Prevention of Postoperative Pulmonary Complications

Intraoperative Use of High-Flow Nasal Cannula in Elderly Patients Undergoing Hip Fracture Repair Under Spinal Anesthesia: A Randomized Controlled Study

BACKGROUND

The procedure of hip fracture repair poses a risk for postoperative pulmonary complications (PPCs) in elderly patients, accompanied by anesthesia and operations. Various noninvasive methods of respiratory support are used as prophylactic and therapeutic, mainly in the postoperative period.  Objective: This study aims to determine whether intraoperative use of a high-flow nasal cannula (HFNC) impacts elderly patient outcomes after hip fracture surgery.

METHOD

Seventy patients aged 65 and older undergoing traumatic hip surgery under spinal anesthesia for isolated hip fractures were randomly assigned to either an interventional group (I) utilizing a high-flow nasal cannula or a control group (C) without respiratory intervention in a six-month single-blind controlled study at Sahloul Teaching Hospital.

RESULTS

The two groups had identical socio-demographic traits and baseline data. Respiratory postoperative complications occurred in two patients in group (I) and in nine patients in group (C), with a significant difference (p = 0.023). The main respiratory postoperative complications in group (I) were atelectasis (one case) and pulmonary edema (one case). The main respiratory postoperative complications in group (C) were atelectasis (four cases), pneumonia (two cases), COPD decompensation (two cases), and pulmonary edema (one case). No intensive care unit admissions or intraoperative complications were associated with using HFNC. The mean length of stay (LOS) in the hospital was 8.83 ± 2.91 for group I and 10.46 ± 3.4 for group (C), which differed significantly (p = 0.03) with no in-hospital mortality for the two groups.

CONCLUSION

The intraoperative administration of HFNC may lower the incidence of postoperative respiratory complications and the duration of hospital stays.

Analysis of postoperative pulmonary complications after gastrectomy for gastric cancer: development and validation of a nomogram

Background

Postoperative pulmonary complications (PPCs) are common in gastric cancer patients after gastrectomy. The aim of our study was to investigate the perioperative risk factors and to develop a nomogram to identify patients who are at significant risk of PPCs.

Methods

The clinical data of gastric cancer patients who underwent elective gastrectomy in the First Affiliated Hospital of Nanjing Medical University from 2017 to 2021 were retrospectively collected. All patients were randomly divided into a training and a validation cohort at a ratio of 7:3. Univariate and multivariate analysis were applied to identify the independent risk factors that might predict PPCs, and a nomogram was constructed. Both discrimination and calibration abilities were estimated by the area under a receiver operating characteristic curve (AUC) and calibration curves. The clinical effectiveness of the nomogram was further quantified with the decision curve analysis (DCA).

Results

Of 2,124 included patients, one hundred and fifty patients (7.1%) developed PPCs. Binary logistic analysis showed that age > 65 years, higher total cholesterol level, longer duration of surgery, total gastrectomy, and the dose of oxycodone > 5.5 mg were independent risk factors for the occurrence of PPCs, which were contained in the nomogram. The predictive nomogram showed good discrimination and calibration [an AUC of 0.735 (95% CI: 0.687-0.783) in a training cohort and 0.781 (95% CI: 0.715-0.847) in a validation cohort]. The calibration curve and decision curve analysis showed a good agreement between nomogram predictions and actual observations.

Conclusion

We developed a nomogram model based on age, total cholesterol, extent of resection, duration of surgery, and the dose of oxycodone to predict the risk of PPCs in gastric cancer patients after elective gastrectomy.

The fully engaged inspiratory muscle training reduces postoperative pulmonary complications rate and increased respiratory muscle function in patients with upper abdominal surgery: a randomized controlled trial

BACKGROUND

Upper abdominal surgical treatment may reduce respiratory muscle function and mucociliary clearance, which might be a cause of postoperative pulmonary complications (PPCs). Threshold inspiratory muscle training (IMT) may serve as an effective modality to improve respiratory muscle strength and endurance in patients. However, whether this training could help patients with upper abdominal surgery remains to be determined. The aim of the present investigation was to determine the effect of a fully engaged IMT on PPCs and respiratory function in patients undergoing upper abdominal surgery. We hypothesized that the fully engaged IMT could reduce PPCs and improve respiratory muscle function in patients with upper abdominal surgery.

METHODS

This is a randomized controlled trial (RCT) with 28 patients who underwent upper abdominal surgery. Patients were randomly assigned to the control (CLT) group or the IMT group. The CTL group received regular health care. The IMT group received 3 weeks of IMT with 50% of MIP as the initial intensity before the operation. The intensity of MIP increased by 5-10% per week. The IMT was continued for 4 weeks after the operation. The study investigated the outcomes including PPCs, respiratory muscle strength, diaphragmatic function, cardiopulmonary function, and quality of life (QoL).

RESULTS

We found that IMT improved respiratory muscle strength and diaphragmatic excursion. IMT also had a beneficial effect on the incidence of postoperative pulmonary complications (PPCs) compared to CLT care.

CONCLUSION

The results from this study revealed that IMT provided positive effects on parameters associated with the respiratory muscle function and reduced the incidence of PPCs. We propose that fully engaged IMT should be a part of clinical management in patients with upper abdominal surgery.KEY MESSAGESThe fully engaged inspiratory muscle training reduces postoperative pulmonary complications rate in patients with upper abdominal surgery.The fully engaged inspiratory muscle training increases maximal inspiratory pressure in patients with upper abdominal surgery.The fully engaged inspiratory muscle training increases diaphragm function in patients with upper abdominal surgery.The fully engaged inspiratory muscle training increases the quality of life in patients with upper abdominal surgery.

