The effect of neostigmine on postoperative delirium after colon carcinoma surgery: a randomized, double-blind, controlled trial

Background

Postoperative delirium (POD) is a critical complication in patients accepting colon carcinoma surgery. Neostigmine, as a cholinesterase inhibitor, can enhance the transmission of cholinergic transmitters in synaptic space, and play an important role in maintaining the normal level of cognition, attention and consciousness. The objective of this study was to investigate the effect of neostigmine on POD and clinical prognosis.

Methods

A randomized, double-blind controlled trial was implemented in Qingdao Municipal Hospital Affiliated to Qingdao University. A total of 454 patients aged 40 to 90 years old accepted colon carcinoma surgery were enrolled between June 7, 2020, and June 7, 2021, with final follow-up on December 8, 2021. Patients were randomly assigned to two groups: the neostigmine group (group N) and the placebo group (group P), the patients in group N were injected with 0.04 mg/kg neostigmine and 0.02 mg/kg atropine intravenously. The primary endpoint was the incidence of POD, researchers evaluated the occurrence of POD by the Confusion Assessment Method (CAM) twice daily (at 10 a.m. and 2 p.m.) during the first 7 postoperative days, POD severity was assessed by the Memorial Delirium Assessment Scale (MDAS). The secondary endpoints were the extubating time, postanesthesia care unit (PACU) time, the incidence of various postoperative complications, length of hospital stays, and 6 months postoperative mortality.

Results

The incidence of POD was 20.20% (81/401), including 19.39% (38/196) in group N and 20.98% (43/205) in group P. There was no significant statistical significance in the incidence of POD between group N and group P (P > 0.05); Compared to group P, the extubating time and PACU time in group N were significantly reduced (P < 0.001), the incidence of postoperative pulmonary complications (POPCs) decreased significantly in group N (P < 0.05), while no significant differences were observed in postoperative hospital stay and mortality in 6 months between the two groups (P > 0.05).

Conclusion

For patients accepted colon carcinoma surgery, neostigmine did not significantly reduce the incidence of POD, postoperative mortality and postoperative hospital stay, while it indeed reduced the extubating time, PACU time and the incidence of POPCs.

Trial registration

The randomized, double-blind, controlled trial was registered retrospectively at www.chictr.org.cn on 07/06/2020 (ChiCTR2000033639).

Prognostic Nutritional Index and Postoperative Pulmonary Complications in Patients With Major Burns

INTRODUCTION

Burns can cause multiple organ systemic derangements, particularly in respiratory systems. The prognostic nutritional index (PNI) can predict postoperative outcomes. We evaluated the incidence and risk factors, including PNI, for postoperative pulmonary complications (PPCs) in patients with major burns.

METHODS

PNI was calculated as 10 × (serum albumin level) + 0.005 × (total lymphocyte count). Major burn patients admitted to the ICU without burn-induced lung injuries were retrospectively included. The incidence of PPCs was measured within 1 wk of burn surgery. A multivariable logistic regression analysis was performed to evaluate the risk factors for PPCs. Receiver operating characteristic curve analysis and propensity-score matched analysis were conducted to estimate the influence of PNI on PPCs. Outcomes after burn surgery were also assessed.

RESULTS

Of 444 major burn patients, 138 (31.1%) showed PPCs. Risk factors for PPCs were PNI, gender, total body surface area burned, interval between burn and surgery, and red blood cell transfusion rate. The area under the curve of PNI for predicting PPCs was 0.709 (cutoff value = 31.5). The incidence of PPCs was significantly higher in the PNI ≤ 31.5 group than in the PNI > 31.5 group (55.7% versus 22.8%, P < 0.001) after propensity-score matching. The intensive care unit stay duration was longer and 90-d mortality was higher in patients who developed PPCs (19 [9-27] d versus 8 [4-17] d, P < 0.001; 11.6% versus 0.3%, P < 0.001).

CONCLUSIONS

The prevalence of PPCs in patients with major burns was 31.1% and preoperative PNI was a predictor of PPCs in these patients. PNI ≤ 31.5 was significantly related to a higher incidence of PPCs.

Double epidural catheter technique in a patient with severe COPD undergoing major abdominal surgery: A case report

INTRODUCTION AND IMPORTANCE

Chronic Obstructive Pulmonary Disease (COPD) leads to the development of postoperative pulmonary complications (PPC), such as atelectasis, pneumonia and respiratory failure. The use of epidural anesthesia, alone or combined with general anesthesia, is known to reduce the incidence of PPC and shorten tracheal intubation time. In major procedures involving both the lower and upper abdomen, central neuraxial block at a single level may be inadequate to provide sufficient metameric extension of anesthesia. This limitation could be overcome with the use of double epidural catheter (DEC), has proved effective in diverse surgical scenarios.

CASE PRESENTATION AND CLINICAL DISCUSSION

We present the case of a woman affected by moderate-severe COPD scheduled for major abdominal cytoreductive surgery due to ovarian malignancy with planned xypho-pubic laparotomy. We developed and implemented a DEC-based strategy for perioperative pain management based on the extent of surgical incision and the high risk of difficult weaning from ventilation and PPC. We used intraoperative monitoring to guarantee adequate antinociception throughout the entire 350 min long demolitive surgical procedure. No additional top-ups of intravenous analgesia or neuromuscular blocking agent (NMBA) was needed during surgery; at the end of the procedure, the patient was extubated in the operating theatre, maintaining adequate respiratory function during the whole postoperative period.

