Post-operative pulmonary complications: Understanding definitions and risk assessment

First mobilisation after abdominal and cardiothoracic surgery: when is it actually performed? A national, multicentre, cross-sectional study

OBJECTIVES

Knowledge of clinical practice regarding mobilisation after surgery is lacking. This study therefore aimed to reveal current mobilisation routines after abdominal and cardiothoracic surgery and to identify factors associated with mobilisation within 6 hours postoperatively.

DESIGN

A prospective observational national multicentre study.

SETTING

18 different hospitals in Sweden.

PARTICIPANTS

1492 adult patients undergoing abdominal and cardiothoracic surgery with duration of anaesthesia>2 hours.

PRIMARY AND SECONDARY OUTCOMES

Primary outcome was time to first postoperative mobilisation. Secondary outcomes were the type and duration of the first mobilisation. Data were analysed using multivariate logistic regression and general structural equation modelling, and data are presented as ORs with 95% CIs.

RESULTS

Among the included patients, 52% were mobilised to at least sitting on the edge of the bed within 6 hours, 70% within 12 hours and 96% within 24 hours. Besides sitting on the edge of the bed, 76% stood up by the bed and 22% were walking away from the bedside the first time they were mobilised. Patients undergoing major upper abdominal surgery required the longest time before mobilisation with an average time of 11 hours post surgery. Factors associated with increased likelihood of mobilisation within 6 hours of surgery were daytime arrival at the postoperative recovery unit (OR: 5.13, 95% CI: 2.16 to 12.18), anaesthesia <4 hours (OR: 1.68, 95% CI: 1.17 to 2.40) and American Society of Anaesthesiologists (ASA) classification 1-2, (OR: 1.63, 95% CI: 1.13 to 2.36).

CONCLUSIONS

In total, 96% if the patients were mobilised within 24 hours after surgery and 52% within 6 hours. Daytime arrival at the postoperative recovery unit, low ASA classification and shorter duration of anaesthesia were associated with a shorter time to mobilisation.

TRIAL REGISTRATION NUMBER

FoU, Forskning och Utveckling in VGR, Vastra Gotaland Region (Id:275357) and Clinical Trials (NCT04729634).

Effects of midline laparotomy on cough strength: a prospective study measuring cough pressure

BACKGROUND

Laparotomy is assumed to decrease cough strength due to three factors: abdominal muscle trauma, postoperative pain, and diaphragmatic dysfunction. However, the effect of trauma from laparotomy itself on strength (net of the other two factors) has not been measured to our knowledge. The aim of this study was to measure the effect of laparotomy on cough strength after first measuring the effect of epidural analgesia.

METHODS

In 11 patients scheduled for open midline laparotomy, cough pressure (PCOUGH), a proxy for strength, was measured with a rectal balloon at three moments: before the procedure, at baseline; before surgery, under epidural bupivacaine to T6; and postoperatively, under epidural bupivacaine to the same analgesic level (T6). Continuous variables were compared using the Wilcoxon signed-rank test. The repeatability of PCOUGH measurements was confirmed with the intraclass correlation coefficient (ICC). Pain on coughing, hand grip strength, and the Ramsay and modified Bromage scores were also recorded.

RESULTS

Median (interquartile range) PCOUGH decreased from a baseline of 103 (89-137) to 71 (56-116) cmH2O under presurgical epidural bupivacaine (P=0.003). Postoperative PCOUGH remained unchanged at 76 (46-85) cmH2O under epidural analgesia (P=0.131). The ICCs indicated excellent repeatability of the PCOUGH measurements (P<0.001). Pain on coughing was 0 to 1 in all subjects. Hand grip strength and the Ramsay and Bromage scores were unchanged.

CONCLUSIONS

Although thoracic epidural bupivacaine reduces cough strength as measured by PCOUGH, midline laparotomy does not further reduce strength in the presence of adequate epidural analgesia.

Effects of penehyclidine hydrochloride combined with dexmedetomidine on pulmonary function in patients undergoing heart valve surgery: a double-blind, randomized trial

AIM

To investigate the effects of penehyclidine hydrochloride combined with dexmedetomidine on pulmonary function in patients undergoing heart valve surgery with cardiopulmonary bypass (CPB).

METHODS

A total of 180 patients undergoing elective heart valve surgery with CPB were randomly divided into four groups: 45 in group P (intravenous penehyclidine hydrochloride 0.02 mg/kg 10 min before anesthesia induction and at the beginning of CPB, total 0.04 mg/kg); 43 in group D (dexmedetomidine 0.5 μg/kg/h after induction of anesthesia until the end of anesthesia); 44 in group PD ( penehyclidine hydrochloride 0.04 mg/kg combined with dexmedetomidine 0.5 μg/kg/h intravenously during anesthesia); and 43 in group C (same amount of normal saline 10 min before and after anesthesia induction, to the end of anesthesia, and at the beginning of CPB). The main outcomes were the incidence and severity of postoperative pulmonary complications (PPCs). The secondary outcomes were: (1) extubation time, length of stay in intensive care, and postoperative hospital stay, and adverse events; and (2) pulmonary function evaluation indices (oxygenation index and respiratory index) and plasma inflammatory factor concentrations (tumor necrosis factor-α, interleukin-6, C-reactive protein and procalcitonin) during the perioperative period.

