Studies into optimization of care provided in the operating room and the intensive care unit

Intraoperative mechanical ventilation is a potentially harmful intervention. So-called ‘lung-protective’ ventilation improves outcome of intensive care patients, and maybe even of patients who need short-lasting intraoperative ventilation. A single center randomized clinical trial assessed the effect of intraoperative ventilation with lower tidal volumes (V_T) with positive end-expiratory pressure (PEEP) versus intermediate V_T without PEEP on pulmonary inflammation, lung injury and intraoperative fluid and vasopressor use in patients undergoing minimally invasive esophagectomy for cancer. While ventilation with lower tidal volumes (V_T) with PEEP did not affect pulmonary inflammation or lung injury, the use of PEEP was associated with more use of vasopressors. Intermediate tidal volumes (without PEEP) may already be sufficiently protective but use of PEEP comes with side-effects which may have an adverse impact on outcome.
A secondary analysis of large worldwide observational study showed an increased use of lung–protective ventilation during general for surgery anesthesia, also during intrathoracic surgeries like for esophagectomy for cancer – however, in one-third of patients tidal volumes are still too large.
ICU patients typically suffer from pain, agitation or delirium – timely recognition and treatment of these symptoms may impact outcome. Current attitudes toward pain measurement and implementation of the ‘Pain, Agitation and Delirium’ (PAD) guideline in ICU patients in the Netherlands were evaluated in a prospective multicenter, before–after intervention study in seven Dutch ICUs. Implementing of these guidelines appears to be challenging, as scoring of pain and sedation increased, while scoring of delirium decreased.