Protective intraoperative ventilation with higher versus lower levels of positive end-expiratory pressure in obese patients (PROBESE): study protocol for a randomized controlled trial

BACKGROUND

Postoperative pulmonary complications (PPCs) increase the morbidity and mortality of surgery in obese patients. High levels of positive end-expiratory pressure (PEEP) with lung recruitment maneuvers may improve intraoperative respiratory function, but they can also compromise hemodynamics, and the effects on PPCs are uncertain. We hypothesized that intraoperative mechanical ventilation using high PEEP with periodic recruitment maneuvers, as compared with low PEEP without recruitment maneuvers, prevents PPCs in obese patients.

METHODS/DESIGN

The PRotective Ventilation with Higher versus Lower PEEP during General Anesthesia for Surgery in OBESE Patients (PROBESE) study is a multicenter, two-arm, international randomized controlled trial. In total, 2013 obese patients with body mass index ≥35 kg/m² scheduled for at least 2 h of surgery under general anesthesia and at intermediate to high risk for PPCs will be included. Patients are ventilated intraoperatively with a low tidal volume of 7 ml/kg (predicted body weight) and randomly assigned to PEEP of 12 cmH₂O with lung recruitment maneuvers (high PEEP) or PEEP of 4 cmH₂O without recruitment maneuvers (low PEEP). The occurrence of PPCs will be recorded as collapsed composite of single adverse pulmonary events and represents the primary endpoint.

DISCUSSION

To our knowledge, the PROBESE trial is the first multicenter, international randomized controlled trial to compare the effects of two different levels of intraoperative PEEP during protective low tidal volume ventilation on PPCs in obese patients. The results of the PROBESE trial will support anesthesiologists in their decision to choose a certain PEEP level during general anesthesia for surgery in obese patients in an attempt to prevent PPCs.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02148692. Registered on 23 May 2014; last updated 7 June 2016.

Risk factors of postoperative pulmonary complications in patients with asthma and COPD

Background

Postoperative pulmonary complications (PPC) in patients with pulmonary diseases remain to be resolved clinical issue. However, most evidence regarding PPC has been established more than 10 years ago. Therefore, it is necessary to evaluate perioperative management using new inhalant drugs in patients with obstructive pulmonary diseases.

Methods

April 2014 through March 2015, 346 adult patients with pulmonary diseases (257 asthma, 89 chronic obstructive pulmonary disease (COPD)) underwent non-pulmonary surgery except cataract surgery in our university hospital. To analyze the risk factors for PPC, we retrospectively evaluated physiological backgrounds, surgical factors and perioperative specific treatment for asthma and COPD.

Results

Finally, 29 patients with pulmonary diseases (22 asthma, 7 COPD) had PPC. In patients with asthma, smoking index (≥ 20 pack-years), peripheral blood eosinophil count (≥ 200/mm³) and severity (Global INitiative for Asthma(GINA) STEP ≥ 3) were significantly associated with PPC in the multivariate logistic regression analysis [odds ratio (95% confidence interval) = 5.4(1.4–20.8), 0.31 (0.11–0.84) and 3.2 (1.04–9.9), respectively]. In patients with COPD, age, introducing treatment for COPD, upper abdominal surgery and operation time (≥ 5 h) were significantly associated with PPC [1.18 (1.00–1.40), 0.09 (0.01–0.81), 21.2 (1.3–349) and 9.5 (1.2–77.4), respectively].

Conclusions

History of smoking or severe asthma is a risk factor of PPC in patients with asthma, and age, upper abdominal surgery, or long operation time is a risk factor of PPC in patients with COPD. Adequate inhaled corticosteroids treatment in patients with eosinophilic asthma and introducing treatment for COPD in patients with COPD could reduce PPCs.

Associations of dynamic driving pressure and mechanical power with postoperative pulmonary complications-posthoc analysis of two randomised clinical trials in open abdominal surgery

BACKGROUND

While an association of the intraoperative driving pressure with postoperative pulmonary complications has been described before, it is uncertain whether the intraoperative mechanical power is associated with postoperative pulmonary complications.