RESULTS

The incidence of PPCs in groups P, D and PD after CPB was lower than that in group C (P < 0.05), and the incidence in group PD was significantly lower than that in groups P and D (P < 0.05). The scores for PPCs in groups P, D and PD were lower than those in group C (P < 0.05).

CONCLUSION

Combined use of penehyclidine hydrochloride and dexmedetomidine during anesthesia reduced the occurrence of postoperative pulmonary dysfunction, and improved the prognosis of patients undergoing heart valve surgery with CPB.

TRIAL REGISTRATION

The trial was registered in the Chinese Clinical Trial Registry on 3/11/2020 (Registration No.: ChiCTR2000039610).

Association between driving pressure and postoperative pulmonary complications in patients undergoing lung resection surgery: A randomised clinical trial

BACKGROUND

It is uncertain whether an association exists for decreases in driving pressure and the occurrence of postoperative pulmonary complications (PPCs) in patients undergoing selective lung resection surgery. Thus, we designed this study to determine whether the positive end-expiratory pressure (PEEP) titration to the lowest driving pressure compared with conventional low PEEP level during one-lung ventilation (OLV) in patients undergoing selective lung resection surgery decreases PPCs.

METHODS

This single-centre, randomised trial approved by the Ethical Committee of the Sun Yat-Sen University Cancer Center involved patients who signed written consent. Patients were randomised to the PEEP titration to the lowest driving pressure group (n = 104), or to the conventional low level of PEEP group (n = 103), consisting a PEEP level of 4 cm H₂O during OLV. All patients received volume-controlled ventilation with a tidal volume of 6 mL/kg of predicted body weight. The primary outcome was defined as positive if 4 or more of eight Melbourne Group Scale (MGS) variables developed within the first 3 days after surgery. The incidence of major PPCs occurring during postoperative 7 days was also recorded.

RESULTS

Among 222 patients who were randomised, 207 (93%) completed the trial (109 men [53%]; mean age, 56.9 years). The primary outcome occurred in 4 of 104 patients (4%) in the PEEP titration to the lowest driving pressure group compared with 13 of 103 patients (13%) in the conventional low level of PEEP group (risk ratio, 0.32 [95% CI, 0.10-0.90]; P = 0.021).

CONCLUSIONS

Among patients undergoing selective lung surgery, intraoperative OLV with PEEP titration to the lowest driving pressure compared with conventional low PEEP level (4 cm H₂O) significantly reduced PPCs within the first 3 postoperative days, however, did not significantly reduce PPCs within the first 7 postoperative days.

Identification of risk factors for postoperative pulmonary complications in general surgery patients in a low-middle income country

BACKGROUND

Postoperative pulmonary complications (PPCs) are an important cause of perioperative morbidity and mortality. Although risk factors for PPCs have been identified in high-income countries, less is known about PPCs and their risk factors in low- and middle-income countries, such as South Africa. This study examined the incidence of PPCs and their associated risk factors among general surgery patients in a public hospital in the province of KwaZulu-Natal, South Africa to inform future quality improvement initiatives to decrease PPCs in this clinical population.

METHODS

A retrospective secondary analysis of adult patients with general surgery admissions from January 1, 2013 to December 31, 2017 was conducted using data from the health system's Hybrid Electronic Medical Registry. The sample was comprised of 5352 general surgery hospitalizations. PPCs included pneumonia, atelectasis, acute respiratory distress syndrome, pulmonary edema, pulmonary embolism, prolonged ventilation, hemothorax, pneumothorax, and other respiratory morbidity which encompassed empyema, aspiration, pleural effusion, bronchopleural fistula, and lower respiratory tract infection. Risk factors examined were age, tobacco use, number and type of pre-existing comorbidities, emergency surgery, and number and type of surgeries. Bivariate and multivariable logistic regression models were conducted to identify risk factors for developing a PPC.

RESULTS

The PPC rate was 7.8%. Of the 418 hospitalizations in which a patient developed a PPC, the most common type of PPC was pneumonia (52.4%) and the mortality rate related to the PPC was 11.7%. Significant risk factors for a PPC were increasing age, greater number of comorbidities, emergency surgery, greater number of general surgeries, and abdominal surgery.

CONCLUSIONS

PPCs are common in general surgery patients in low- and middle-income countries, with similar rates observed in high-income countries. These complications worsen patient outcomes and increase mortality. Quality improvement initiatives that employ resource-conscious methods are needed to reduce PPCs in low- and middle-income countries.

