Preoperative Pulmonary Risk Assessment

Intersurgeon variations in postoperative length of stay after video-assisted thoracoscopic surgery lobectomy

Objectives

To identify factors associated with prolonged postoperative length of stay (LOS) after VATS lobectomy (VATS-L), explore potential intersurgeon variation in LOS and ascertain whether or not early discharge influences hospital readmission rates.

Methods

We conducted a retrospective analysis of patients who underwent VATS-L at a single academic center between 2018 and 2021. Each VATS lobectomy procedure was performed by 1 of 7 experienced thoracic surgeons. The primary end point of interest was prolonged LOS, defined as an index LOS >3 days.

Results

Among 1006 patients who underwent VATS lobectomy, 632 (63%) had a prolonged LOS. On multivariate analysis, the factors independently associated with prolonged LOS were: surgeon (P < .001), patient age (odds ratio [OR], 1.03; 95% CI, 1.02-1.06), operation time (OR, 1.01; 95% CI, 1.01-1.01), postoperative complication (OR, 3.60; 95% CI, 2.45-5.29), and prolonged air leak (OR, 8.95; 95% CI, 4.17-19.23). There was no significant association between LOS and gender, body mass index, coronary artery disease, prior atrial fibrillation, American Society of Anesthesiologists score >3, and prior ipsilateral thoracic surgery or sternotomy. There was no association between LOS ≤3 days and hospital readmission (20 [5.3%] vs 39 [5.9%]; OR, 0.88; 95% CI, 0.50-1.53).

Conclusions

An intersurgeon variation in postoperative LOS after VATS-L exists and is independent of patient baseline characteristics or perioperative complications. This variation seems to be more closely related to differences in postoperative management and discharge practices rather than to surgical quality. Postoperative discharge within 3 days is safe and does not increase hospital readmissions.

Risk Factors for Postoperative Cognitive Decline After Orthopedic Surgery in Elderly Chinese Patients: A Retrospective Cohort Study

Purpose

We aimed to identify the risk factors for postoperative cognitive decline (POCD) by evaluating the outcomes from preoperative comprehensive geriatric assessment (CGA) and intraoperative anesthetic interventions.

Patients and Methods

Data used in the study were obtained from the Aged Patient Perioperative Longitudinal Evaluation-Multidisciplinary Trial (APPLE-MDT) cohort recruited from the Department of Orthopedics in Xuanwu Hospital, Capital Medical University between March, 2019 and June, 2022. All patients accepted preoperative CGA by the multidisciplinary team using 13 common scales across 15 domains reflecting the multi-organ functions. The variables included demographic data, scales in CGA, comorbidities, laboratory tests and intraoperative anesthetic data. Cognitive function was assessed by Montreal Cognitive Assessment scale within 48 hours after admission and after surgery. Dropping of ≥1 point between the preoperative and postoperative scale was defined as POCD.

Results

We enrolled 119 patients. The median age was 80.00 years [IQR, 77.00, 82.00] and 68 patients (57.1%) were female. Forty-two patients (35.3%) developed POCD. Three cognitive domains including calculation (P = 0.046), recall (P = 0.047) and attention (P = 0.007) were significantly worsened after surgery. Univariate analysis showed that disability of instrumental activity of daily living, incidence rate of postoperative respiratory failure (PRF) ≥4.2%, STOP-Bang scale score, Caprini risk scale score and Sufentanil for maintenance of anesthesia were different between the POCD and non-POCD patients. In the multivariable logistic regression analysis, PRF ≥ 4.2% (odds ratio [OR] = 2.343; 95% confidence interval [CI]: 1.028-5.551; P = 0.046) and Sufentanil for maintenance of anesthesia (OR = 0.260; 95% CI: 0.057-0.859; P = 0.044) was independently associated with POCD as risk and protective factors, respectively.

