Elevated preoperative heart rate associated with increased risk of cardiopulmonary complications after resection for lung cancer

One-lung ventilation with fixed and variable tidal volumes on oxygenation and pulmonary outcomes: A randomized trial

OBJECTIVE

Test the hypothesis that one-lung ventilation with variable tidal volume improves intraoperative oxygenation and reduces postoperative pulmonary complications after lung resection.

BACKGROUND

Constant tidal volume and respiratory rate ventilation can lead to atelectasis. Animal and human ARDS studies indicate that oxygenation improves with variable tidal volumes. Since one-lung ventilation shares characteristics with ARDS, we tested the hypothesis that one-lung ventilation with variable tidal volume improves intraoperative oxygenation and reduces postoperative pulmonary complications after lung resection.

DESIGN

Randomized trial.

SETTING

Operating rooms and a post-anesthesia care unit.

PATIENTS

Adults having elective open or video-assisted thoracoscopic lung resection surgery with general anesthesia were randomly assigned to intraoperative ventilation with fixed (n = 70) or with variable (n = 70) tidal volumes.

INTERVENTIONS

Patients assigned to fixed ventilation had a tidal volume of 6 ml/kgPBW, whereas those assigned to variable ventilation had tidal volumes ranging from 6 ml/kg PBW ± 33% which varied randomly at 5-min intervals.

MEASUREMENTS

The primary outcome was intraoperative oxygenation; secondary outcomes were postoperative pulmonary complications, mortality within 90 days of surgery, heart rate, and SpO2/FiO2 ratio.

RESULTS

Data from 128 patients were analyzed with 65 assigned to fixed-tidal volume ventilation and 63 to variable-tidal volume ventilation. The time-weighted average PaO2 during one-lung ventilation was 176 (86) mmHg in patients ventilated with fixed-tidal volume and 147 (72) mmHg in the patients ventilated with variable-tidal volume, a difference that was statistically significant (p < 0.01) but less than our pre-defined clinically meaningful threshold of 50 mmHg. At least one composite complication occurred in 11 (17%) of patients ventilated with variable-tidal volume and in 17 (26%) of patients assigned to fixed-tidal volume ventilation, with a relative risk of 0.67 (95% CI 0.34-1.31, p = 0.24). Atelectasis in the ventilated lung was less common with variable-tidal volumes (4.7%) than fixed-tidal volumes (20%) in the initial three postoperative days, with a relative risk of 0.24 (95% CI 0.01-0.8, p = 0.02), but there were no significant late postoperative differences. No other secondary outcomes were both statistically significant and clinically meaningful.

CONCLUSION

One-lung ventilation with variable tidal volume does not meaningfully improve intraoperative oxygenation, and does not reduce postoperative pulmonary complications.

Construction of a mortality risk prediction model for elderly people at risk of lobectomy for NSCLC

Background

An increasing number of lung cancer patients are opting for lobectomy for oncological treatment. However, due to the unique organismal condition of elderly patients, their short-term postoperative mortality is significantly higher than that of non-elderly patients. Therefore, there is a need to develop a personalised predictive tool to assess the risk of postoperative mortality in elderly patients.

Methods

Information on the diagnosis and survival of 35,411 older patients with confirmed lobectomy NSCLC from 2009 to 2019 was screened from the SEER database. The surgical group was divided into a high-risk mortality population group (≤90 days) and a non-high-risk mortality population group using a 90-day criterion. Survival curves were plotted using the Kaplan-Meier method to compare the differences in overall survival (OS) and lung cancer-specific survival (LCSS) between the two groups. The data set was split into modelling and validation groups in a ratio of 7.5:2.5, and model risk predictors of postoperative death in elderly patients with NSCLC were screened using univariate and multifactorial logistic regression. Columnar plots were constructed for model visualisation, and the area under the subject operating characteristic curve (AUC), DCA decision curve and clinical impact curve were used to assess model predictiveness and clinical utility.

Results

Multi-factor logistic regression results showed that sex, age, race, histology and grade were independent predictors of the risk of postoperative death in elderly patients with NSCLC. The above factors were imported into R software to construct a line graph model for predicting the risk of postoperative death in elderly patients with NSCLC. The AUCs of the modelling and validation groups were 0.711 and 0.713 respectively, indicating that the model performed well in terms of predictive performance. The DCA decision curve and clinical impact curve showed that the model had a high net clinical benefit and was of clinical application.