Perioperative administration of methylprednisolone was associated with postoperative pulmonary complications in elderly patients undergoing hip fracture surgery

BACKGROUND

Postoperative pulmonary complications (PPCs) seriously affect the postoperative prognosis of elderly patients underwent hip fracture surgery. Although methylprednisolone is increasingly used, the association between perioperative methylprednisolone and PPCs is still controversial. The study aims to determine whether perioperative administration of methylprednisolone is associated with PPCs in elderly patients during hip fracture surgery.

PATIENTS AND METHODS

In this retrospective cohort study, records of 584 patients (≥ 65 years) who underwent hip fracture surgery between January 2013 and October 2020 were extracted. Univariate and multivariate regression analysis were performed to identify the risk factors for PPCs. To further explore the association between administration of methylprednisolone and PPCs, 53 patients received methylprednisolone and 53 patients without methylprednisolone were matched for the confounding factors using propensity score matching (PSM) analysis. The odds ratios (OR) and 95% confidence intervals (CI) for the above variables were analyzed.

RESULTS

The incidence of PPCs during postoperative hospitalization was 6.83% (38/556) among the elderly patients following hip fracture surgery. Patients with PPCs had higher postoperative mortality rate, longer hospital stay, more hospitalization cost, and higher incidence of cardiac arrest (all P < 0.05). Multivariate logistic regression analysis showed that age, hypertension, hypoglycemia, hypoproteinemia and perioperative methylprednisolone were independent risk factors for PPCs. Moreover, administration of methylprednisolone was significantly correlated with PPCs both before PSM adjustment (OR = 3.25; 95% CI, 1.67 to 6.33; P = 0.001) and after PSM adjustment (OR = 6.68; 95% CI, 1.40 to 31.82; P = 0.017).

CONCLUSION

Perioperative administration of methylprednisolone is a risk factor for PPCs in elderly patients undergoing hip fracture surgery.

Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy)

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.

Shortness of Breath on Day 1 After Surgery Alerting the Presence of Early Respiratory Complications After Surgery in Lung Cancer Patients

PURPOSE

Patient-reported outcome (PRO)-based symptom assessment with a threshold can facilitate the early alert of adverse events. The purpose of this study was to determine whether shortness of breath (SOB) on postoperative day 1 (POD1) can inform postoperative pulmonary complications (PPCs) for patients after lung cancer (LC) surgery.

METHODS

Data were extracted from a prospective cohort study of patients with LC surgery. Symptoms were assessed by the MD Anderson Symptom Inventory-lung cancer module (MDASI-LC) before and daily after surgery. Types and grades of complications during hospitalization were recorded. SOB and other symptoms were tested for a possible association with PPCs by logistic regression models. Optimal cutpoints of SOB were derived, using the presence of PPCs as an anchor.

RESULTS

Among 401 patients with complete POD1 MDASI-LC and records on postoperative complications, 46 (11.5%) patients reported Clavien-Dindo grade II-IV PPCs. Logistic regression revealed that higher SOB score on POD1 (odds ratio [OR]=1.13, 95% CI=1.01-1.27), male (OR=2.86, 95% CI=1.32-6.23), open surgery (OR=3.03, 95% CI=1.49-6.14), and lower forced expiratory volume in one second (OR=1.78, 95% CI=1.66-2.96) were significantly associated with PPCs. The optimal cutpoint was 6 (on a 0-10 scale) for SOB. Patients reporting SOB < 6 on POD1 had shorter postoperative length of stay than those reporting 6 or greater SOB (median, 6 vs 7, P =0.007).

CONCLUSION

SOB on POD1 can inform the onset of PPCs in patients after lung cancer surgery. PRO-based symptom assessment with a clinically meaningful threshold could alert clinicians for the early management of PPCs.

Prognostic Value of Preoperative Peak Expiratory Flow to Predict Postoperative Pulmonary Complications in Surgical Lung Cancer Patients

Objectives

Cough impairment may lead to excessive accumulation of pulmonary secretions and increase the risk of postoperative pulmonary complications (PPCs). Peak expiratory flow (PEF) is a sensitive indicator of cough ability. We aimed to investigate the correlation between PEF and PPCs for lung cancer patients undergoing lobectomy or segmental resection for improved risk assessment.

Methods

This retrospective study assessed 560 patients with non-small cell lung cancer admitted for surgery between January 2014 to June 2016. The measurements of PEF were performed before surgery and the clinical outcomes were recorded, including PPCs, postoperative hospital stay, hospitalization costs, and other variables.

Results

Preoperative PEF was significantly lower in PPCs group compared to non-PPCs group (294.2 ± 95.7 vs. 363.0 ± 105.6 L/min, P < 0.001). Multivariable regression analysis showed that high PEF (OR=0.991, 95%CI: 0.988-0.993, P < 0.001) was an independent protective factor for PPCs. According to the receiver operating characteristic (ROC) curve, a PEF value of 250 L/min was selected as the optimal cutoff value in female patients, and 320 L/min in male patients. Patients with PEF under cutoff value of either sex had higher PPCs rate and unfavorable clinical outcomes.

Conclusions

Preoperative PEF was found to be a significant predictor of PPCs for surgical lung cancer patients. It may be beneficial to consider the cutoff value of PEF in perioperative risk assessment.

