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Elbardan IM, Ahmed Sayed Shehab AS, Mabrouk IM. Comparison of transversus thoracis muscle plane block and pecto-intercostal fascial plane block for enhanced recovery after pediatric open-heart surgery. Anaesth Crit Care Pain Med 2023; 42:101230. [PMID: 37031816 DOI: 10.1016/j.accpm.2023.101230] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 03/18/2023] [Accepted: 03/19/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Effective analgesia after cardiac surgery contributes to enhanced recovery. AIM To compare the perioperative analgesic effectiveness of Transversus Thoracis Muscle Plane Block (TTPB) and Pecto-Intercostal-Fascial Plane Block (PIFB) for controlling post-sternotomy pain in the pediatric population for ultrafast track cardiac surgery. METHODS Double-blind randomized study of 60 children, 2-12 years old, undergoing cardiac surgery via median sternotomy in whom a bilateral ultrasound-guided TTPB or TIBP block was performed preemptively. RESULTS Epidemiologic data of both groups were comparable. TTPB group had a lower median Modified Objective Pain Score (MOPS) all over the time postoperatively. Fentanyl consumption was significantly lower in TTBP group compared with PIFB group, only 4/30 received supplemental fentanyl during surgery in the TTPB group vs. 11/30 in the PIFB group (p = 0.033). The median [interquartile] values of postoperative fentanyl consumption were significantly lower in the TTBP compared with PIFB group: 12.0 [10.0-12.0] vs. 15.0 [15.0-16.0] µg/kg (p < 0.001), respectively. First rescue analgesia was later in the TTPB group compared to the PIFB group with median times of 7.25 and 5.0 hours, respectively (p < 0.001). Both groups had a comparable ICU length of stay (p = 0.919), with a median of 3 days. Furthermore, in the PIFB group, the incidence of non-sternal wound chest pain (53.3%) was significantly higher than in the TTPB group (3.3%) (p < 0.05). CONCLUSION TTPB and PIFB are safe regional blocks that could enhance recovery after pediatric cardiac surgery. In our series, TTPB provided better and longer-lasting postoperative analgesia with less incidence of non-sternal wound pain than PIFB.
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Affiliation(s)
- I M Elbardan
- Anaesthesia and Surgical Intensive Care Department, Faculty of Medicine, Alexandria University, Champollion Street, 21521 Azaritta, Alexandria, Egypt.
| | - A S Ahmed Sayed Shehab
- Anaesthesia and Surgical Intensive Care Department, Faculty of Medicine, Alexandria University, Champollion Street, 21521 Azaritta, Alexandria, Egypt.
| | - I M Mabrouk
- Anaesthesia and Surgical Intensive Care Department, Faculty of Medicine, Alexandria University, Champollion Street, 21521 Azaritta, Alexandria, Egypt.
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Ohliger S, Harb A, Al-Haddadin C, Bennett DP, Frazee T, Hoffmann C. Addition of Deep Parasternal Plane Block to Enhanced Recovery Protocol for Pediatric Cardiac Surgery. Local Reg Anesth 2023; 16:11-18. [PMID: 36814520 PMCID: PMC9940490 DOI: 10.2147/lra.s387631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 01/27/2023] [Indexed: 02/17/2023] Open
Abstract
Purpose This study aims to evaluate if the addition of deep parasternal plane blocks to a pre-existing enhanced recovery pathway for pediatric cardiac surgery improves outcomes. Patients and Methods A retrospective review through an EMR query from June 2019 to June 2021 was performed for patients less than 18 years of age who underwent cardiac surgery via median sternotomy and were extubated immediately following surgery in a single academic tertiary care hospital. Patients receiving deep parasternal blocks as part of an enhanced recovery protocol were compared to similar patients from the year prior to block implementation. Results The primary outcome was intraoperative and postoperative opioid consumption. Secondary outcomes were pain scores, intensive care unit (ICU) length of stay and time to first oral intake. There was a statistically significant reduction in intraoperative opioid administration and pain scores in the first 24 hours post-operatively. There was also a statistically significant reduction in ICU length of stay. There was no statistically significant difference in post-operative opioid consumption and time to first oral intake. Conclusion Bilateral deep parasternal blocks may reduce opioid consumption, provide effective postoperative pain control, and result in decreased length of intensive care unit stay across both simple and complex pediatric cardiac procedures when added to a pre-existing enhanced recovery protocol.
