The population of the United States (US) is growing and aging.The US Census Bureau projects that the number of Americans age 65 years and older will more than double between 2010 and 2050. The percentage of Americans 65 and older will grow from 13% to more than 20% of the total population by 2030, and the fastest growing segment of this group (individuals 85 years and older) is expected to triple in number over the next 4 decades.These changes in the age demographics of the US population are largely due to people living longer and the “baby boomer” generation

https://www.journalacs.org/article/S1072-7515(12)00493-0/pdf

Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society.

BACKGROUND:Incomplete recovery of neuromuscular function may impair pulmonary and upper airway function and contribute to adverse respiratory events in the postanesthesia care unit (PACU). The aim of this investigation was to assess and quantify the severity of neuromuscular blockade in patients wit

Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit

Postoperative pulmonary complications are an important part of the risk of surgery and prolong the hospital stay by an average of one to two weeks.1 Much of the literature on the assessment of perioperative risk has focused on identifying the now well-defined cardiac risk factors. However, clinically significant postoperative pulmonary complications are as common as postoperative cardiac complications. According to one review, pulmonary complications were at least as common as or more common than cardiac complications in 17 of 25 studies of postoperative complications.2 This article reviews patient- and procedure-related risk factors, clinical evaluation, pulmonary-function testing, and risk-reduction strategies. The . . .

https://www.nejm.org/doi/pdf/10.1056/NEJM199903253401207

Preoperative Pulmonary Evaluation

This background review supports the American College of Physicians' clinical practice guideline on reducing postoperative pulmonary complications after noncardiothoracic surgery.

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Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the American College of Physicians.

Background: Residual neuromuscular blockade remains a problem even after short surgical procedures. The train-of-four (TOF) ratio at the adductor pollicis required to avoid residual paralysis is now considered to be at least 0.9. The incidence of residual paralysis using this new threshold is not known, especially after a single intubating dose of intermediate-duration nondepolarizing relaxant. Therefore, the aim of the study was to determine the incidence of residual paralysis in the postanesthesia care unit after a single intubating dose of twice the ED95 of a nondepolarizing muscle relaxant with an intermediate duration of action. Methods: Five hundred twenty-six patients were enrolled. They received a single dose of vecuronium, rocuronium, or atracurium to facilitate tracheal intubation and received no more relaxant thereafter. Neuromuscular blockade was not reversed at the end of the procedure. On arrival in the postanesthesia care unit, the TOF ratio was measured at the adductor pollicis, using acceleromyography. Head lift, tongue depressor test, and manual assessment of TOF and DBS fade were also performed. The time delay between the injection of muscle relaxant and quantitative measurement of neuromuscular blockade was calculated from computerized anesthetic records. Results: The TOF ratios less than 0.7 and 0.9 were observed in 16% and 45% of the patients, respectively. Two hundred thirtynine patients were teste d2ho rmore after the administration of the muscle relaxant. Ten percent of these patients had a TOF ratio less than 0.7, and 37% had a TOF ratio less than 0.9. Clinical tests (head lift and tongue depressor) and manual assessment of fade showed a poor sensitivity (11–14%) to detect residual blockade (TOF < 0.9). Conclusion: After a single dose of intermediate-duration muscle relaxant and no reversal, residual paralysis is common, even more than 2 h after the administration of muscle relaxant. Quantitative measurement of neuromuscular transmission is the only recommended method to diagnose residual block.

Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action.

Background: After anaesthesia involving pancuronium a high incidence of both residual neuromuscular block and postoperative pulmonary complications (POPC) has been reported. The aim of this study was to compare the incidence of POPC following the use of pancuronium, atracurium, and vecuronium, and to examine the effect of residual neuromuscular block on the incidence of POPC.

Methods: A total of 691 adult patients undergoing abdominal, gynaecological, or orthopaedic surgery under general anaesthesia were randomised to receive either pancuronium, atracurium, or vecuronium. Perioperatively, the response to train-of-four (TOF) nerve stimulation was evaluated manually. Post-operatively, the TOF ratios were measured mechanomyograph-ically, and through a 6-day follow-up the patients were examined for pulmonary complications.

Results: The incidence of residual block, defined as a TOF ratio <0.7, was significantly higher in the pancuronium group (59/226: 26%) than in the atracurium/vecuronium groups (24/450: 5.3%). In the pancuronium group, significantly more patients with residual block developed POPC (10/59: 16.9%) as compared to patients without residual block (8/167 4.8%). In the atracurium/vecuronium groups, the incidence of POPC was not significantly different in patients with (1/24: 4.2%) or without (23/426: 5.4%) residual block. Multiple regression analysis indicated that abdominal surgery, age, long-lasting surgery, and a TOF ratio<0.7 following the use of pancuronium were potential risk factors for the development of POPC.

Conclusion: Postoperative residual block caused by pancuronium is a significant risk factor for development of POPC.

Residual neuromuscular block is a risk factor for postoperative pulmonary complications: A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium

Background: As environmental pollution by nitrous oxide may influence the health of the personnel working in operating theatres, the incidence and magnitude of nitrous oxide (N2O) leakage, when using a face mask or a laryngeal mask airway (LMA) for controlled ventilation, were studied in 34 patients scheduled for elective cystoscopy.