Comparative Evaluation of the Incidence of Postoperative Pulmonary Complications After Minimally Invasive Valve Surgery vs. Full Sternotomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Propensity Score-Matched Studies

Background: Postoperative pulmonary complications remain a leading cause of increased morbidity, mortality, longer hospital stays, and increased costs after cardiac surgery; therefore, our study aims to analyze whether minimally invasive valve surgery (MIVS) for both aortic and mitral valves can improve pulmonary function and reduce the incidence of postoperative pulmonary complications when compared with the full median sternotomy (FS) approach. Methods: A comprehensive systematic literature research was performed for studies comparing MIVS and FS up to February 2021. Randomized controlled trials (RCTs) and propensity score-matching (PSM) studies comparing early respiratory function and pulmonary complications after MIVS and FS were extracted and analyzed. Secondary outcomes included intra- and postoperative outcomes. Results: A total of 10,194 patients from 30 studies (6 RCTs and 24 PSM studies) were analyzed. Early mortality differed significantly between the groups (MIVS 1.2 vs. FS 1.9%; p = 0.005). Compared with FS, MIVS significantly lowered the incidence of postoperative pulmonary complications (odds ratio 0.79, 95% confidence interval [0.67, 0.93]; p = 0.004) and improved early postoperative respiratory function status (mean difference -24.83 [-29.90, -19.76]; p < 0.00001). Blood transfusion amount was significantly lower after MIVS (p < 0.02), whereas cardiopulmonary bypass time and aortic cross-clamp time were significantly longer after MIVS (p < 0.00001). Conclusions: Our study showed that minimally invasive valve surgery decreases the incidence of postoperative pulmonary complications and improves postoperative respiratory function status.

Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy)

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.

An improved predictive model for postoperative pulmonary complications after free flap reconstructions in the head and neck

BACKGROUND

Commonly used predictive models for postoperative pulmonary complications (PPCs) do not perform when applied to head and neck cases. A head and neck-specific risk prediction tool is needed.

METHODS

Data on 794 free flap head and neck surgery cases at a single center were abstracted from the electronic medical record. Each case was reviewed for the development of PPCs. A predictive model was developed and was then compared to existing predictive models for PPCs.

RESULTS

The least absolute shrinkage and selection operator procedure identified age, alcohol use, history of congestive heart failure, preoperative packed cell volume, preoperative oxygen saturation, and preoperative metabolic equivalents as predictors of PPCs in the head and neck population. The model demonstrated an area under the receiving operating characteristic curve of 0.75 (0.69-0.80) with moderately good calibration. Comparisons to the performance of existing models demonstrate superior performance.

CONCLUSIONS

The model for the development of PPCs developed in this article displays superior performance to existing models.

Mobilization Started Within 2 Hours After Abdominal Surgery Improves Peripheral and Arterial Oxygenation: A Single-Center Randomized Controlled Trial

OBJECTIVE

The aim of this study was to investigate if mobilization out of bed, within 2 hours after abdominal surgery, improved participants' respiratory function and whether breathing exercises had an additional positive effect.

METHODS

Participants were 214 consecutively recruited patients who underwent elective open or robot-assisted laparoscopic gynecological, urological, or endocrinological abdominal surgery with an anesthetic duration of >2 hours. They were recruited to a randomized controlled trial. Immediately after surgery, patients were randomly assigned to 1 of 3 groups: mobilization (to sit in a chair) and standardized breathing exercises (n = 73), mobilization (to sit in a chair) only (n = 76), or control (n = 65). The interventions started within 2 hours after arrival at the postoperative recovery unit and continued for a maximum of 6 hours. The primary outcomes were differences in peripheral oxygen saturation (SpO2, as a percentage) and arterial oxygen pressure (PaO2, measured in kilopascals) between the groups. Secondary outcomes were arterial carbon dioxide pressure, spirometry, respiratory insufficiency, pneumonia, and length of stay.

RESULTS

Based on intention-to-treat analysis (n = 214), patients who received mobilization and breathing exercises had significantly improved SpO2 (mean difference [MD] = 2.5%; 95% CI = 0.4 to 4.6) and PaO2 (MD = 1.40 kPa; 95% CI = 0.64 to 2.17) compared with the controls. For mobilization only, there was an increase in PaO2 (MD = 0.97 kPa; 95% CI = 0.20 to 1.74) compared with the controls. In the per-protocol analysis (n = 201), there were significant improvements in SpO2 and PaO2 for both groups receiving mobilization compared with the controls. Secondary outcome measures did not differ between groups.

CONCLUSION

Mobilization out of bed, with or without breathing exercises, within 2 hours after elective abdominal surgery improved SpO2 and PaO2.

IMPACT

The respiratory effect of mobilization (out of bed) immediately after surgery has not been thoroughly evaluated in the literature. This study shows that mobilization out of bed following elective abdominal surgery can improve SpO2 and PaO2.