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Affiliation(s)
- Shelley Ohliger
- Department of Anesthesiology and Perioperative Medicine, University Hospitals/Rainbow Babies and Children’s Hospital, Cleveland, OH, 44106, USA,Correspondence: Shelley Ohliger, Department of Anesthesiology and Perioperative Medicine, University Hospitals/Rainbow Babies and Children’s Hospital, 11100 Euclid Ave, Cleveland, OH, 44106, USA, Tel +1 216 844 7340, Fax +1 216 844 3780, Email
| | - Alain Harb
- Department of Anesthesiology and Perioperative Medicine, University Hospitals/Rainbow Babies and Children’s Hospital, Cleveland, OH, 44106, USA
| | - Caroline Al-Haddadin
- Department of Anesthesiology and Perioperative Medicine, University Hospitals/Rainbow Babies and Children’s Hospital, Cleveland, OH, 44106, USA
| | - David P Bennett
- Department of Anesthesiology and Perioperative Medicine, University Hospitals/Rainbow Babies and Children’s Hospital, Cleveland, OH, 44106, USA
| | - Tiffany Frazee
- Department of Anesthesiology and Perioperative Medicine, University Hospitals/Rainbow Babies and Children’s Hospital, Cleveland, OH, 44106, USA
| | - Cassandra Hoffmann
- Department of Anesthesiology and Perioperative Medicine, University Hospitals/Rainbow Babies and Children’s Hospital, Cleveland, OH, 44106, USA
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Abdelbaser II, Mageed NA. Analgesic efficacy of ultrasound guided bilateral transversus thoracis muscle plane block in pediatric cardiac surgery: a randomized, double-blind, controlled study. J Clin Anesth 2020; 67:110002. [DOI: 10.1016/j.jclinane.2020.110002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/01/2020] [Accepted: 07/17/2020] [Indexed: 10/23/2022]
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Hanada S, Kurosawa A, Randall B, Van Der Horst T, Ueda K. Impact of high spinal anesthesia technique on fast-track strategy in cardiac surgery: retrospective study. Reg Anesth Pain Med 2019; 45:22-26. [PMID: 31772035 DOI: 10.1136/rapm-2018-100213] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 10/25/2019] [Accepted: 11/03/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND OBJECTIVES Although high spinal anesthesia (HSA) has been used in cardiac surgery, the technique has not yet been widely accepted. This retrospective study was designed to investigate the impact of HSA technique on fast-track strategy in cardiac surgery. METHODS Elective cardiac surgery cases (n=1025) were divided into two groups: cases with HSA combined with general anesthesia (GA) (HSA group, n=188) and cases with GA only (GA group, n=837). In the HSA group, bupivacaine and morphine were intrathecally administered immediately before GA was induced. Outcomes included fast-track extubation (less than 6 hours), extubation in the operating room, fast-track discharge from the intensive care unit (ICU) (less than 48 hours) and hospital (less than 7 days). RESULTS In the HSA group, 60.1% were extubated in less than 6 hours after ICU admission, as compared with 39.9% in the GA group (p<0.001). In the HSA group, 33.0% were extubated in the operating room, as compared with 4.4% in the GA group (p<0.001). LOS in the ICU was less than 48 hours in 67.6% in the HSA group, as compared with 57.2% of those in the GA group (p=0.033). LOS in the hospital was less than 7 days in 63.3% in the HSA group, as compared with 53.5% in the GA group (p=0.084). CONCLUSIONS HSA technique combined with GA in cardiac surgery increased the rate of fast-track extubation (less than 6 hours) when compared with GA only.