METHODS

Posthoc analysis of two international, multicentre randomised clinical trials (ISRCTN70332574 and NCT02148692) conducted between 2011-2013 and 2014-2018, in patients undergoing open abdominal surgery comparing the effect of two different positive end-expiratory pressure (PEEP) levels on postoperative pulmonary complications. Time-weighted average dynamic driving pressure and mechanical power were calculated for individual patients. A multivariable logistic regression model adjusted for confounders was used to assess the independent associations of driving pressure and mechanical power with the occurrence of a composite of postoperative pulmonary complications, the primary endpoint of this posthoc analysis.

FINDINGS

In 1191 patients included, postoperative pulmonary complications occurrence was 35.9%. Median time-weighted average driving pressure and mechanical power were 14·0 [11·0-17·0] cmH₂O, and 7·6 [5·1-10·0] J/min, respectively. While driving pressure was not independently associated with postoperative pulmonary complications (odds ratio, 1·06 [95% CI 0·88-1·28]; p=0.534), the mechanical power had an independent association with the occurrence of postoperative pulmonary complications (odds ratio, 1·28 [95% CI 1·05-1·57]; p=0.016). These findings were independent of body mass index or the level of PEEP used, i.e., independent of the randomisation arm.

INTERPRETATION

In this merged cohort of surgery patients, higher intraoperative mechanical power was independently associated with postoperative pulmonary complications. Mechanical power could serve as a summary ventilatory biomarker for the risk for postoperative pulmonary complications in these patients, but our findings need confirmation in other, preferably prospective studies.

FUNDING

The two original studies were supported by unrestricted grants from the European Society of Anaesthesiology and the Amsterdam University Medical Centers, Location AMC. For this current analysis, no additional funding was requested. The funding sources had neither a role in the design, collection of data, statistical analysis, interpretation of data, writing of the report, nor in the decision to submit the paper for publication.

ICEAGE (Incidence of Complications following Emergency Abdominal surgery: Get Exercising): study protocol of a pragmatic, multicentre, randomised controlled trial testing physiotherapy for the prevention of complications and improved physical recovery after emergency abdominal surgery

Background

Postoperative complications and delayed physical recovery are significant problems following emergency abdominal surgery. Physiotherapy aims to aid recovery and prevent complications in the acute phase after surgery and is commonplace in most first-world hospitals. Despite ubiquitous service provision, no well-designed, adequately powered, parallel-group, randomised controlled trial has investigated the effect of physiotherapy on the incidence of respiratory complications, paralytic ileus, rate of physical recovery, ongoing need for formal sub-acute rehabilitation, hospital length of stay, health-related quality of life, and mortality following emergency abdominal surgery. We hypothesise that an enhanced physiotherapy care package of additional education, breathing exercises, and early rehabilitation prevents postoperative complications and improves physical recovery following emergency abdominal surgery compared to standard care alone.

Methods

The Incidence of Complications following Emergency Abdominal surgery: Get Exercising (ICEAGE) trial is a pragmatic, investigator-initiated, multicentre, patient- and assessor-blinded, parallel-group, active-placebo controlled randomised trial, powered for superiority. ICEAGE will compare standard care physiotherapy to an enhanced physiotherapy care package in 288 participants admitted for emergency abdominal surgery at three Australian hospitals. Participants will be randomised using concealed allocation to receive either standard care physiotherapy (education, single session of coached breathing exercises, and daily early ambulation for 15 min) or an enhanced physiotherapy care package (education, twice daily coached breathing exercises for a minimum 2 days, and 30 min of daily supervised early rehabilitation for minimum five postoperative days). The primary outcome is a respiratory complication within the first 14 postoperative hospital days assessed daily with standardised diagnostic criteria. Secondary outcomes include referral for sub-acute rehabilitation services, discharge destination, paralytic ileus, hospital length of stay and costs, intensive care unit utilisation, 90-day patient-reported complications and health-related quality of life and physical capacity, and mortality at 30 days and at 1 year following surgery.

Discussion

The morbidity, mortality, and fiscal burdens following emergency abdominal surgery are some of the worst within surgery. Physiotherapy may be an effective, low-cost, minimal harm intervention to improve outcomes and reduce hospital utilisation following this surgery type. ICEAGE will test the benefits of this commonly provided intervention within a methodologically robust, multicentre, double-blinded, active-placebo controlled randomised trial.

Trial registration

ACTRN 12615000318583. Registered 8 April 2015

Electronic supplementary material

The online version of this article (10.1186/s13017-018-0189-y) contains supplementary material, which is available to authorized users.