LAY SUMMARY

Mobilization within 2 hours after elective abdominal surgery, with or without breathing exercises, can improve patients' respiratory function.

Central Sleep Apnea Predicts Pulmonary Complications After Cardiac Surgery

BACKGROUND

Postoperative major pulmonary complications (MPCs) continue to be leading causes of increased morbidity and death after cardiac surgery. Although various risk factors have been identified, reports on the association between sleep-disordered breathing (SDB) and postoperative MPCs remain inconclusive.

RESEARCH QUESTION

What is the incidence of the composite end point postoperative MPCs? What are predictors for postoperative MPCs in patients without SDB, with OSA, and with central sleep apnea (CSA) who undergo cardiac surgery?

STUDY DESIGN AND METHODS

In this subanalysis of the ongoing prospective observational study "Impact of Sleep-disordered breathing on Atrial Fibrillation and Perioperative complications in Patients undergoing Coronary Artery Bypass grafting Surgery (CONSIDER AF)," preoperative risk factors for postoperative MPCs were examined in 250 patients who underwent cardiac surgery. Postoperative MPCs (including respiratory failure, acute respiratory distress syndrome, pneumonia, or pulmonary embolism) were registered prospectively within the first seven postoperative days. Presence and type of SDB were assessed the night prior to surgery with the use of portable SDB-monitoring.

RESULTS

Patients with SDB experienced significantly more often postoperative MPCs than patients without SDB (24% vs 7%; P < .001). Multivariable logistic regression analysis showed that CSA (OR, 4.68 [95% CI, 1.78-12.26]; P = .002), heart failure (OR, 2.65 [95% CI, 1.11-6.31]; P = .028), and a history of transient ischemic attack or stroke (OR, 2.73 [95% CI, 1.07-6.94]; P = .035) were associated significantly with postoperative MPCs. Compared with patients without MPCs, those with postoperative MPCs had a significantly longer hospital stay (median days, 9 [25th/75th percentile, 7/13] vs 19 [25th/75th percentile, 11/38]; P < .001).

INTERPRETATION

Among established risk factors for postoperative MPCs, CSA, heart failure, and history of transient ischemic attack or stroke were associated significantly with postoperative MPCs. Our findings contribute to the identification of patients who are at high-risk for postoperative MPCs.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT02877745.

Prediction of postoperative pulmonary complications using preoperative controlling nutritional status (CONUT) score in patients with resectable non-small cell lung cancer

Postoperative pulmonary complications (PPCs) significantly impact surgical outcome. We investigated the predictive ability of controlling nutritional status (CONUT) for PPC after lung resection in patients with non-small cell lung cancer (NSCLC). We retrospectively reviewed data of 922 patients with NSCLC who underwent complete resection from January 2016–December 2017. We analyzed the frequency and characteristics of PPCs and compared receiver operating characteristic (ROC) curves of various prognostic models to predict PPCs. A CONUT score higher than 1 was considered as a high CONUT score. Total incidence of PPCs was 8.6% (n = 79). The proportion of pneumonia was significantly larger in the high CONUT group (P < 0.05). The CONUT consistently had a higher area under curve (AUC) value (0.64) than other prognostic models (prognostic nutritional index (PNI): AUC = 0.61, Glasgow prognostic score (GPS): AUC = 0.57, and assessment of respiratory risk in surgical patients in Catalonia (ARISCAT): AUC = 0.54). Multivariate analysis identified underweight [Odds ratio (OR) = 4.57, P = 0.002] and high CONUT score (OR = 1.91, P = 0.009) as independent PPCs prognostic factors. One-year mortality rate for high CONUT score was significantly higher (hazard ratio = 7.97; 95% confidence interval, 1.78–35.59). Preoperative CONUT score is an independent predictor of PPCs and 1-year mortality in patients with resectable NSCLC.

Effect of oxygenation modalities among patients with postoperative respiratory failure: a pairwise and network meta-analysis of randomized controlled trials

Background

Postoperative respiratory failure is associated with increased perioperative complications. Our aim is to compare outcomes between non-invasive ventilation (NIV), high-flow nasal cannula (HFNC), and standard oxygen in patients at high-risk for or with established postoperative respiratory failure.

Methods

Electronic databases including PubMed, Embase, and the Cochrane Library were reviewed from inception to September 2019. We included only randomized controlled trials (RCTs) that compared NIV, HFNC, and standard oxygen in patients at high risk for or with established postoperative respiratory failure. We performed a Bayesian network meta-analysis to calculate the odds ratio (OR) and Bayesian 95% credible intervals (CrIs).