CONCLUSIONS

The DEC technique could be beneficial for patients undergoing cytoreductive surgery. In our case, this technique granted optimal analgesic coverage and was instrumental in achieving fast weaning from mechanical ventilation and early tracheal extubation. Systematic studies on this subject are warranted.

Detection of residual pulmonary alterations with lung ultrasound and effects on postoperative pulmonary complications for patients with asymptomatic SARS-CoV-2 infection undergoing surgeries

BACKGROUND

For patients with a clinical course of active SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection, there may be a higher risk of perioperative complications. Our main objective is to detect the residual pulmonary alterations in asymptomatic patients after SARS-CoV-2 infection undergoing surgery and determine their relationship with the clinical course of SARS-CoV-2 infection. The secondary aim is to investigate whether the presence of residual pulmonary alterations have any affects on the severity of postoperative pulmonary complications.

METHODS

After approval by the Hospital's Ethical Committee, this prospective observational study included consecutive patients (n=103) undergoing various surgical procedures and anesthetic techniques with a history of past SARS-CoV-2 infection. On the day of surgery these patients remained asymptomatic and the polymerase chain reaction (PCR) test for SARS-CoV-2 was negative. The history, physical findings, and clinical course of SARS-CoV-2 infection were recorded. Lung ultrasound was performed before surgery to evaluate the possible residual pulmonary alterations (≥ 3 B-lines and pleural thickening), along with determitation of pulmonary static compliance values during surgery. Postoperative pulmonary complications were collected during hospital stay.

RESULTS

24.27% (n=25) patients presented ≥ 3 B-lines, and 28% (n=29) patients presented pleural thickening. For 15 patients (21.7%) the pulmonary compliance was < 40 mL/cm H₂O. Patients with pleural thickening had a higher incidence of pneumonia, acute respiratory syndrome distress, a need for vasoactive drugs and required more days of hospitalization during SARS-CoV-2 infection (p= 0.004, 0.001, 0.03, 0.00 respectively). Patients with ≥ 3 B-lines needed more days in an intensive care unit and vasoactive drugs during SARS-CoV2 infection (p= 0.04, 0.004 respectively). Postoperative pulmonary complications were observed in 5.8% (n=6) of the patients, and were more frequent in the presence of both, ≥ 3 B-lines and pleural thickening (p= 0.01).

CONCLUSIONS

In asymptomatic post-COVID-19 patients, pathological findings detected by lung ultrasound before surgery are associated with the severity of the SARS-CoV2 infection and resulted in more postoperative pulmonary complications. In these patients, the incidence of postoperative pulmonary complications appears similar to that described in the surgical population before the pandemic.

TRIAL REGISTRATION

clinicaltrials.gov (NCT04922931). June 21, 2021. "Retrospectively registered".

Implementation of perioperative breathing exercises and its effect on postoperative pulmonary complications and long-term prognosis in elderly patients undergoing laparoscopic colorectal surgery: A randomized controlled trial

OBJECTIVE

This study was to investigate the impact of breathing exercises on recovery in elderly patients receiving laparoscopic colorectal surgery.

DESIGN

A prospective randomized controlled trial.

SETTING

University hospital.

SUBJECT

A total of 264 elder patients undergoing laparoscopic colorectal surgery participated in this study.

INTERVENTION

Patients in intervention group received respiratory-related exercises based on standardized enhanced recovery after surgery strategies from admission to 90 days after surgery. The control group received perioperative standardized enhanced recovery after surgery strategies without formatted breathing exercises.

MAIN MEASURES

The primary outcome was the incidence of postoperative pulmonary complications. The secondary outcomes included 6-minute walking distance, surgery-related complications, length of stay, mortality postoperatively, and hospitalization costs.

RESULTS

Completion rate of breathing exercise in intervention group was over 80% till 90 days postoperatively. The incidence of postoperative pulmonary complications was lower in breathing exercises group (17/132 [12.9%] vs. 43/132 [32.6%], p < 0.001). The mean value of 6-minute walking distance increased more in intervention group compared with baseline values preoperatively (44.2 ± 4.3 vs. 3.2 ± 0.2, p < 0.001). On 90 days postoperatively, the mean value of 6-minute walking distance in breathing exercises group increased by 18.8 m compared with its baseline (557.0 ± 133.5 vs. 538.2 ± 112.7, p = 0.022), while that of control group decreased by 53.2 m from baseline (481.9 ± 102.5 vs. 535.1 ± 123.4, p < 0.001). Patients who received breathing exercises had shorter length of stay and lower hospitalization costs (p < 0.050).

CONCLUSIONS

Perioperative breathing exercises helped prevent postoperative pulmonary complications and improve long-term prognosis in elderly patients undergoing laparoscopic colorectal surgery.

Comparison of the effects of neostigmine and sugammadex on postoperative residual curarization and postoperative pulmonary complications by means of diaphragm and lung ultrasonography: a study protocol for prospective double-blind randomized controlled trial

Background

Postoperative residual curarization (PORC) may be a potential risk factor of postoperative pulmonary complications (PPCs), and both of them will lead to adverse consequences on surgical patient recovery. The train-of-four ratio (TOFr) which is detected by acceleromyography of the adductor pollicis is thought as the gold standard for the measurement of PORC. However, diaphragm function recovery may differ from that of the peripheral muscles. Recent studies suggested that diaphragm ultrasonography may be useful to reveal the diaphragm function recovery, and similarly, lung ultrasound was reported for the assessment of PPCs in recent years as well. Sugammadex reversal of neuromuscular blockade is rapid and complete, and there appear to be fewer postoperative complications than with neostigmine. This study aims to compare the effects of neostigmine and sugammadex, on PORC and PPCs employing diaphragm and lung ultrasonography, respectively.

