Temporal trends and current practice patterns for intraoperative ventilation at US academic medical centers: a retrospective study

• Type of Material: Article
• Authors: Jonathan P. Wanderer, Vanderbilt University; Jesse M. Ehrenfeld, Vanderbilt University; Richard H. Epstein, Thomas Jefferson University; Daryl J. Kor, Mayo Clinic; Raquel R. Bartz, Duke University; Ana Fernandez-Bustamante, University of Colorado; Marcos F. Vidal Melo, Massachusetts General Hospital; James Blum, Emory University
• Language: English
• Date: 2015-03-28
• Publisher: BioMed Central
• Publication Version: Final Published Version
• Copyright Statement: © Wanderer et al.; licensee BioMed Central.
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1186/s12871-015-0010-3
• Title of Journal or Parent Work: BMC Anesthesiology
• ISSN: 1471-2253
• Volume: 15
• Issue: 1
• Start Page: 40
• End Page: 40
• Grant/Funding Information: This perioperative medical investigation was funded by departmental sources and, in part, the Foundation for Anesthesia Education and Research (FAER) (to Drs. Wanderer and Fernandez-Bustamante), the Anesthesia Quality Institution (Dr. Wanderer) and NHLBI Grant R01 HL121228 (Dr. Vidal Melo).
• Keywords: Anesthesiology; Intraoperative ventilation; Life Sciences & Biomedicine; INFLAMMATION; TIDAL-VOLUME VENTILATION; Lung protective ventilation; STRATEGY; ABDOMINAL-SURGERY; PULMONARY COMPLICATIONS; Science & Technology; LUNG-PROTECTIVE VENTILATION; RISK; INJURY; Practice patterns; RESPIRATORY-DISTRESS-SYNDROME; SURGICAL-PATIENTS
• Research Categories: Health Sciences, Medicine and Surgery; Engineering, Biomedical

Abstract

Background: Lung protective ventilation strategies utilizing lower tidal volumes per predicted body weight (PBW) and positive end-expiratory pressure (PEEP) have been suggested to be beneficial in a variety of surgical populations. Recent clinical studies have used control groups ventilated with high tidal volumes without PEEP based on the assumption that this reflects current clinical practice. We hypothesized that ventilation strategies have changed over time, that most anesthetics in U.S. academic medical centers are currently performed with lower tidal volumes, and that most receive PEEP. Methods: Intraoperative data were pooled for adults undergoing general anesthesia with tracheal intubation. Median tidal volumes per kilogram of PBW were categorized as>10, 8-10 and<8 mL per kg of PBW. The percentages of cases in 2013 that were performed with median tidal volumes<8 mL per kg of PBW and PEEP were determined. As a secondary analysis, a proportional odds model using institution, year, height, weight and gender determined the relative associations of these factors using categorical and interquartile odds ratios. Results: 295,540 cases were analyzed from 5 institutions over a period of 10 years. In 2013, 59.3% of cases used median tidal volumes<8 mL per kg of PBW, 83.3% used PEEP, and 51.0% used both. Of those cases with PEEP, 60.9% used a median pressure of≤5 cmH<inf>2</inf>O. Predictors of lower categories of tidal volumes included height (odds ratio (OR) 10.83, 95% confidence interval [10.50, 11.16]), institution (lowest OR 0.98 [0.96, 1.00], highest OR 9.63 [9.41, 9.86]), year (lowest OR 1.32 [1.21, 1.44], highest OR 6.31 [5.84, 6.82]), male gender (OR 1.10 [1.07, 1.12]), and weight (OR 0.30 [0.29, 0.31]). Conclusion: Most general anesthetics with tracheal intubation at the institutions surveyed are currently performed with a median tidal volume<8 mL per kg of PBW, most are managed with PEEP of≤5 cmH<inf>2</inf>O and approximately half utilize both. Given the diversity of the institutions included, this is likely reflective of practice in U.S. academic medical centers. The utilization of higher tidal volumes without PEEP in control groups for clinical research studies should be reconsidered.