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Affiliation(s)
- Satoshi Hanada
- Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Atsushi Kurosawa
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Benjamin Randall
- Mountain West Anesthesia, Intermountain Medical Center, Murray, Utah, USA
| | - Theodore Van Der Horst
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Kenichi Ueda
- Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Yu S, Valencia MB, Roques V, Aljure OD. Regional analgesia for minimally invasive cardiac surgery. J Card Surg 2019; 34:1289-1296. [DOI: 10.1111/jocs.14177] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Soojie Yu
- Department of AnesthesiologyJackson Memorial Hospital/University of MiamiMiami Florida
| | - Marta Berrio Valencia
- Department of Cardiac and Transplant AnesthesiologyLondon Health Sciences CentreLondon Ontario Canada
| | - Vicente Roques
- Department of Intensive Care and Chronic Pain TreatmentUniversity Hospital Virgen de la ArrixacaMurcia Spain
| | - Oscar David Aljure
- Department of AnesthesiologyJackson Memorial Hospital/University of MiamiMiami Florida
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Raj N. Regional anesthesia for sternotomy and bypass-Beyond the epidural. Paediatr Anaesth 2019; 29:519-529. [PMID: 30861264 DOI: 10.1111/pan.13626] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 03/05/2019] [Accepted: 03/05/2019] [Indexed: 12/18/2022]
Abstract
Systemic opioids have been the main stay for the management of perioperative pain in children undergoing cardiac surgery with sternotomy. The location, distribution, and duration of pain in these children have not been studied as extensively as in adults. Currently, there is no consensus to the dose of opioids required to provide optimum analgesia and attenuate the stress response while minimizing their unwanted side effects. At present there is a tendency to use lower dose aiming for early extubation and minimize opioid-related side effects, but this may not obtund the stress response in all children. The development of chronic pain although rare when compared to adults is still a risk that needs further investigation. Regional anesthetic techniques, by blocking the afferent impulses, have been shown to be advantageous in reducing the stress response to surgery as well as pain and opioid requirements in children up to 24 hours after cardiac surgery. Central neuraxial blockades have not gained wide spread acceptance in these procedures due to the worry of hematoma, although rare, leading to catastrophic neurological outcomes. This review focuses on blocks outside the vertebral column, ie, peripheral nerve blocks, performed either in the front or the back of the chest wall to target the thoracic intercostal nerves. Techniques of ultrasound-guided bilateral single shot paravertebral block and erector spinae block posteriorly and transversus thoracic plane block anteriorly are discussed. In addition, parasternal block and wound infiltration by surgeon as well as continuous local anesthetic infusion via catheters placed at end of procedures are summarized. Current evidence available for use of these techniques in children undergoing cardiac surgery are reviewed. These are based on small studies and case series and further studies are required to evaluate the risks and benefits of local anesthetic blocks in children undergoing cardiac surgery.
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Affiliation(s)
- Naveen Raj
- Jackson Rees Department of Anesthesia, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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Florkiewicz P, Musialowicz T, Hippeläinen M, Lahtinen P. Continuous Ropivacaine Infusion Offers No Benefit in Treating Postoperative Pain After Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 33:378-384. [DOI: 10.1053/j.jvca.2018.09.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Indexed: 12/11/2022]
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Mittnacht AJ, Shariat A, Weiner MM, Malhotra A, Miller MA, Mahajan A, Bhatt HV. Regional Techniques for Cardiac and Cardiac-Related Procedures. J Cardiothorac Vasc Anesth 2019; 33:532-546. [DOI: 10.1053/j.jvca.2018.09.017] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Indexed: 12/31/2022]
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Kumar A, Dhir U, Jain V, Yadav S, Purohit A. Off-pump coronary bypass grafting in a post-pneumonectomy patient: Challenges and management. Ann Card Anaesth 2019; 22:86-88. [PMID: 30648686 PMCID: PMC6350433 DOI: 10.4103/aca.aca_37_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Pulmonary complications are common in cardiac surgical patients. Limited respiratory reserves along with the pain associated with sternotomy add to the morbidity. Patients undergoing cardiac surgery who have had a pneumonectomy done before can be even more challenging to manage perioperatively due to a single-functioning lung. We present a case of a postpneumonectomy patient who underwent off-pump coronary artery bypass grafting. Perioperative optimization of lung function tests was stressed upon including the chest physiotherapy and early mobilization. Preoperative thoracic epidural catheter was inserted for postoperative pain and other proven benefits of thoracic epidural in coronary artery disease patients. We could conclude from our experience that proper optimization of lung function tests and meticulous pain management along with fast-tracking are keys to the management of such patients.
