-based surgical cohort.

              Current knowledge of the risk for postoperative pulmonary complications (PPCs) rests on studies that narrowly selected patients and procedures. Hypothesizing that PPC occurrence could be predicted from a reduced set of perioperative variables, we aimed to develop a predictive index for a broad surgical population. Patients undergoing surgical procedures given general, neuraxial, or regional anesthesia in 59 hospitals were randomly selected for this prospective, multicenter study. The main outcome was the development of at least one of the following: respiratory infection, respiratory failure, bronchospasm, atelectasis, pleural effusion, pneumothorax, or aspiration pneumonitis. The cohort was randomly divided into a development subsample to construct a logistic regression model and a validation subsample. A PPC predictive index was constructed. Of 2,464 patients studied, 252 events were observed in 123 (5%). Thirty-day mortality was higher in patients with a PPC (19.5%; 95% [CI], 12.5-26.5%) than in those without a PPC (0.5%; 95% CI, 0.2-0.8%). Regression modeling identified seven independent risk factors: low preoperative arterial oxygen saturation, acute respiratory infection during the previous month, age, preoperative anemia, upper abdominal or intrathoracic surgery, surgical duration of at least 2 h, and emergency surgery. The area under the receiver operating characteristic curve was 90% (95% CI, 85-94%) for the development subsample and 88% (95% CI, 84-93%) for the validation subsample. The risk index based on seven objective, easily assessed factors has excellent discriminative ability. The index can be used to assess individual risk of PPC and focus further research on measures to improve patient care.
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                Author and article information

                Journal
                Br J Anaesth
                Br J Anaesth
                BJA: British Journal of Anaesthesia
                The Author(s). Published by Elsevier Ltd.
                0007-0912
                1471-6771
                13 December 2017
                July 2014
                13 December 2017
                : 113
                : 1
                : 97-108
                Affiliations
                [1 ]Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1010, New York, NY 10029, USA
                [2 ]Department of Health Evidence and Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1010, New York, NY 10029, USA
                [3 ]Department of Cardiothoracic Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1010, New York, NY 10029, USA
                Author notes
                [* ]Corresponding author
                Article
                S0007-0912(17)31550-7
                10.1093/bja/aeu054
                9585620
                24623057
                674bc0e7-ddd0-4702-a8d2-36c9c585455a
                © 2014 The Author(s)

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                : 28 December 2013
                Categories
                Clinical Practice

                Anesthesiology & Pain management
                intraoperative care,pulmonary ventilation,tidal volume
                Anesthesiology & Pain management
                intraoperative care, pulmonary ventilation, tidal volume

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