Methods for determination of optimal positive end-expiratory pressure: a protocol for a scoping review.

INTRODUCTION: Titrated application of positive end-expiratory pressure (PEEP) is an important part of any mechanical ventilation strategy. However, the method by which the optimal PEEP is determined and titrated varies widely. Methods for determining optimal PEEP have been assessed using a variety of different study designs and patient populations. We will conduct a scoping review to systematically identify all methods for determining optimal PEEP, and to identify the patient populations, outcomes measured and study designs used for each method. The goal will be to identify gaps in the optimal PEEP literature and identify areas where there may be an opportunity to further systematically synthesise and meta-analyse existing literature. METHODS AND ANALYSIS: Using scoping review methodology, we will generate a comprehensive search strategy based on inclusion and exclusion criteria generated using the population, concept, context framework. Five different databases will be searched (MEDLINE, EMBASE, CENTRAL, Web of Science and Scopus). Three investigators will independently screen titles and abstracts, and two investigators will independently complete full-text review and data extraction. Included citations will be categorised in terms of PEEP method, study design, patient population and outcomes measured. The methods for PEEP titration will be described in detail, including strengths and limitations. ETHICS AND DISSEMINATION: Given this is a synthesis of existing literature, ethics approval is not required. The results will be disseminated to stakeholders via presentation at local, regional and national levels, as well as publication in a high-impact critical care journal. There is also the potential to impact local clinical care protocols and inform broader clinical practice guidelines undertaken by societies.

Improving prevention, early recognition and management of acute kidney injury after major surgery: results of a planning meeting with multidisciplinary stakeholders.

PURPOSE OF REVIEW: Acute kidney injury (AKI) is common after major surgery, and is associated with morbidity, mortality, increased length of hospital stay, and high health care costs. Although recent guidelines for AKI provide recommendations for identification of patients at risk, monitoring, diagnosis, and management of AKI, there is lack of understanding to guide successful implementation of these recommendations into clinical practice. SOURCES OF INFORMATION: We held a planning meeting with multidisciplinary stakeholders to identify barriers, facilitators, and strategies to implement recommendations for prevention, early identification, and management of AKI after major surgery. Barriers and facilitators to knowledge use for peri-operative AKI prevention and care were discussed. FINDINGS: Stakeholders identified barriers in knowledge (how to identify high-risk patients, what criteria to use for diagnosis of AKI), attitudes (self-efficacy in preventive care and management of AKI), and behaviors (common use of diuretics, non-steroidal anti-inflammatory drugs, withholding of intravenous fluids, and competing time demands in peri-operative care). Educational, informatics, and organizational interventions were identified by stakeholders as potentially useful elements for future interventions for peri-operative AKI. LIMITATION: Meeting participants were from a single centre. IMPLICATIONS: The information and recommendations obtained from this stakeholder's meeting will be useful to design interventions to improve prevention and early care for AKI after major surgery.

OBJECTIF DE L'ÉTUDE: L'insuffisance rénale aiguë (IRA) est fréquente à la suite d'une chirurgie importante et elle est associée à une morbidité, à une mortalité, à une hospitalisation prolongée et à des coûts élevés liés aux soins de santé. Bien que les lignes directrices récentes concernant l'IRA fournissent des recommandations pour déterminer les patients à risque, de même que pour contrôler, diagnostiquer et prendre en charge l'IRA, la compréhension fait défaut pour mener leur mise en place réussie dans la pratique clinique. SOURCES D'INFORMATION: Nous avons tenu une réunion de planification avec des acteurs pluridisciplinaires afin de cibler les obstacles, les appuis et les stratégies de mise en œuvre des recommandations pour la prévention, l'identification précoce et la prise en charge de l'IRA suite à une chirurgie importante. On a abordé les obstacles et les appuis à l'utilisation des connaissances dans la prévention périopératoire de l'IRA et les soins qui s'y rattachent. RÉSULTATS: Les acteurs ont déterminé les obstacles à la connaissance (comment identifier les patients à risque élevé, le choix de critères diagnostiques pour l'IRA), les attitudes (l'auto-efficacité dans les soins préventifs et la prise en charge de l'IRA), et les comportements (l'usage courant de diurétiques, d'anti-inflammatoires non stéroïdiens, la non-administration de solutés intraveineux, et les contraintes de temps dans les soins périopératoires). Les acteurs ont défini les interventions éducatives, informatiques et organisationnelles comme des éléments potentiellement utiles dans les interventions futures en soins périopératoires pour l'IRA. LIMITES DE L'ÉTUDE: Les participants à la réunion provenaient d'un seul et même centre. IMPACTS: Les informations et recommandations obtenues au cours de la réunion des acteurs seront utiles pour l'élaboration des interventions afin d'améliorer la prévention et les soins précoces relatifs à l'IRA suite à une chirurgie majeure.