Methods/design

In this prospective, double-blind, randomized controlled trial, patients of the American Society of Anesthesiologists Physical Status I–III, aged over 60, will be enrolled. They will be scheduled to undergo arthroplasty under general anesthesia. All patients will be allocated randomly into two groups, group NEO (neostigmine) and group SUG (sugammadex), using these two drugs for reversing rocuronium. The primary outcome of the study is the incidence of PPCs in the NEO and SUG groups. The secondary outcomes are the evaluation of diaphragm ultrasonography and lung ultrasound, performed by an independent sonographer before anesthesia, and at 10 min and 30 min after extubation in the post-anesthesia care unit, respectively.

Discussion

Elimination of PORC is a priority at the emergence of anesthesia, and it may be associated with reducing postoperative complications like PPCs. Sugammadex was reported to be superior to reverse neuromuscular blockade than neostigmine. Theoretically, complete recovery of neuromuscular function should be indicated by TOFr > 0.9. However, the diaphragm function recovery may not be the same matter, which probably harms pulmonary function. The hypothesis will be proposed that sugammadex is more beneficial than neostigmine to reduce the incidence of PPCs and strongly favorable for the recovery of diaphragm function in our study setting.

Trial registration

ClinicalTrials.gov NCT05040490. Registered on 3 September 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06328-3.

Postoperative pulmonary complications with adjuvant regional anesthesia versus general anesthesia alone: a sub-analysis of the Perioperative Research Network study

BACKGROUND

Adjuvant regional anesthesia is often selected for patients or procedures with high risk of pulmonary complications after general anesthesia. The benefit of adjuvant regional anesthesia to reduce postoperative pulmonary complications remains uncertain. In a prospective observational multicenter study, patients scheduled for non-cardiothoracic surgery with at least one postoperative pulmonary complication surprisingly received adjuvant regional anesthesia more frequently than those with no complications. We hypothesized that, after adjusting for surgical and patient complexity variables, the incidence of postoperative pulmonary complications would not be associated with adjuvant regional anesthesia.

METHODS

We performed a secondary analysis of a prospective observational multicenter study including 1202 American Society of Anesthesiologists physical status 3 patients undergoing non-cardiothoracic surgery. Patients were classified as receiving either adjuvant regional anesthesia or general anesthesia alone. Predefined pulmonary complications within the first seven postoperative days were prospectively identified. Groups were compared using bivariable and multivariable hierarchical logistic regression analyses for the outcome of at least one postoperative pulmonary complication.

RESULTS

Adjuvant regional anesthesia was performed in 266 (22.1%) patients and not performed in 936 (77.9%). The incidence of postoperative pulmonary complications was greater in patients receiving adjuvant regional anesthesia (42.1%) than in patients without it (30.9%) (site adjusted p = 0.007), but this association was not confirmed after adjusting for covariates (adjusted OR 1.37; 95% CI, 0.83-2.25; p = 0.165).

CONCLUSION

After adjusting for surgical and patient complexity, adjuvant regional anesthesia versus general anesthesia alone was not associated with a greater incidence of postoperative pulmonary complications in this multicenter cohort of non-cardiothoracic surgery patients.

The efficacy of different alveolar recruitment maneuvers in holmium laser lithotripsy surgery under general anesthesia using a laryngeal mask

Background

Alveolar recruitment maneuvers (ARMs) is an important part of lung-protective ventilation strategies (LPVSs), but the optimal duration and interval Remain unclear.

Methods

Patients:252 patients who underwent holmium laser lithotripsy surgery and meet inclusion criteria were included and randomized into three groups based on the duration and frequency of ARMs (Regular, one 30 s ARM (RARMs); Improved and intermittent, three 10s ARMs (IARMs); and Control (C), no ARMs).Interventions: Groups R and I received ARMs at 20 cmH2O pressures every 30 min. All patients received the same anesthesia and mechanical ventilation. Measurements:Outcomes included heart rate and mean arterial pressure changes during ARMs and postoperative pulmonary complications (PPCs) within the first 7 postoperative days.

Main results

Incidences of PPCs in groups R(7.1%) and I (5.0%)were slightly lower than those in group C (8.9%).This indicated the potential to reduce lung injury. Heart rate and mean arterial pressure fluctuations during ARMs were significantly higher in groups R and I than in group C (P < 0.01). The rate of blood pressure decrease was significantly higher in group R than in group I (P < 0.01).

Conclusions

IARMs can reduce cycle fluctuations than RARMs in patients Undergoing holmium laser lithotripsy surgery with laryngeal mask general anesthesia. Low tidal volume ventilation and low PEEP combined with ARM did not significantly reduce the incidence of PPCs in healthy lung patients, but tended to reduce lung injury.

Trial registration

The study was registered on the Chinese Clinical Trial Registry.

(ChiCTR2000030815,15/03/2020). This study was approved by the ethics committee of Chengdu Fifth People’s Hospital with approval number(2020–005(Study)-1).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01664-y.

Postoperative pulmonary complications and outcomes in cytoreductive surgery for ovarian cancer: a propensity-matched analysis

Objectives

To assess the prevalence of postoperative pulmonary complications (PPCs), the perioperative factors associated with PPCs, and the association of PPCs with postoperative outcomes in ovarian cancer patients undergoing cytoreductive surgery.