Conclusion

The construction and validation of a predictive model for death within 90 days of lobectomy in elderly patients with lung cancer will help the clinic to identify high-risk groups and give timely intervention or adjust treatment decisions.

Perioperative cardiovascular pathophysiology in patients undergoing lung resection surgery: a narrative review

Although thoracic surgery is understood to confer a high risk of postoperative respiratory complications, the substantial haemodynamic challenges posed are less well appreciated. This review highlights the influence of cardiovascular comorbidity on outcome, reviews the complex pathophysiological changes inherent in one-lung ventilation and lung resection, and examines their influence on cardiovascular complications and postoperative functional limitation. There is now good evidence for the presence of right ventricular dysfunction postoperatively, a finding that persists to at least 3 months. This dysfunction results from increased right ventricular afterload occurring both intraoperatively and persisting postoperatively. Although many patients adapt well, those with reduced right ventricular contractile reserve and reduced pulmonary vascular flow reserve might struggle. Postoperative right ventricular dysfunction has been implicated in the aetiology of postoperative atrial fibrillation and perioperative myocardial injury, both common cardiovascular complications which are increasingly being appreciated to have impact long into the postoperative period. In response to the physiological demands of critical illness or exercise, contractile reserve, flow reserve, or both can be overwhelmed resulting in acute decompensation or impaired long-term functional capacity. Aiding adaptation to the unique perioperative physiology seen in patients undergoing thoracic surgery could provide a novel therapeutic avenue to prevent cardiovascular complications and improve long-term functional capacity after surgery.

Development of a scoring system for survival following surgery for metastatic bone disease

AIMS

The incidence of bone metastases is between 20% to 75% depending on the type of cancer. As treatment improves, the number of patients who need surgical intervention is increasing. Identifying patients with a shorter life expectancy would allow surgical intervention with more durable reconstructions to be targeted to those most likely to benefit. While previous scoring systems have focused on surgical and oncological factors, there is a need to consider comorbidities and the physiological state of the patient, as these will also affect outcome. The primary aim of this study was to create a scoring system to estimate survival time in patients with bony metastases and to determine which factors may adversely affect this.

METHODS

This was a retrospective study which included all patients who had presented for surgery with metastatic bone disease. The data collected included patient, surgical, and oncological variables. Univariable and multivariable analysis identified which factors were associated with a survival time of less than six months and less than one year. A model to predict survival based on these factors was developed using Cox regression.

RESULTS

A total of 164 patients were included with a median survival time of 1.6 years (interquartile range 0.5 to 3.1) after surgery. On multivariable analysis, a higher American Society of Anesthesiologists grade (p < 0.001), a high white cell count (p = 0.002), hyponatraemia (p = 0.001), a preoperative resting heart rate of > 100 bpm (p = 0.052), and the type of primary cancer (p = 0.026) remained significant predictors of reduced survival time. The predictive model developed showed good discrimination and calibration to predict both six- and 12-month survival in patients with metastatic bone disease.

CONCLUSION

In addition to surgical and oncological factors, the level of comorbidity and physiological state of the patient has a significant impact on survival in patients with metastatic bone disease. These factors should be considered when assessing the appropriateness of surgical intervention. This is the first study to examine other patient factors alongside surgical and oncological data to identify a relationship between these and survival. Cite this article: Bone Joint J 2021;103-B(11):1725-1730.

Risk factors for the systemic inflammatory response syndrome and sepsis following surgical management of acute intestinal obstruction

OBJECTIVES

Infection is one of the major complications following intestinal obstruction surgery, yet predictors of its occurrence are not sufficiently reported. In this study, we examine the factors leading to postoperative inflammatory response syndrome (SIRS) and sepsis.

METHODS

The data of 213 patients who underwent intestinal obstruction surgery between 2015 to 2020 in King Abdulaziz Medical City, Riyadh, Saudi Arabia, were reviewed retrospectively. Patients' demographic characteristics and preoperative, intraoperative, and 30-day postoperative data were compared between patients who had postoperative SIRS/sepsis and patients who had no complications.