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Affiliation(s)
- Anand Kumar
- Department of Cardiac Anaesthesia, Fortis Memorial Research Institute, Gurgaon, Haryana, India
| | - Udgeath Dhir
- Department of CTVS, Fortis Memorial Research Institute, Gurgaon, Haryana, India
| | - Vishal Jain
- Department of Cardiac Anaesthesia, Fortis Memorial Research Institute, Gurgaon, Haryana, India
| | - Surendra Yadav
- Department of CTVS, Fortis Memorial Research Institute, Gurgaon, Haryana, India
| | - Ankit Purohit
- Department of Cardiac Anaesthesia, Fortis Memorial Research Institute, Gurgaon, Haryana, India
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Porizka M, Koudelkova K, Kopecky P, Porizkova H, Dohnalova A, Kunstyr J. High thoracic anesthesia offers no major benefit over general anesthesia in on-pump cardiac surgery patients: a retrospective study. SPRINGERPLUS 2016; 5:799. [PMID: 27390640 PMCID: PMC4916068 DOI: 10.1186/s40064-016-2541-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 06/08/2016] [Indexed: 01/06/2023]
Abstract
BACKGROUND Thoracic epidural anesthesia (TEA) has been proposed to improve and facilitate early postoperative outcome in cardiac surgery. The aim of our study was to analyze early postoperative outcome data of patients undergoing cardiac surgery under general anesthesia (GA) with comparison to patients receiving combined TEA and GA. METHODS Medical records data from 288 patients who underwent elective on-pump cardiac surgery were retrieved and analyzed. Patients were divided into two study groups according to the type of anesthesia used: GA group (n = 141) and TEA group (n = 147). Early postoperative outcome data including quality of analgesia and major organ outcome parameters were compared between the study groups. RESULTS There was no major difference in early postoperative outcome data between the study groups, except for shorter time to extubation (6.0 ± 10.0 vs. 6.9 ± 8.8 h, respectively, P < 0.05) and hospital stay (10.7 ± 5.9 vs. 12.9 ± 8.8 days, respectively, P < 0.05) in TEA group compared to GA group. Also TEA group as compared to GA group had lower pain numeric rating scale scores (1 ± 1.1 vs. 1.4 ± 1.5 at 24 h, respectively, P < 0.05) and morphine requirements during the first 24 h after surgery (148.2 vs. 193 ± 85.4 μg/kg, respectively, P < 0.05). CONCLUSION Both anesthetic methods were equivalent in most postoperative outcome measures. Thoracic epidural analgesia provided superior pain relief, shorter time to extubation and earlier hospital discharge.
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Affiliation(s)
- Michal Porizka
- Department of Anaesthesiology, Resuscitation and Intensive Medicine, First Faculty of Medicine, General University Hospital, Charles University in Prague, U Nemocnice 2, 128 08 Prague 2, Czech Republic
| | - Katerina Koudelkova
- Department of Anaesthesiology, Resuscitation and Intensive Medicine, First Faculty of Medicine, General University Hospital, Charles University in Prague, U Nemocnice 2, 128 08 Prague 2, Czech Republic
| | - Petr Kopecky
- Department of Anaesthesiology, Resuscitation and Intensive Medicine, First Faculty of Medicine, General University Hospital, Charles University in Prague, U Nemocnice 2, 128 08 Prague 2, Czech Republic
| | - Hana Porizkova
- Department of Anaesthesiology, Resuscitation and Intensive Medicine, First Faculty of Medicine, General University Hospital, Charles University in Prague, U Nemocnice 2, 128 08 Prague 2, Czech Republic
| | - Alena Dohnalova
- Institute of Physiology, First Faculty of Medicine, Charles University in Prague, Albertov 5, Prague 2, 128 00 Czech Republic
| | - Jan Kunstyr
- Department of Anaesthesiology, Resuscitation and Intensive Medicine, First Faculty of Medicine, General University Hospital, Charles University in Prague, U Nemocnice 2, 128 08 Prague 2, Czech Republic
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Kim HC, Bae JY, Kim TK, Jeon Y, Min JJ, Goo EK, Hong DM. Efficacy of intrathecal morphine for postoperative pain management following open nephrectomy. J Int Med Res 2015; 44:42-53. [PMID: 26689781 PMCID: PMC5536567 DOI: 10.1177/0300060515595650] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 06/18/2015] [Indexed: 01/02/2023] Open
Abstract