Methods: A semi-closed gas delivery ventilation system with active scavenging was used. The N2O concentrations were measured every 8 s at a position 30 cm above the patient's mouth with a N2O gas monitor (GD 200, Simrad Optronics).



Results: When using a face mask, the leakage of N2O resulted in a N2O concentration of 157 (85–332) p.p.m. (parts per million) (median concentration and 25% and 75% percentiles). With the LMA, a lower median concentration of N2O of 60 (28–126) p.p.m. was found (P=0.04). With the face mask, a concentration above 100 p.p.m. was found during 51% of the exposure time compared to 24% of the time in the LMA group.



Conclusion: Environmental pollution was less with the LMA than the face mask, but under the conditions of the study both modes of airway management were associated with levels of N2O peak concentrations in the breathing zone of anaesthetists that are deemed to be excessively high by the Danish National Institute for Occupational Safety.

Pollution with nitrous oxide using laryngeal mask or face mask.

Background and objective: Remifentanil has a short duration of action and constant elimination, which allow administration of high doses, without prolonging recovery. Remifentanil has been compared to alfentanil, as partof a total intravenous anaesthetic technique, where remifentanil provided better anaesthetic conditions than alfentanil, without adverse effect on recovery. However, these results were obtained during anaesthesia involving neuromuscular blockade, which may mask both signs of insufficient anaesthesia and side-effects such as muscle rigidity. The aim of this study was to compare remifentanil with alfentanil for anaesthesia without neuromuscular blockade. Methods: We performed a prospective, randomized, double-blind, four-centre study to compare remifentanil infusion 15 μg kg - 1 h - 1 and alfentanil infusion 60 μg kg - 1 h - 1 , using a total intravenous technique for non-paralysed patients, and the laryngeal mask airway for airway management. We enrolled 192 patients, 18-65 yr of age with ASA I-II, undergoing minor surgery. The primary endpoint was the number of patients having pre-defined responses to surgical stimulation. A number of secondary criteria was evaluated to assess undesirable properties of the procedures. Results: In the alfentanil group, 85% of patients responded to surgical stimulation, vs. 35% in the remifentanil group (P < 0.0001). No difference was found in recovery data, or in any other parameter than those related to insufficient anaesthesia. Conclusions: The remifentanil-based technique provided significantly better anaesthetic conditions than the alfentanil-based technique in the setting of this study, without causing any significant adverse effects.

Remifentanil vs. alfentanil infusion in non-paralysed patients: a randomized, double-blind study.

The risk of pulmonary complications is high after major abdominal surgery but may be reduced by prophylactic postoperative noninvasive ventilation using continuous positive airway pressure (CPAP). This study compared the effects of intermittent mask CPAP (ICPAP) and continuous helmet CPAP (HCPAP) on oxygenation and the risk of pulmonary complications following major abdominal surgery. Patients undergoing open abdominal aortic aneurysm repair or pancreaticoduodenectomy were randomized (1:1) to either postoperative ICPAP or HCPAP. Oxygenation was evaluated as the partial pressure of oxygen in arterial blood fraction of inspired oxygen ratio (PaO2/FIO2) at 6 h, 12 h, and 18 h postoperatively. Pulmonary complications were defined as X-ray verified pneumonia/atelectasis, clinical signs of pneumonia, or supplementary oxygen beyond postoperative day 3. Patient-reported comfort during CPAP treatment was also evaluated. In total, 96 patients (ICPAP, n = 48; HCPAP, n = 48) were included, and the type of surgical procedure were evenly distributed between the groups. Oxygenation did not differ between the groups by 6 h, 12 h, or 18 h postoperatively (p = 0.1, 0.08, and 0.67, respectively). Nor was there any difference in X-ray verified pneumonia/atelectasis (p = 0.40) or supplementary oxygen beyond postoperative day 3 (p = 0.53). Clinical signs of pneumonia tended to be more frequent in the ICPAP group (p = 0.06), yet the difference was not statistically significant. Comfort scores were similar in both groups (p = 0.43), although a sensation of claustrophobia during treatment was only experienced in the HCPAP group (11% vs. 0%, p = 0.03). Compared with ICPAP, using HCPAP was associated with similar oxygenation (i.e., PaO2/FIO2 ratio) and a similar risk of pulmonary complications. However, HCPAP treatment was associated with a higher sensation of claustrophobia. 

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Comparing the effects of continuous positive airway pressure via mask or helmet interface on oxygenation and pulmonary complications after major abdominal surgery: a randomized trial

C. R. Mortensen

Papers

Residual neuromuscular block is a risk factor for postoperative pulmonary complications: A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium

Pollution with nitrous oxide using laryngeal mask or face mask.

Remifentanil vs. alfentanil infusion in non-paralysed patients: a randomized, double-blind study.

Comparing the effects of continuous positive airway pressure via mask or helmet interface on oxygenation and pulmonary complications after major abdominal surgery: a randomized trial