Methods

A retrospective analysis was conducted on patients who underwent cytoreductive surgery in our hospital, between September 2017 and January 2021, and patient medical records were reviewed to collect relevant clinical information. Univariable and multivariable analyses were used to identify significant risk factors for PPCs. Analysis of the association of PPCs with postoperative outcomes, mortality and 30-day readmission, was undertaken utilizing propensity score-matched controls and multivariable logistic regression model.

Results

Final analysis was performed with 268 ovarian cancer patients after cytoreductive surgery, among whom the incidence of PPCs was 26.9%, and the most frequent pulmonary complication was pleural effusion. According to the multivariate analysis, the intraoperative fluid infusion volume (L) (odds ratio (OR) 1.34; 95% confidence intervals (CI) 1.01–1.77; P = 0.040), diameter size of diaphragmatic resection (cm) (OR 1.16; 95% CI 1.06–1.28; P = 0.002), and surgical complexity scores (OR 1.26; 95% CI 1.13–1.42; P < 0.001) were significantly associated with the development of PPCs. The multivariable logistic regression analyses with propensity-matched controls demonstrated that the occurrence of PPCs significantly increased the risk of 30-day readmission (OR 6.01; 95% CI 1.12–32.40; P = 0.037) and did not significantly affect inpatient mortality.

Conclusion

Ovarian cancer patients undergoing cytoreductive surgery, especially those with diaphragmatic resection or higher surgical complexity scores, represent a high-risk population for PPCs. In addition, goal-directed fluid therapy is vital to reducing the occurrence of PPCs in patients at risk. PPCs were not associated with in-hospital mortality but were significantly associated with an increased risk of 30-day readmission after cytoreductive surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01660-2.

Frailty is an independent risk factor for postoperative pulmonary complications in elderly patients undergoing video-assisted thoracoscopic pulmonary resections

BACKGROUND

Although frailty as a common geriatric syndrome is associated with postoperative complications, its relationship with postoperative pulmonary complications (PPCs) following pulmonary resections in elderly patients is unclear.

AIMS

To investigate the relationship between frailty and PPCs in elderly patients undergoing video-assisted thoracoscopic pulmonary resections and explore the effect of the addition of frailty assessment to PPC risk index and ASA on their predictive ability.

METHODS

In a prospective cohort study, we measured frailty status using the FRAIL scale in elderly patients undergoing video-assisted thoracoscopic pulmonary resections. Multivariate analysis was used to identify the relationship between frailty and PPCs. Receiver operating characteristic curves were used to examine the predictive power of frailty and other assessment tools.

RESULTS

227 patients were analyzed in the study. The prevalence of PPCs was 24.7%. Significant differences between patients with and without PPCs were observed in the following aspects: BMI, smoking, COPD, respiratory infection within the last month, FEV1/FVC ratio, creatinine, ASA, frailty and PPC risk index (p < 0.05, respectively). After adjusting for all covariates, frailty was significantly related to PPCs in elderly patients (odds ratio: 6.33, 95% confidence interval: 2.45-16.37). Combined with frailty assessment, the area under the curve for ASA class and PPC risk index was increased to 0.759 (95% CI 0.687-0.831) and 0.821 (95% CI 0.758-0.883).

CONCLUSIONS

Frailty was associated with PPCs in elderly patients undergoing video-assisted thoracoscopic pulmonary resections. Combined with the frailty assessment, the predictive power of the PPC risk index and ASA class was improved.

Two-lung ventilation or one-lung ventilation for esophagectomy: maybe the more is better from the evidence of meta-analysis

One-lung ventilation (OLV) is the most commonly used ventilation strategy during esophagectomy. However, two-lung ventilation (TLV) with artificial pneumothorax has been applied in recent years during esophagectomy. It is unclear whether TLV takes advantages over OLV for esophagectomy. Here, we conducted a meta-analysis to compare the effects of TLV and OLV for esophagectomy. We searched relevant studies from the Cochrane Central Register of Controlled Trials, Pubmed, and Embase in November 2020. We included studies that compared the effects of TLV with OLV in esophagectomy and provided sufficient perioperative and postoperative data. We extracted data of postoperative outcomes (postoperative pulmonary complications, anastomotic leak, hospital stay) and surgical variables (thoracic phrase time, blood loss, the number of total resected thoracic lymph nodes). We calculated the risk ratio (RR) for dichotomous data and the weighted mean differences (WMDs) for continuous data. Six studies with 1725 patients were included in this meta-analysis. TLV was associated with significantly lower incidence of postoperative pulmonary complications [RR = 0.714; 95% confidence interval (CI) = (0.534, 0.956); P = 0.023], shorter hospital stay [WMD =  - 0.148; 95% CI = (- 0.246, - 0.051); P = 0.003], less blood loss [WMD =  - 0.352; 95% CI = (- 0.528, - 0.176); P < 0.001] and more resected thoracic lymph nodes [WMD = 0.207; 95% CI = (0.003, 0.4120); P = 0.047] than OLV. Moreover, TLV consumed similar time for thoracic phrase [WMD =  - 0.289; 95% CI = (- 0.661, 0.083); P = 0.128], and yielded a comparable rate of anastomotic leak [RR = 1.086; 95% CI = (0.842, 1.400); P = 0.525] compared with OLV. TLV with artificial pneumothorax resulted in less trauma than OLV. TLV with artificial pneumothorax is safe and could be a choice of ventilation strategy for esophagectomy.