Objective To evaluate the efficacy and safety of intrathecal morphine (ITM) for postoperative pain control in patients with renal cell carcinoma undergoing open nephrectomy. Methods Forty-five patients scheduled for open nephrectomy were randomised to receive 300 µg ITM and intravenous patient-controlled analgesia (IV-PCA) (n = 22) or IV-PCA alone (n = 23) for postoperative analgesia. The numeric pain score (NPS), postoperative IV-PCA requirements and opioid-related complications including nausea, vomiting, dizziness, headache, and pruritus were compared between groups. Results NPS was significantly lower in the ITM group up to 24 h postoperatively. Upon coughing, NPS at 24 h postoperatively was 50 (interquartile range (IQR) 30–60) in the ITM group and 60 (45–70) in the IV-PCA group. Cumulative morphine consumption at 72 h postoperatively was significantly lower in the ITM group compared with the IV-PCA group (20 (9–33) mg vs. 31 (21–49) mg, respectively). Opioid-related complications were similar in both groups with the exception of pruritus (ITM, 77% vs. IV-PCA, 26%). Conclusions ITM was associated with greater analgesia without serious complications in patients undergoing open nephrectomy.
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Affiliation(s)
- Hyun-Chang Kim
- Department of Anaesthesiology and Pain Medicine, Keimyung University, School of Medicine, Daegu, Korea
| | - Jun-Yeol Bae
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Tae Kyong Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yunseok Jeon
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jeong Jin Min
- Department of Anaesthesiology and Pain Medicine, Samsung Medical Center, Seoul, Korea
| | - Eui-Kyoung Goo
- Department of Anaesthesiology and Pain Medicine, The Armed Forces Medical Command, Seongnam, Korea
| | - Deok Man Hong
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
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Yang CK, Teng A, Lee DY, Rose K. Pulmonary complications after major abdominal surgery: National Surgical Quality Improvement Program analysis. J Surg Res 2015; 198:441-9. [PMID: 25930169 DOI: 10.1016/j.jss.2015.03.028] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 03/03/2015] [Accepted: 03/12/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Postoperative pulmonary complications (PPCs) after major abdominal surgery are common and associated with significant morbidity and high cost of care. The objective of this study was to identify the risk factors for PPCs after major abdominal surgery. MATERIALS AND METHODS The American College of Surgeons' National Surgical Quality Improvement Program database from 2005-2012 was queried for patients who underwent major abdominal surgery (esophagectomy, gastrectomy, pacnreatectomy, enterectomy, hepatectomy, colectomy, and proctectomy). Predictors of PPCs were identified using multivariate logistic regression. RESULTS Of 165,196 patients who underwent major abdominal surgery 9595 (5.8%) suffered PPCs (pneumonia 3.2%, prolonged ventilator support ≥48 h 3.0%, and unplanned intubation 2.8%). On multivariate analysis, significant predictors of overall and individual PPCs include esophagectomy, advanced American Society of Anesthesiology Classification System, dependent functional status, prolonged operative time, age ≥80 y, severe chronic obstructive pulmonary disease, preoperative shock, ascites, and smoking. Obesity was not a risk factor. Female gender was overall protective for PPCs. CONCLUSIONS PPCs after abdominal procedures are associated with a number of clinical variables. Esophageal operations and American Society of Anesthesiology Classification System were the strongest predictors. These results provide a framework for identifying patients at risk for developing pulmonary complications after major abdominal surgery.
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Affiliation(s)
- Chun Kevin Yang
- Department of Surgery, Mount Sinai St. Luke's Hospital and Mount Sinai Roosevelt Hospital, New York.
| | - Annabelle Teng
- Department of Surgery, Mount Sinai St. Luke's Hospital and Mount Sinai Roosevelt Hospital, New York
| | - David Y Lee
- Department of Surgery, Mount Sinai St. Luke's Hospital and Mount Sinai Roosevelt Hospital, New York
| | - Keith Rose
- Department of Surgery, Mount Sinai St. Luke's Hospital and Mount Sinai Roosevelt Hospital, New York
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