Results

Nine RCTs representing 1865 patients were included (the mean age was 61.6 ± 10.2 and 64.4% were males). In comparison with standard oxygen, NIV was associated with a significant reduction in intubation rate (OR 0.23; 95% Cr.I. 0.10–0.46), mortality (OR 0.45; 95% Cr.I. 0.27–0.71), and intensive care unit (ICU)-acquired infections (OR 0.43, 95% Cr.I. 0.25–0.70). Compared to standard oxygen, HFNC was associated with a significant reduction in intubation rate (OR 0.28, 95% Cr.I. 0.08–0.76) and ICU-acquired infections (OR 0.41; 95% Cr.I. 0.20–0.80), but not mortality (OR 0.58; 95% Cr.I. 0.26–1.22). There were no significant differences between HFNC and NIV regarding different outcomes. In a subgroup analysis, we observed a mortality benefit with NIV over standard oxygen in patients undergoing cardiothoracic surgeries but not in abdominal surgeries. Furthermore, in comparison with standard oxygen, NIV and HFNC were associated with lower intubation rates following cardiothoracic surgeries while only NIV reduced the intubation rates following abdominal surgeries.

Conclusions

Among patients with post-operative respiratory failure, HFNC and NIV were associated with significantly reduced rates of intubation and ICU-acquired infections compared with standard oxygen. Moreover, NIV was associated with reduced mortality in comparison with standard oxygen.

Effects of intra-operative positive end-expiratory pressure setting guided by oesophageal pressure measurement on oxygenation and respiratory mechanics during laparoscopic gynaecological surgery: A randomised controlled trial

BACKGROUND

The creation of pneumoperitoneum during laparoscopic surgery can lead to adverse effects on the respiratory system. Positive end-expiratory pressure (PEEP) plays an important role in mechanical ventilation during laparoscopic surgery.

OBJECTIVE

To evaluate whether PEEP setting guided by oesophageal pressure (Poeso) measurement would affect oxygenation and respiratory mechanics during laparoscopic gynaecological surgery.

DESIGN

A randomised controlled study.

SETTING

A single-centre trial from March 2018 to June 2018.

PATIENTS

Forty-four adult patients undergoing laparoscopic gynaecological surgery with anticipated duration of surgery more than 2 h.

INTERVENTION

PEEP set according to Poeso measurement (intervention group) versus PEEP constantly set at 5 cmH2O (control group).

MAIN OUTCOME MEASURES

Gas exchange and respiratory mechanics after induction and intubation (T0) and at 15 and 60 min after initiation of pneumoperitoneum (T1 and T2, respectively).

RESULTS

PEEP during pneumoperitoneum was significantly higher in the intervention group than in the control group (T1, 12.5 ± 1.9 vs. 5.0 ± 0.0 cmH2O and T2, 12.4 ± 1.9 vs. 5.0 ± 0.0 cmH2O, both P < 0.001). Partial pressures of oxygen decreased significantly from baseline during pneumoperitoneum in the control group but not in the intervention group. Nevertheless, the changes in partial pressures of oxygen did not differ between groups. Compliance of the respiratory system (CRS) significantly decreased and driving pressure significantly increased during pneumoperitoneum in both groups. However, the changes in CRS and driving pressure were significantly less in the intervention group. Transpulmonary pressure during expiration was maintained in the intervention group while it decreased significantly in the control group.

CONCLUSION

PEEP setting guided by Poeso measurement showed no beneficial effects in terms of oxygenation but respiratory mechanics were better during laparoscopic gynaecological surgery.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03256396.

Individualized lung protective ventilation vs. conventional ventilation during general anesthesia in laparoscopic total hysterectomy

Laparoscopic total hysterectomy is performed by carbon dioxide insufflation, Trendelenburg position and mechanical ventilation of patients under general anesthesia. However, this may induce pulmonary atelectasis and/or hyperdistention of the lungs. Multiple studies have indicated that mechanical ventilation with the use of low tidal volumes, moderate positive end-expiratory pressure (PEEP) and regular alveolar recruitment maneuvers may improve post-operative outcomes. However, the benefits of an individualized level of PEEP have not been clearly established. In the present study, it was hypothesized that a moderate fixed PEEP may not suit all patients and an individually-titrated PEEP during anesthesia may improve the peri-operative pulmonary oxygenation function. The aim of the present study was to compare the pulmonary oxygenation function and post-operative pulmonary complications (PPCs) in patients receiving individualized lung-protective mechanical ventilation (LPV) vs. conventional ventilation (CV) during laparoscopic total hysterectomy. The present study was a randomized double-blinded clinical trial on 87 patients who were randomly divided to receive CV or protective ventilation (PV). An optimal individualized PEEP value was determined using a static pulmonary compliance-directed PEEP titration procedure. Pulmonary oxygenation function, serum inflammatory factors, including interleukin-8 and Clara cell protein 16, the incidence of PPCs and the post-operative length of stay were also determined. Patients in the PV group exhibited improved pulmonary oxygenation function during and after the operation. The total percentage of PPCs during the first 7 days after surgery was significantly lower in the PV group compared with those in the CV group. In conclusion, as compared to CV, intra-operative individualized LPV significantly improved pulmonary oxygenation function and reduced the incidence of PPCs during the first 7 days after laparoscopic total hysterectomy (Clinical trial registration no. ChiCTR1900027738).