Unilateral pulmonary edema associated factors after minimally invasive mitral valve surgery

BACKGROUND AND OBJECTIVES

In recent years, minimally invasive cardiac surgery (MICS) has been developed and applied to a greater number of pathologies, especially in mitral valve surgeries, as it obtains results comparable to those of conventional techniques while entailing lower surgical trauma and shorter recovery time. MICS requiring one-lung ventilation has been associated to the appearance of unilateral pulmonary edema (UPE), which is a potentially serious complication. The objective is determining the incidence of UPE after mitral MICS and its development associated factors.

MATERIAL AND METHODS

Observational descriptive and single-center study analyzing data from patients undergoing mitral valve MICS (right mini-thoracotomy) consecutively collected between the years 2015 and 2017.

RESULTS

A total of 93 patients were included and 26 presented UPE. The most common complications after mitral valve MICS were atrial fibrillation (38.7%), UPE (28%) and transient and/or definitive second- or third-degree auriculoventricular block (19.4%). The UPE group had longer ICU stay (3.3 ± 8.0 vs. 1.84 ± 2.23 days) and longer total hospitalization length-of-stay (15.5 ± 34.7 vs. 10.6 ± 7.5 days). The mortality in the UPE group was 3.9%. A significant association was found between the following collected variables and the development of postoperative UPE: preoperative baseline pulse oximetry, preoperative use of ACE inhibitors, postoperative atrial fibrillation and 24 first-hours cumulative chest tube drainage volume on the first 24 h.

CONCLUSIONS

The incidence of UPE is high and its appearance is associated with a longer ICU and total length of stay. More studies are required to understand its pathophysiology and apply measures to help decreasing its appearance.

Impact of drains positioning on pulmonary function after coronary artery bypass grafting: an observational study

INTRODUCTION

Coronary artery bypass grafting (CABG) is a procedure associated with a decline in pulmonary function. Among the main causes is the presence of the drain that is usually positioned in the intercostal or subxiphoid region.

OBJECTIVE

To measure the interference of drains positioning on pulmonary function in patients undergoing CABG.

METHODS

Observational study that assessed preoperative pulmonary function through vital capacity (VC), maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), and peak expiratory flow (PEF). These variables were evaluated in three different moments: in the presence of two drains, when removing one, and after removing all drains.

RESULTS

We evaluated 45 patients with a mean age of 62 ± 7 years with male prevalence of 29 (64%) individuals. The insertion of drains caused a decline in pulmonary function after surgery by reducing MIP by 48%, MEP by 11%, VC by 39%, and PEF by 6%.

CONCLUSION

This study has demonstrated that drains positioning after CABG surgery may produce weakness of the respiratory muscles, change ventilatory mechanics, and impair normal pulmonary function postoperatively.

Epidemiology, ventilation management and outcome in patients receiving intensive care after non-thoracic surgery - Insights from the LAS VEGAS study

INTRODUCTION AND OBJECTIVES

Information about epidemiology, ventilation management and outcome in postoperative intensive care unit (ICU) patients remains scarce. The objective was to test whether postoperative ventilation differs from that in the operation room.

MATERIAL AND METHODS

This was a substudy of the worldwide observational LAS VEGAS study, including patients undergoing non-thoracic surgeries. Of 146 study sites participating in the LAS VEGAS study, 117 (80%) sites reported on the postoperative ICU course, including ventilation and complications. The coprimary outcomes were two key elements of ventilator management, i.e., tidal volume (V_T) and positive end-expiratory pressure (PEEP). Secondary outcomes included the proportion of patients receiving low V_T ventilation (LTVV, defined as ventilation with a median V_T < 8.0 ml/kg PBW), and the proportion of patients developing postoperative pulmonary complications (PPC), including ARDS, pneumothorax, pneumonia and need for escalation of ventilatory support, ICU and hospital length of stay, and mortality at day 28.

RESULTS

Of 653 patients who were admitted to the ICU after surgery, 274 (42%) patients received invasive postoperative ventilation. Median postoperative V_T was 8.4 [7.3-9.8] ml/kg predicted body weight (PBW), PEEP was 5 [5-5] cm H₂O, statistically significant but not meaningfully different from median intraoperative V_T (8.1 [7.3-8.9] ml/kg PBW; P < 0.001) and PEEP (4 [2-5] cm H₂O; P < 0.001). The proportion of patients receiving LTVV after surgery was 41%. The PPC rate was 10%. Length of stay in ICU and hospital was independent of development of a PPC, but hospital mortality was higher in patients who developed a PPC (24 versus 4%; P < 0.001).

CONCLUSIONS

In this observational study of patients undergoing non-thoracic surgeries, postoperative ventilation was not meaningfully different from that in the operating room. Like in the operating room, there is room for improved use of LTVV. Development of PPC is associated with mortality.

Development and validation of a nomogram to predict postoperative pulmonary complications following thoracoscopic surgery

Background

Postoperative pulmonary complications (PPCs) after thoracoscopic surgery are common. This retrospective study aimed to develop a nomogram to predict PPCs in thoracoscopic surgery.

Methods

A total of 905 patients who underwent thoracoscopy were randomly enrolled and divided into a training cohort and a validation cohort at 80%:20%. The training cohort was used to develop a nomogram model, and the validation cohort was used to validate the model. Univariate and multivariable logistic regression were applied to screen risk factors for PPCs, and the nomogram was incorporated in the training cohort. The discriminative ability and calibration of the nomogram for predicting PPCs were assessed using C-indices and calibration plots.