Conclusion

Our study suggests that POCD is frequent among older patients undergoing elective orthopedic surgery, in which decline of calculation, recall and attention was predominant. Preoperative comprehensive geriatric assessments are important to identify the high-risk individuals of POCD.

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).

Risk factors for postoperative pulmonary complications in neonates: a retrospective cohort study

Objective

Postoperative pulmonary complications (PPCs) are an important quality indicator and are associated with significantly increased mortality in infants. The objective of this study was to identify risk factors for PPCs in neonates undergoing non-cardiothoracic surgery.

Methods

In this retrospective study, all neonates who underwent non-cardiothoracic surgery in a children's hospital from October 2020 to September 2022 were included for analysis. Demographic data and perioperative variables were obtained. The primary outcome was the occurrence of PPCs. Univariate analysis and multivariable logistic regression analysis were used to investigate the effect of patient-related factors on the occurrence of PPCs.

Results

Totally, 867 neonatal surgery patients met the inclusion criteria in this study, among which 35.3% (306/867) patients experienced pulmonary complications within 1 week postoperatively. The PPCs observed in this study were 51 exacerbations of pre-existing pneumonia, 198 new patchy shadows, 123 new pulmonary atelectasis, 10 new pneumothorax, and 6 new pleural effusion. Patients were divided into two groups: PPCs (n=306) and non-PPCs (n=561). The multivariate stepwise logistic regression analysis revealed five independent risk factors for PPCs: corrected gestational age (OR=0.938; 95% CI 0.890 to 0.988), preoperative pneumonia (OR=2.139; 95% CI 1.033 to 4.426), length of surgery (> 60 min) (OR=1.699; 95% CI 1.134 to 2.548), preoperative mechanical ventilation (OR=1.857; 95% CI 1.169 to 2.951), and intraoperative albumin infusion (OR=1.456; 95% CI 1.041 to 2.036) in neonates undergoing non-cardiothoracic surgery.

Conclusion

Identifying risk factors for neonatal PPCs will allow for the identification of patients who are at higher risk and intervention for any modifiable risk factors identified.

Preoperative moderate to severe anemia is associated with increased postoperative major adverse cardiac and cerebral events and pulmonary complications: a propensity score-matched analysis in hip fracture surgery patients over 80 years old

BACKGROUND

Anemia is a common health problem in the elderly. Preoperative anemia is a risk factor for postoperative outcomes in the elderly for hip fracture. The objective of the study was to explore the relationship between preoperative moderate to severe anemia and postoperative morbidity and mortality in hip fracture patients over 80 years old.

METHODS

We performed a retrospective cohort study exploring preoperative moderate to severe anemia and postoperative morbidity and mortality. Patients over 80 years old undergoing hip fracture surgery were included in the study. Data were collected for major adverse cardiac and cerebral events (MACCE), postoperative pulmonary complications (PPCs), in-hospital mortality, delirium, gastrointestinal complication, deep venous thrombus (DVT), acute renal failure, ICU admission, and perioperative transfusion > 2 units rate.

RESULTS

A total of 912 eligible patients were included for unmatched cohort analysis, and 512 patients were included for matched cohort analysis after propensity score matching. Baseline characteristics between the normal to mild anemia and moderate to severe anemia groups were significantly different. More patients in the moderate to severe cohort had a higher ASA classification grade III and female ratio. Patients in the moderate and severe anemia cohorts had more MACCE (unadjusted: odds ratio [OR] 1.968, 96% CI 1.090-3.555, P 0.023; adjusted: OR 1.929, 95% CI 1.014-3.668, P 0.045) and PPCs (unadjusted: OR 2.616, 95% CI 1.442-4.748, P 0.001; adjusted: OR 2.352, 95% CI 1.225-4.516, P 0.010) than patients with normal or mild anemia. However, the transfusion > 2 units rate was not significantly different between the two cohorts (unadjusted: OR 0.967, 95% CI 0.737-1.270, P 0.811; adjusted: OR 0.941, 95% CI 0.693-1.278, P 0.697). The in-hospital mortality, delirium rate, gastrointestinal complication, ICU admission, and DVT were similar. However, the in-hospital mortality was much higher (3.6%, 21/591 vs 1.6%, 5/321) in the moderate to severe anemia cohort. Furthermore, after propensity score-matched analysis, MACCE and PPCs were also significantly increased in the moderate to severe anemia cohort (OR 2.196 & 3.171, 95% CI 1.0794.470 & 1.563-6.436, P 0.027 & 0.001), which were in accordance with the unadjusted and adjusted results in the unmatched cohorts.