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.

Smoking, Obesity, and the Elective Operation

Smoking and obesity are commonly encountered problems in the elective, perioperative setting. This article reviews the risks posed by smoking and diabetes and explores way to mitigate such risks. Other means of perioperative optimization are also discussed in an effort to describe perioperative strategies that can improve patient outcomes.

Determination of the optimal surgical procedure by identifying risk factors for pneumonia after transthoracic esophagectomy

BACKGROUND

Esophagectomy is associated with a high risk of postoperative complications, and the respiratory complications are the most common. Therefore, stratification of patients based on preoperative risk factors is essential. This study aimed to identify the risk of postoperative pneumonia (POP) based on the preoperative factors and determine the optimal perioperative surgical management strategy.

METHODS

This retrospective study involved 207 patients who underwent esophagectomy. The patients were divided into two groups, namely, with POP and without POP. To identify the risk factors for POP, the pre- and perioperative characteristics were analyzed. A receiver operating characteristics curve was used to determine a cutoff value of 2.40 L for the forced expiratory volume in 1 s (FEV1.0) and the cohort was divided into a high- and low-FEV1.0 group. A second analysis was then performed to determine the optimal surgical management for patients at a high risk for POP.

RESULTS

POP occurred in 45 (21.7%) patients. A multiple logistic regression analysis showed that FEV1.0 was significantly lower in the POP (+) group (P = 0.020); thus, a low FEV1.0 was found to be a risk factor for POP. Multiple logistic regression analysis showed that open thoracotomy was a significant risk factor for POP in low FEV1.0 patients (P = 0.013).

CONCLUSIONS

A low FEV1.0 and an open thoracotomy are risk factors for POP. Therefore, patients with low FEV1.0 should be managed carefully and video-assisted thoracic surgery should be considered.

Incidência e fatores de complicações pulmonares pós-operatórias em pacientes submetidos à cirurgias de tórax e abdome

RESUMO Objetivos: avaliar a incidência de complicações pulmonares pós-operatórias em pacientes submetidos à cirurgias de tórax e abdome e os principais fatores envolvidos. Métodos: estudo analítico observacional prospectivo dos pacientes submetidos à cirurgias de tórax e abdome no Hospital Santo Antônio de Blumenau, SC. Os dados foram coletados dos prontuários eletrônicos e através de entrevistas estruturadas com os pacientes. Foram avaliados dados relativos às características dos pacientes e da cirurgia. A variável de desfecho foi a ocorrência de complicações pulmonares pós-operatórias. Resultados: foram estudados 314 pacientes, 65,6% do sexo feminino, com média de idade de 46,61 anos, 51,6% classificados como ASA II. Cirurgias por vídeo foram realizadas em 55,7% dos casos, abdominais em 85,4% e 61,5% dos procedimentos foram classificados como potencialmente contaminadas e de porte médio. O tempo médio de cirurgia foi de 126,65 minutos e os pacientes ficaram internados em média por 2,59 dias. A incidência de complicações pulmonares pós-operatórias foi de 11,5%. As complicações mais comuns foram a insuficiência respiratória, o derrame pleural e a pneumonia. Os fatores de risco mais importantes para estas complicações foram diabetes, internação hospitalar por mais de cinco dias e presença de doença pulmonar prévia. Os pacientes submetidos às cirurgias por vídeo apresentaram menor incidência de complicações. Conclusão: as complicações pulmonares pós-operatórias são frequentes e os fatores associados a maior risco foram diabetes, internação prolongada e presença de doença pulmonar prévia.

Complications after emergency laparotomy beyond the immediate postoperative period - a retrospective, observational cohort study of 1139 patients

Mortality and morbidity occur commonly following emergency laparotomy, and incur a considerable clinical and financial healthcare burden. Limited data have been published describing the postoperative course and temporal pattern of complications after emergency laparotomy. We undertook a retrospective, observational, multicentre study of complications in 1139 patients after emergency laparotomy. A major complication occurred in 537/1139 (47%) of all patients within 30 days of surgery. Unadjusted 30-day mortality was 20.2% and 1-year mortality was 34%. One hundred and thirty-seven of 230 (60%) deaths occurred between 72 h and 30 days after surgery; all of these patients had complications, indicating that there is a prolonged period with a high frequency of complications and mortality after emergency laparotomy. We conclude that peri-operative, enhanced recovery care bundles for preventing complications should extend their focus on continuous complication detection and rescue beyond the first few postoperative days.

Pre-operative pulmonary evaluation in the patient with suspected respiratory disease

Post-operative pulmonary complications (POPC) occur frequently, especially in patients with pre-existing pulmonary disease and have a significant effect on post-surgical morbidity and mortality. By understanding the patient's existing pulmonary diseases that have a significant effect on post-operative morbidities a combination of information has to be gathered from a thorough history and physical exam as well as selected laboratory and diagnostic tests. Evidence based scores can then be employed to predict the risk of significant POPC. Numbers and testing alone, however, such as diagnosis of chronic obstructive pulmonary disease based on spirometry, may not provide as clear a picture as of the true risk of POPC that is determined by a combination of estimations of the patient's functional status, (b) measured by the patient's estimates of activity and (c) confirmed by the patient's ability to perform simple tasks such as the 6-minute walk test. This information can then be used to rationalize perioperative interventions and improve the safety of the perioperative experience.