Results

Among the patients, 207 (22.87%) presented PPCs, including 166 cases in the training cohort and 41 cases in the validation cohort. Using backward stepwise selection of clinically important variables with the Akaike information criterion (AIC) in the training cohort, the following seven variables were incorporated for predicting PPCs: American Society of Anesthesiologists (ASA) grade III/IV, operation time longer than 180 min, one-lung ventilation time longer than 60 min, and history of stroke, heart disease, chronic obstructive pulmonary disease (COPD) and smoking. With incorporation of these factors, the nomogram achieved good C-indices of 0.894 (95% confidence interval (CI) [0.866–0.921]) and 0.868 (95% CI [0.811–0.925]) in the training and validation cohorts, respectively, with well-fitted calibration curves.

Conclusion

The nomogram offers good predictive performance for PPCs after thoracoscopic surgery. This model may help distinguish the risk of PPCs and make reasonable treatment choices.

Effect of ventilation strategy during cardiopulmonary bypass on postoperative pulmonary complications after cardiac surgery: a randomized clinical trial

BACKGROUND

To determine whether maintaining ventilation during cardiopulmonary bypass (CPB) with a different fraction of inspired oxygen (FiO₂) had an impact on the occurrence of postoperative pulmonary complications (PPCs).

METHODS

A total of 413 adult patients undergoing elective cardiac surgery with CPB were randomly assigned into three groups: 138 in the NoV group (received no mechanical ventilation during CPB), 138 in the LOV group (received a tidal volume (V_T) of 3-4 ml/kg of ideal body weight with the respiratory rate of 10-12 bpm, and the positive end-expiratory pressure of 5-8 cmH₂O during CPB; the FiO₂ was 30%), and 137 in the HOV group (received the same ventilation parameters settings as the LOV group while the FiO₂ was 80%).

RESULTS

The primary outcomes were the incidence and severity of PPCs during hospitalization. The composite incidence of PPCs did not significantly differ between the NoV (63%), LOV (49%) and HOV (57%) groups (P = 0.069). And there was also no difference regarding the incidence of PPCs between the non-ventilation (NoV) and ventilation (the combination of LOV and HOV) groups. The LOV group was observed a lower proportion of moderate and severe pulmonary complications (grade ≥ 3) than the NoV group (23.1% vs. 44.2%, P = 0.001).

CONCLUSION

Maintaining ventilation during CPB did not reduce the incidence of PPCs in patients undergoing cardiac surgery.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1800015261. Prospectively registered 19 March 2018. http://www.chictr.org.cn/showproj.aspx?proj=25982.

Development and validation of a novel nomogram for postoperative pulmonary complications following minimally invasive esophageal cancer surgery

Postoperative pulmonary complications (PPCs) are the most common complications following minimally invasive esophagectomy (MIE) and can be associated with adverse outcomes. This study aims to construct a nomogram based on clinical factors to predict PPCs and investigate related early outcomes. Clinical data of 969 consecutive patients receiving MIE were retrospectively collected. Univariate and multivariate analysis were performed to select independent predictors. Using independent predictors to develop a nomogram and using a bootstrap-resampling approach to conduct internal verification. Early outcomes of PPCs were analyzed. The incidence of PPCs following MIE was 39.6% (384 out of 969). In multivariate analysis, older age (Odds ratio (OR) 1.034, P < 0.001), higher body mass index (OR 0.993, P = 0.003), heavy smoking (OR 1.396, P = 0.027), FEV₁/FVC < 105% (OR 1.958, P < 0.001), chemoradiotherapy (OR 0.653, P = 0.039), estimated blood loss ≥ 400 mL (OR 2.582, P = 0.018), general anesthesia (vs Combined thoracic paravertebral blockade, OR 1.578, P = 0.014), operative time ≥ 240 min (OR 1.388, P = 0.027), squamous cell carcinoma (OR 2.099, P = 0.036) and conversion to thoracotomy (OR 2.820, P = 0.026) were independent predictors for PPCs. These ten independent predictors were used to develop a nomogram, with concordance index (C index) value of 0.662 and good calibration. After internal validation, similarly good calibration and discrimination (C index, 0.654; 95% CI 0.614-0.690) were observed. Patients developing PPCs had higher rates of anastomotic leakage, reoperation, ICU and 30-day readmissions, and prolonged ICU and hospital stays (P < 0.05). Our study identified ten predictors for PPCs, which were associated with poor early outcomes. The proposed nomogram can be a useful tool to identify patients at high risk of PPCs after MIE.

Incidence of postoperative pulmonary complications in patients undergoing minimally invasive versus median sternotomy valve surgery: propensity score matching

Objective

Postoperative pulmonary complications (PPCs) are common incidents associated with an increased hospital stay, readmissions into the intensive care unit (ICU), increased costs, and mortality after cardiac surgery. Our study aims to analyze whether minimally invasive valve surgery (MIVS) can reduce the incidence of postoperative pulmonary complications compared to the full median sternotomy (FS) approach.

Methods

We reviewed the records of 1076 patients who underwent isolated mitral or aortic valve surgery (80 MIVS and 996 FS) in our institution between January 2015 and December 2019. Propensity score-matching analysis was used to compare outcomes between the groups and to reduce selection bias.