RESULTS

Ninety-six patients (44%) developed SIRS/sepsis within 30 days after surgery. More than half of the patients were males (55.8%), and the mean age at operation was 56.7(SD=20.0)years. Preoperative high heart rate, low albumin levels, and postoperative intensive care unit (ICU) admission were independently and significantly associated with developing SIRS/sepsis post-operation. The mortality rate in this study was estimated to be 7.5%; of those, 93.8% had SIRS/sepsis.

CONCLUSION

The 30-day mortality rate is considerably higher among patients who developed SIRS/sepsis after intestinal obstruction surgery. The independent risk factors of developing SIRS/sepsis after operation were elevated heart rate, low albumin levels preoperation, and ICU admission post-operation.

Prognostic Potential of Heart Rate and Hypertension in Multiple Myeloma Patients

Background: The prognosis of patients with multiple myeloma (MM) is variable and partly depends on their cardiovascular status. The presence of arrhythmias can lead to worse outcomes. Therefore, this study aimed to evaluate the potential of heart rate (HR) and hypertension in predicating the outcomes of MM patients. Methods: This study retrospectively enrolled patients with MM between January 1, 2010, and December 31, 2018, at the First Affiliated Hospital of Xi'an Jiaotong University. The endpoint was all-cause mortality. The Pearson's chi-square test was used to assess the association between hypertension and outcomes. Univariate and multivariate Cox proportional hazards models were developed to evaluate the relationship between HR and all-cause mortality. Results: A total of 386 patients were included. The mean HR was 83.8 ± 23.1 beats per minute (bpm). Patients with HR >100 bpm had a higher all-cause mortality (79.4%, 50/63) than those with 60 ≤ HR ≤ 100 bpm (39.9%, 110/276) and <60 bpm (19.1%, 9/47) (p < 0.001). Subgroup analysis based on the International Staging System and sex revealed similar relationships (p < 0.01). When stratified by age, patients with HR >100 bpm had higher all-cause mortality than those with a lower HR when age was <65 years or 65-75 years (p < 0.001) but not >75 years. The proportion of patients with hypertension was 54.7% (211/386). However, hypertension was not associated with all-cause mortality in MM patients (χ²=1.729, p > 0.05). MM patients with HR >100 bpm had the highest all-cause mortality. Conclusions: The prognostic potential of HR may be useful in aiding risk stratification and promoting the management of these patients.

Utility of the Pleth Variability Index in predicting anesthesia-induced hypotension in geriatric patients

Background/aim

Anesthesia-induced hypotension may have negative consequences in geriatric patients. Therefore, predicting hypotension remains an important topic for anesthesiologists. Pleth Variability Index (PVI) measurement provides information about the fluid status and vascular tonus of patients. In this study, the ability of the Pleth Variability Index to predict hypotension after general anesthesia induction was evaluated.

Materials and methods

PVI values ​​obtained from pulse oximetry were recorded, in addition to preoperative standard anesthesia monitoring. The correlation between the PVI value and mean arterial pressure (MAP), systolic arterial blood pressure (SAP) changes, and the power of PVI values ​​to predict the incidence of hypotension after anesthesia induction (>20% MAP decrease) was tested.

Results

Eighty patients over 65 years of age who were operated under general anesthesia were included in the study. Hypotension was observed in 20 patients (25%). PVI values were mild and positively correlated with MAP changes (r = 0.195 and P = 0.041). According to receiver operating characteristic (ROC) analysis, the incidence of hypotension increased in patients with PVI values above 15.45%. We also found the following diagnostic results for PVI value for predicting hypotension: P = 0.044 and area under the ROC curve of 0.651 ± 0.073 (95% confidence interval (CI): 0.507–0.794), 40% sensitivity, 80% specificity, a PPV of 40%, an NPV of 80%, a cut-off value of 15.45, a positive likelihood ratio of 2, a negative likelihood ratio of 0.75, and a Youden Index of 0.2.

Conclusion

Predicting hypotension in geriatric patients is an important issue for anesthesiologists. As an easily applicable test, the Pleth Variability Index is useful in predicting MAP reduction in patients. This practical technique can be used routinely in all geriatric patient groups.