CONCLUSIONS

Moderate to severe preoperative anemia (< 11 g/dl) is associated with increased postoperative major adverse cardiac and cerebral events and pulmonary complications. Additionally, in-hospital mortality was not significant but was higher in the preoperative moderate to severe anemia cohort. Preoperative assessment and correction of hemoglobin level to above 11 g/dl might reduce MACCE, PPCs, and in-hospital mortality in hip fracture patients over 80 years old.

Effects of 30% vs. 60% inspired oxygen fraction during mechanical ventilation on postoperative atelectasis: a randomised controlled trial

BACKGROUND

There is the ongoing debate over the effect of inspired oxygen fraction (FiO2) during mechanical ventilation on postoperative atelectasis. We aimed to compare the effects of low (30%) and moderate (60%) FiO2 on postoperative atelectasis. The hypothesis of the study was that 30% FiO2 during mechanical ventilation could reduce postoperative atelectasis volume compared with 60% FiO2.

METHODS

We performed a randomized controlled trial with 120 patients. Subjects were randomly assigned to receive 30% or 60% FiO2 during mechanical ventilation in a 1:1 ratio. The primary outcome was the percentage of postoperative atelectasis volume in the total lung measured using chest CT within 30 min after extubation. The secondary outcomes included different aeration region volumes, incidence of clinically significant atelectasis, and oxygenation index.

RESULTS

In total, 113 subjects completed the trial, including 55 and 58 subjects in the 30% and 60% FiO2 groups, respectively. The percentage of the postoperative atelectasis volume in the 30% FiO2 group did not differ from that in the 60% FiO2 group. Furthermore, there was no significant difference in the atelectasis volume between the two groups after the missing data were imputed by multiple imputation. Additionally, there were no significant differences in the volumes of the over-aeration, normal-aeration, and poor-aeration regions between the groups. No significant differences in the incidence of clinically significant atelectasis or oxygenation index at the end of surgery were observed between the groups.

CONCLUSIONS

Compared with 60% FiO2, the use of 30% FiO2 during mechanical ventilation does not reduce the postoperative atelectasis volume.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ( http://www.chictr.org.cn ). Identifier: ChiCTR1900021635. Date: 2 March 2019. Principal invetigator: Weidong Gu.

A novel nephrectomy-specific respiratory failure index using the ACS-NSQIP dataset

PURPOSE

Post-operative pulmonary failure is a major complication of nephrectomy that may lead to severe morbidity and mortality. Hence, we aimed to derive a nephrectomy-specific post-operative respiratory failure index.

METHODS

Our cohort was derived from The American College of Surgeons-National Surgical Quality Improvement Program database between 2005 and 2019. The outcome of interest was post-operative respiratory failure (PRF) defined as any incidence of unplanned intubation post-operatively or requiring mechanical ventilation post-operatively for a period > 48 h. A multivariable logistic regression model was constructed, and model calibration and performance were assessed using a ROC analysis and the Hosmer-Lemeshow test. Finally, we derived the nephrectomy-specific respiratory failure (NSRF) index and compared it to Gupta's index.