Preoperative pulmonary function tests do not predict the development of pulmonary complications after elective major abdominal surgery: A prospective cohort study

BACKGROUND

Data describing the association of preoperative pulmonary function testing (PFT) with postoperative pulmonary complications (PPC) are inconsistent. We conducted this prospective study to determine the ability of PFT to predict PPC.

MATERIALS AND METHODS

Data were prospectively collected from 676 patients who underwent elective abdominal surgery (emergency and thoracic operations excluded). The primary outcome was the occurrence of PPC within 30 days. Patient and procedure-related factors were examined as risk factors. Multivariate logistic regression analysis was performed using risk factors identified with univariate analysis and area under the curve (AUC) analysis performed.

RESULTS

PPC occurred in 29 patients (4.9%). History of smoking or abnormal physical examination were not significantly associated. Multivariate analysis identified age (p = 0.03), operative time (p = 0.02), blood transfusions (p = 0.002), and %VC (p = 0.001) as significant risk factors. AUC with a model including age, operative time, and blood transfusion was 0.83. The addition of %VC to these three variables increased the AUC to 0.89 (p = 0.1).

CONCLUSIONS

Age, operative time, blood transfusion, and %VC are significantly associated with an increased risk of PPC. The addition of %VC to other risk factors did not significantly improve the ability to predict PPC, showing that preoperative PFT is not helpful to predict PPC.

Effect of different fraction of inspired oxygen on development of atelectasis in mechanically ventilated children: A randomized controlled trial

BACKGROUND

The use of high fraction of inspired oxygen (F_I O₂ ) can cause direct pulmonary toxicity and pulmonary complications. The purpose of this study was to evaluate the effect of different F_I O₂ on development of intraoperative atelectasis in mechanically ventilated children using lung ultrasound.

METHODS

In this randomized controlled, patient- and sonographer-blinded trial, 86 children (≤6 years) undergoing noncardiac surgery were allocated into a low (n = 43) or high (n = 43) F_I O₂ group. The low F_I O₂ group consistently received 30% air-oxygen mixture during preoxygenation, ultrasound-guided recruitment maneuver, and mechanical ventilation. The high F_I O₂ group received 100% oxygen during preoxygenation and ultrasound-guided recruitment maneuver and 60% air-oxygen mixture during mechanical ventilation. Positive end-expiratory pressure of 5 cm H₂ O was applied in both groups. Lung ultrasound was performed one minute after the start of mechanical ventilation and at the end of surgery in both groups. Primary outcome was significant atelectasis incidence (consolidation score of ≥2 in any region) on the postoperative lung ultrasound. Secondary outcomes included significant atelectasis incidence on the preoperative lung ultrasound, incidences of intra- and postoperative desaturation, and incidences of postoperative fever and postoperative pulmonary complications.

RESULTS

Significant atelectasis incidence on the postoperative lung ultrasound was similar between the low and high F_I O₂ groups (28% vs 37%; Pearson chi-square value = 0.847; P = .357; OR 1.531; 95% CI 0.617-3.800). Significant atelectasis incidence on the preoperative lung ultrasound was also similar between the groups (12% vs 9%; Pearson chi-square value = 0.124; P = .725; OR 0.779; 95% CI 0.194-3.125). There were no statistically significant differences in the other secondary outcomes.

CONCLUSIONS

F_I O₂ did not affect significant atelectasis formation in mechanically ventilated children who received ultrasound-guided recruitment maneuver and positive end-expiratory pressure.

Effects of preoperative oral management by dentists on postoperative outcomes following esophagectomy: Multilevel propensity score matching and weighting analyses using the Japanese inpatient database

The purpose of this study was to investigate the effects of preoperative oral management (POM) by dentists on the incidence of postoperative pulmonary complications (PPCs), length of hospital stay, medical costs, and days of antibiotics administration following both open and thoracoscopic esophagectomy.Dental plaque is an established risk factor for postoperative pneumonia, which could be reduced by POM. However, few clinical guidelines for cancer treatment, including those for esophageal cancer, recommend POM as routine perioperative care.We extracted data of esophagectomy cases from the Japanese Diagnosis Procedure Combination database. We subsequently conducted propensity score (PS) analyses for multilevel data, including matching, inverse probability of treatment weighting (IPTW), and standardized mortality ratio weighting (SMRW), to estimate the effect of POM by dentists on the outcomes of esophagectomy.We analyzed 3412 esophagectomy cases of which 812 were open, and 2600 were thoracoscopic surgery. In IPTW analysis to estimate the average treatment effect, the risk difference of postoperative aspiration pneumonia ranged from -2.49% to -2.02% between the POM and control groups of both open and thoracoscopic esophagectomy cases. IPTW analyses indicated that the total medical costs of thoracoscopic esophagectomy were reduced by 221,200 to 253,100 Japanese Yen (equivalent to about $2000-$2200). In PS matching and SMRW analyses to estimate average treatment effect on treated, there was no difference in outcomes between the POM and control groups.Our results suggested that in patients undergoing open or thoracoscopic esophagectomy, POM by dentists prevented the occurrence of postoperative aspiration pneumonia. It could also reduce the total medical costs of thoracoscopic esophagectomy. Thus, POM by dentists can be considered as a routine perioperative care for all patients undergoing esophagectomy, regardless of the expected risk for PPC.