Results

Propensity score matching revealed no significant difference in hospital mortality between the groups. The incidence of PPCs was significantly less in the MIVS group than in the FS group (19% vs. 69%, respectively; P < 0.0001). The most common PPCs were atelectasis (P = 0.034), pleural effusions (P = 0.042), and pulmonary infection (P = 0.001). Prolonged mechanical ventilation time (> 24 h) (P = 0.016), blood transfusion amount (P = 0.006), length of hospital stay (P < 0.0001), and ICU stay (P < 0.0001) were significantly less in the MIVS group. Cardiopulmonary bypass (CBP), aortic cross-clamping, and operative time intervals were significantly longer in the MIVS group than in the matched FS group (P < 0.001). A multivariable analysis revealed a decreased risk of PPCs in patients undergoing MIVS (odds ratio, 0.25; 95% confidence interval, 0.006–0.180; P < 0.0001).

Conclusion

MIVS for isolated valve surgery reduces the risk of PPCs compared with the FS approach.

Influence of sugammadex versus neostigmine for neuromuscular block reversal on the incidence of postoperative pulmonary complications: a meta-analysis of randomized controlled trials

BACKGROUND

The influence of sugammadex for reversal of neuromuscular block (NMB) on postoperative pulmonary complications (PPCs), compared with neostigmine, remains to be determined. We performed a meta-analysis of randomized controlled trials (RCTs) to compare the incidence of PPCs between patients who received sugammadex versus neostigmine.

METHODS

Relevant studies were obtained by searching the PubMed, Embase, and Cochrane Library databases. A random effects model incorporating the potential heterogeneity was used to pool the results.

RESULTS

Fourteen RCTs including 1478 adult patients who underwent surgeries with general anesthesia were included, and of these, 753 received sugammadex and 725 received neostigmine for reversal of NMB. The pooled results showed that sugammadex was associated with a lower risk of overall PPCs compared to neostigmine (odds ratio [OR]: 0.62, 95% confidence interval [CI]: 0.43-0.89, p = 0.01; I² = 0%). This finding remained consistent after exclusion of two studies with potential overlapping events (OR: 0.58, 95% CI: 0.36-0.96, p = 0.03; I²=9%). Stratified analyses according to the categories of PPCs showed that sugammadex was associated with a significantly lower risk of postoperative respiratory failure (OR: 0.60, 95% CI: 0.38-0.97, p = 0.04; I² = 0%) but not of postoperative pulmonary infection (OR: 0.79, p = 0.71), atelectasis (OR: 0.78, p = 0.33), or pneumothorax (OR: 0.87, p = 0.79).

CONCLUSIONS

Compared with neostigmine, the use of sugammadex for reversal of NMB was associated with a lower risk of PPCs, mainly due to a lower incidence of postoperative respiratory failure with the use of sugammadex.

Preoperative incentive spirometry for preventing postoperative pulmonary complications in patients undergoing coronary artery bypass graft surgery: a prospective, randomized controlled trial

BACKGROUND

Postoperative pulmonary complications (PPCs) often occur after cardiac operations and are a leading cause of morbidity, inhibit oxygenation, and increase hospital length of stay and mortality. Although clinical evidence for PPCs prevention is often unclear and crucial, measures occur to reduce PPCs. One device usually used for this reason is incentive spirometry (IS). The aim of the study is to evaluate the effect of preoperative incentive spirometry to prevent postoperative pulmonary complications, improve postoperative oxygenation, and decrease hospital stay following coronary artery bypass graft (CABG) surgery patients.

METHODS

This was a clinical randomized prospective study. A total of 80 patients were selected as candidates for CABG at An-Najah National University Hospital, Nablus-Palestine. Patients had been randomly assigned into two groups: incentive spirometry group (IS), SI performed before surgery (study group) and control group, preoperative spirometry was not performed. The 40 patients in each group received the same protocol of anesthesia and ventilation in the operating room.

RESULT

The study findings showed a significant difference between the IS and control groups in the incidence of postoperative atelectasis. There were 8 patients (20.0%) in IS group and 17 patients (42.5%) in the control group (p = 0.03). Mechanical ventilation duration was significantly less in IS group. The median was four hours versus six hours in the control group (p < 0.001). Hospital length of stay was significantly less in IS group, and the median was six days versus seven days in the control group (p < 0.001). The median of the amount of arterial blood oxygen and oxygen saturation was significantly improved in the IS group (p < 0.005).

CONCLUSION

Preoperative incentive spirometry for two days along with the exercise of deep breathing, encouraged coughing, and early ambulation following CABG are in connection with prevention and decreased incidence of atelectasis, hospital stay, mechanical ventilation duration and improved postoperative oxygenation with better pain control. A difference that can be considered both significant and clinically relevant. Trial registration Thai Clinical Trials Registry: TCTR20201020005. Registered 17 October 2020-retrospectively registered.

Intraoperative protective ventilation in patients undergoing major neurosurgical interventions: a randomized clinical trial

BACKGROUND

Post-operative pulmonary complications (PPC) can develop in up to 13% of patients undergoing neurosurgical procedures and may adversely affect clinical outcome. The use of intraoperative lung protective ventilation (LPV) strategies, usually including the use of a low V_t, low PEEP and low plateau pressure, seem to reduce the risk of PPC and are strongly recommended in almost all surgical procedures. Nonetheless, feasibility of LPV strategies in neurosurgical patients are still debated because the use of low Vt during LPV might result in hypercapnia with detrimental effects on cerebrovascular physiology. Aim of our study was to determine whether LPV strategies would be feasible compared with a control group in adult patients undergoing cranial or spinal surgery.