RESULTS

Seventy-nine thousand five hundred and twenty-three patients underwent nephrectomy between the years 2005 and 2019 of which nine hundred and sixty-two patients developed PRF. The final NSRF model encompassed ten variables: age, smoking status, American society of anesthesiology class, abnormal creatinine (≥ 1.5 mg/dL), anemia (< 36%), functional health status, chronic obstructive pulmonary disease, surgical approach, emergency case, and obesity (≥ 40 kg/m²). The NSRF ROC analysis provided C-statistic = 0.78, calibration R² = 0.99, and proper goodness of fit. In comparison, the C-statistics of Gupta's index was found to be 0.71 (p value < 0.001).

CONCLUSION

The NSRF is a procedure tailored index for predicting post-operative respiratory failure. It is a valuable tool in the pre-operative evaluation setting that can help identify high-risk patients who will require additional respiratory evaluation and preparation for their surgery.

Individualized risk estimation for postoperative pulmonary complications after hepatectomy based on perioperative variables

BACKGROUND

At present, there is no perfect system to evaluate pulmonary complications of liver surgery using perioperative variables.

AIM

To design and verify a risk assessment system for predicting postoperative pulmonary complications (PPCs) after hepatectomy based on perioperative variables.

METHODS

A retrospective analysis was performed on 1633 patients who underwent liver surgery. The variables were screened using univariate and multivariate analyses, and graded scores were assigned to the selected variables. Logistic regression was used to develop the liver operation pulmonary complication scoring system (LOPCSS) for the prediction of PPCs. The LOPCSS was verified using the receiver operating characteristic curve.

RESULTS

According to the multivariate correlation analysis, the independent factors which influenced PPCs of liver surgery were age [≥ 65 years old/< 65 years old, odds ratio (OR) = 1.926, P = 0.011], medical diseases requiring drug treatment (yes/no, OR = 3.523, P < 0.001), number of liver segments to be removed (≥ 3/≤ 2, OR = 1.683, P = 0.002), operation duration (≥ 180 min/< 180 min, OR = 1.896, P = 0.004), and blood transfusion (yes/no, OR = 1.836, P = 0.003). The area under the curve (AUC) of the LOPCSS was 0.742. The cut-off value of the expected score for complications was 5. The incidence of complications in the group with ≤ 4 points was significantly lower than that in the group with ≥ 6 points (2.95% vs 33.40%, P < 0.001). Furthermore, in the validation dataset, the corresponding AUC of LOPCSS was 0.767.

CONCLUSION

As a novel and simplified assessment system, the LOPCSS can effectively predict PPCs of liver surgery through perioperative variables.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Defining the Time Benefit of Awake Versus General Anesthesia for Single-Level Lumbar Spine Surgery

BACKGROUND

Awake anesthesia with monitored anesthesia care (MAC) might confer time benefits compared with traditional general anesthesia (GA) in the setting of single-level lumbar spine surgery. Therefore, we sought to define the quantitative time difference spent in the operating room between the MAC and GA approaches for single-level lumbar spine surgery.

METHODS

A prospectively maintained database of the senior surgeon was reviewed for single-level lumbar spine surgeries from 2019 to 2020 performed with the patient under either GA or MAC. The patient demographics, clinical features, time in the operating room, and postoperative outcomes were all summarized and statistically compared.

RESULTS

A total of 53 patients satisfied all the selection criteria, with 25 (47%) in the GA group and 28 (53%) in the MAC group. Overall, most patients were men, with a median age of 60 years. The 2 groups were statistically comparable with respect to the demographics and preoperative anesthesia parameters. The time from room arrival to sedation start (median time, 26 vs. 38 minutes; P < 0.01), sedation time (median time, 55 vs. 87 minutes; P < 0.01), and time from sedation end to room exit (median time, 4 vs. 13 minutes; P < 0.01) were all significantly shorter for the MAC group. Additionally, the estimated blood loss was less in the MAC group (P < 0.01).

CONCLUSIONS

We found MAC to be a safe anesthesia option for use in single-level lumbar spine surgery, which led to statistically significant benefits regarding the time under sedation and time in the operating room compared with GA. Future studies are required to understand whether MAC will require other synergistic measures to generate observable change at a health systems level.