Utility of Perioperative Lung Ultrasound in Pediatric Cardiac Surgery

Background

Pediatric cardiac patients are at risk for perioperative respiratory insufficiency. The objective of this study was to assess the utility of perioperative lung ultrasound examination in pediatric cardiac surgery.

Methods

In this randomized, controlled trial, children (5 yr old or younger) undergoing cardiac surgery were allocated into a control (n = 61) or intervention (n = 61) group. The control group received only lung ultrasound examinations at the end of surgery and 6 to 12 h after surgery. The intervention group received lung ultrasound examinations and an ultrasound-guided recruitment maneuver depending on ultrasound findings after inducing anesthesia, at the end of surgery, and 6 to 12 h after surgery. Primary outcomes were incidences of intra- and postoperative desaturation, and postoperative pulmonary complications. Multiple comparisons were corrected (P ≤ 0.017) in the primary outcome analysis.

Results

Of the 120 children included in the analysis, postoperative desaturation (64% vs. 27%; P &lt; 0.001; odds ratio [OR], 0.210; 95% CI, 0.097 to 0.456) occurred more in the control group. The incidences of intraoperative desaturation (36% vs. 19%; P = 0.033; OR, 0.406; 95% CI, 0.176 to 0.939) and postoperative pulmonary complications (12% vs. 3%; P = 0.093; OR, 0.271; 95% CI, 0.054 to 1.361) were similar between the groups. Lung ultrasound scores were better in the intervention group than in the control group. Duration of mechanical ventilation was longer in the control group than in the intervention group (38 ± 43 vs. 26 ± 25 h; 95% CI of mean difference, 0 to 25; P = 0.048).

Conclusions

Perioperative lung ultrasound examination followed by ultrasound-guided recruitment maneuver helped decrease postoperative desaturation events and shorten the duration of mechanical ventilation in pediatric cardiac patients.

[Can Preoperative Peak Expiratory Flow Predict Postoperative Pulmonary Complications in Lung Cancer Patients Undergoing Lobectomy?]

BACKGROUND

Postoperative pulmonary complications (PPCs), especially postoperative pneumonia (POP), directly affect the rapid recovery of lung cancer patients after surgery. Peak expiratory flow (PEF) can reflect airway patency and cough efficiency. Moreover, cough impairment may lead to accumulation of pulmonary secretions which can increase the risk of PPCs. The aim of this study is to investigate the effect of preoperative PEF on PPCs in patients with lung cancer.

METHODS

Retrospective research was conducted on 433 lung cancer patients who underwent lobectomy at the West China Hospital of Sichuan University from January 2014 to December 2015. The associations between preoperative PEF and PPCs were analyzed based on patients' basic characteristics and clinical data in hospital.

RESULTS

Preoperative PEF value in PPCs group (280.93±88.99) L/min was significantly lower than that in non-PPCs group (358.38±93.69) L/min (P<0.001). According to the binary logistics regression analysis, PEF and operative time were independent risk factors for PPCs. Further, ROC curve showed that PEF=320 L/min was the cut-off value for predicting the occurrence of PPCs (AUC=0.706, 95%CI: 0.661-0.749). The incidence of PPCs in PEF≤320 L/min group (26.6%) was significantly higher than that in PEF>320 L/min group (9.4%)(P<0.001).

CONCLUSIONS

Preoperative PEF and PPCs are correlated, and PEF may be used as a predictor of PPCs.

American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on prevention of postoperative infection within an enhanced recovery pathway for elective colorectal surgery

BACKGROUND

Colorectal surgery (CRS) patients are an at-risk population who are particularly vulnerable to postoperative infectious complications. Infectious complications range from minor infections including simple cystitis and superficial wound infections to life-threatening situations such as lobar pneumonia or anastomotic leak with fecal peritonitis. Within an enhanced recovery pathway (ERP), there are multiple approaches that can be used to reduce the risk of postoperative infections.

METHODS

With input from a multidisciplinary, international group of experts and through a focused (non-systematic) review of the literature, and use of a modified Delphi method, we achieved consensus surrounding the topic of prevention of postoperative infection in the perioperative period for CRS patients.

DISCUSSION

As a part of the first Perioperative Quality Initiative (POQI-1) workgroup meeting, we sought to develop a consensus statement describing a comprehensive, yet practical, approach for reducing postoperative infections, specifically for CRS within an ERP. Surgical site infection (SSI) is the most common postoperative infection. To reduce SSI, we recommend routine use of a combined isosmotic mechanical bowel preparation with oral antibiotics before elective CRS and that infection prevention strategies (also called bundles) be routinely implemented as part of colorectal ERPs. We recommend against routine use of abdominal drains. We also give consensus guidelines for reducing pneumonia, urinary tract infection, and central line-associated bloodstream infection (CLABSI).