METHODS

This single-centre, pilot randomized clinical trial was conducted at the University Hospital "Maggiore della Carità" (Novara, Italy). Adult patients undergoing major cerebral or spinal neurosurgical interventions with risk index for pulmonary post-operative complications > 2 and not expected to need post-operative intensive care unit (ICU) admission were considered eligible. Patients were randomly assigned to either LPV (Vt = 6 ml/kg of ideal body weight (IBW), respiratory rate initially set at 16 breaths/min, PEEP at 5 cmH2O and application of a recruitment manoeuvre (RM) immediately after intubation and at every disconnection from the ventilator) or control treatment (Vt = 10 ml/kg of IBW, respiratory rate initially set at 6-8 breaths/min, no PEEP and no RM). Primary outcomes of the study were intraoperative adverse events, the level of cerebral tension at dura opening and the intraoperative control of PaCO_2. Secondary outcomes were the rate of pulmonary and extrapulmonary complications, the number of unplanned ICU admissions, ICU and hospital lengths of stay and mortality.

RESULTS

A total of 60 patients, 30 for each group, were randomized. During brain surgery, the number of episodes of intraoperative hypercapnia and grade of cerebral tension were similar between patients randomized to receive control or LPV strategies. No difference in the rate of intraoperative adverse events was found between groups. The rate of postoperative pulmonary and extrapulmonary complications and major clinical outcomes were similar between groups.

CONCLUSIONS

LPV strategies in patients undergoing major neurosurgical intervention are feasible. Larger clinical trials are needed to assess their role in postoperative clinical outcome improvements.

TRIAL REGISTRATION

registered on the Australian New Zealand Clinical Trial Registry ( www.anzctr.org.au ), registration number ACTRN12615000707561.

Effects of intraoperative lung-protective ventilation on clinical outcomes in patients with traumatic brain injury: a randomized controlled trial

Background

Secondary lung injury is the most common non-neurological complication after traumatic brain injury (TBI). Lung-protective ventilation (LPV) has been proven to improve perioperative oxygenation and lung compliance in some critical patients. This study aimed to investigate whether intraoperative LPV could improve respiratory function and prevent postoperative complications in emergency TBI patients.

Methods

Ninety TBI patients were randomly allocated to three groups (1:1:1): Group A, conventional mechanical ventilation [tidal volume (VT) 10 mL/kg only]; Group B, small VT (8 mL/kg) + positive end-expiratory pressure (PEEP) (5 cmH₂O); and Group C, small VT (8 mL/kg) + PEEP (5 cmH₂O) + recruitment maneuvers (RMs). The primary outcome was the incidence of total postoperative pulmonary complications; Secondary outcomes were intraoperative respiratory mechanics parameters and serum levels of brain injury markers, and the incidence of each postoperative pulmonary and neurological complication.

Results

Seventy-nine patients completed the final analysis. The intraoperative PaO₂ and dynamic pulmonary compliance of Groups B and C were higher than those of Group A (P = 0.028; P = 0.005), while their airway peak pressure and plateau pressure were lower than those of group A (P = 0.004; P = 0.005). Compared to Group A, Groups B and C had decreased 30-day postoperative incidences of total pulmonary complications, hypoxemia, pulmonary infection, and atelectasis (84.0 % vs. 57.1 % vs. 53.8 %, P = 0.047; 52.0 % vs. 14.3 % vs. 19.2 %, P = 0.005; 84.0 % vs. 50.0 % vs. 42.3 %, P = 0.006; 24.0 % vs. 3.6 % vs. 0.0 %, P = 0.004). Moreover, intraoperative hypotension was more frequent in Group C than in Groups A and B (P = 0.007). At the end of surgery, the serum levels of glial fibrillary acidic protein and ubiquitin carboxyl-terminal hydrolase isozyme L1 in Group B were lower than those in Groups A and C (P = 0.002; P < 0.001). The postoperative incidences of neurological complications among the three groups were comparable.

Conclusions

Continuous intraoperative administration of small VT + PEEP is beneficial to TBI patients. Additional RMs can be performed with caution to prevent disturbances in the stability of cerebral hemodynamics.

Trial registration

Chinese Clinical Trial Registry (ChiCTR2000038314), retrospectively registered on September 17, 2020.

Prolonged Postoperative Mechanical Ventilation (PPMV) in children undergoing abdominal operations: An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database

BACKGROUND

Prolonged postoperative mechanical ventilation (PPMV) increases length of stay, hospitalization costs, and postoperative complications. Independent risk factors associated with PPMV are not well-known for children.

METHOD

We identified children (<18 years) in the ACS NSQIP-P database who underwent a general surgical abdominal operation. We excluded children with preoperative ventilator dependence and mortality within 48 h of surgery. PPMV was defined as cumulative postoperative mechanical ventilation exceeding 72 h. A multivariable logistic regression model identified independent predictors of PPMV.

RESULTS

We identified 108,392 children who underwent a general surgical abdominal operation in the ACS NSQIP-P database from 2012 to 2017. We randomly divided the population into a derivation cohort of 75,874(70%) and a validation cohort of 32,518(30%). In the derivation cohort, we identified PPMV in 1,643(2.2%). In the multivariable model, the strongest independent predictor of PPMV was neonatal age (OR:20.66; 95%CI:16.44-25.97). Other independent risk factors for PPMV were preoperative inotropic support (OR:10.56; 95%CI:7.56-14.77), an operative time longer than 150 min (OR:4.30; 95%CI:3.72-4.52), and an American Society of Anesthesiologists classification >3 (OR:12.16; 95%CI:10.75-13.75).

CONCLUSION

Independent preoperative risk factors for PPMV in children undergoing a general surgical operation were neonatal age, preoperative ionotropic support, duration of operation, and ASA classification >3.