Optimizing Management of Acute Respiratory Distress Syndrome in Critically Ill Surgical Patients: A Systematic Review.

Summary

This PRISMA-compliant, PROSPERO-registered systematic review (15 studies) in surgical ARDS reports that prone positioning and ECMO are associated with lower mortality. Lung-protective ventilation targets and methylprednisolone correlate with survival benefits, and conservative fluids shorten ICU/ventilator duration while improving oxygenation.

Key Findings

• Prone positioning reduced mortality, ICU length of stay, ventilator days, and improved oxygenation (P<0.001).
• ECMO use was associated with lower mortality versus no ECMO (36.4% vs 43.9%, P<0.001).
• Lung-protective ventilation (tidal volume ≤8 mL/kg PBW and plateau pressure ≤35 cmH2O) was linked to reduced mortality.
• Methylprednisolone use was associated with lower mortality in surgical ARDS.
• Conservative fluid management decreased ICU/ventilator days and improved oxygenation.

Clinical Implications

Support early adoption of prone positioning, strict lung-protective ventilation (≤8 mL/kg PBW, plateau ≤35 cmH2O), conservative fluid strategies, and consideration of methylprednisolone; evaluate ECMO for refractory hypoxemia in surgical ARDS within multidisciplinary protocols.

Limitations

• Heterogeneity of included studies (designs, interventions) with likely residual confounding; many nonrandomized.
• No comprehensive quantitative meta-analysis reported; surgical-only focus may limit generalizability.

Future Directions

Prospective multicenter RCTs in surgical ARDS to test prone protocols, steroid dosing/timing, conservative fluid strategies, and to define ECMO selection/timing; standardized ventilation and perioperative pathways.