Optimizing Prophylactic CPAP in Patients Without Obstructive Sleep Apnoea for High-Risk Abdominal Surgeries: A Meta-regression Analysis

INTRODUCTION

Prophylactic continuous positive airway pressure (CPAP) can prevent pulmonary adverse events following upper abdominal surgeries. The present meta-regression evaluates and quantifies the effect of degree/duration of (CPAP) on the incidence of postoperative pulmonary events.

METHODS

Medical databases were searched for randomized controlled trials involving adult patients, comparing the outcome in those receiving prophylactic postoperative CPAP versus no CPAP, undergoing high-risk abdominal surgeries. Our meta-analysis evaluated the relationship between the postoperative pulmonary complications and the use of CPAP. Furthermore, meta-regression was used to quantify the effect of cumulative duration and degree of CPAP on the measured outcomes.

RESULTS

Seventy-three potentially relevant studies were identified, of which 11 had appropriate data, allowing us to compare a total of 362 and 363 patients in CPAP and control groups, respectively. Qualitatively, Odds ratio for CPAP showed protective effect for pneumonia [0.39 (0.19-0.78)], atelectasis [0.51 (0.32-0.80)] and pulmonary complications [0.37 (0.24-0.56)] with zero heterogeneity. For prevention of pulmonary complications, odds ratio was better for continuous than intermittent CPAP. Meta-regression demonstrated a positive correlation between the degree of CPAP and the incidence of pneumonia with a regression coefficient of +0.61 (95 % CI 0.02-1.21, P = 0.048, τ (2) = 0.078, r (2) = 7.87 %). Overall, adverse effects were similar with or without the use of CPAP.

CONCLUSIONS

Prophylactic postoperative use of continuous CPAP significantly reduces the incidence of postoperative pneumonia, atelectasis and pulmonary complications in patients undergoing high-risk abdominal surgeries. Quantitatively, increasing the CPAP levels does not necessarily enhance the protective effect against pneumonia. Instead, protective effect diminishes with increasing degree of CPAP.

Risk Factors Analysis of Postoperative Pleural Effusion after Liver Resection

BACKGROUND

Pulmonary complications remain relatively high in morbidities that arise after liver surgery and are associated with increased length of hospital stay and higher cost. Identification of possible risk factors in this retrospective analysis may help reduce operative morbidity and achieve better outcomes.

METHODS

In all, 363 consecutive patients underwent elective hepatectomies between July 2008 and November 2013 and these were identified and analyzed retrospectively. Patient demographics and perioperative variables were collected. The main outcome was an analysis of risk factors associated with postoperative pleural effusion (PPE).

RESULTS

Of 363 patients receiving hepatectomies, 80 patients (22.0%) developed pulmonary complications. The predominant pulmonary complication in this series is pleural effusion (76 patients, 95%). Univariate analysis found that older age, higher body mass index (BMI), chronic obstructive lung disease, asthma, heart disease, hepatitis C infection, heavy smoking, American Society of Anesthesiology class III and IV, hepatectomy site, combined surgeries, perioperative blood transfusion, and cirrhosis of liver were associated with PPE. Only older age, higher BMI, asthma, heavy smoker, combined gastrointestinal surgeries, and perioperative blood transfusion were identified as independent risk factors in multivariate analysis.

CONCLUSION

This study identifies 6 risk factors for PPE. Identification and management of some of these factors could possibly reduce morbidity and improve short-term surgical outcomes.

Predictive Value of Interstitial Lung Abnormalities for Postoperative Pulmonary Complications in Elderly Patients with Early-stage Lung Cancer

Purpose

Identifying pretreatment interstitial lung abnormalities (ILAs) is important because of their predictive value for complications after lung cancer treatment. This study aimed to assess the predictive value of ILAs for postoperative pulmonary complications (PPCs) in elderly patients undergoing curative resection for early-stage non-small cell lung cancer (NSCLC).

Materials and Methods

Elderly patients (age ≥ 70 years) who underwent curative resection for pathologic stage I or II NSCLC with normal preoperative spirometry results (pre-bronchodilator forced expiratory volume in 1 s to forced vital capacity [FVC] ratio > 0.70 and FVC ≥ 80% of the predicted value) between January 2012 and December 2019 were retrospectively identified. Univariable and multivariable regression analyses were performed to assess risk factors for PPCs. The Kaplan-Meier method and log-rank test were used to analyze the relationship between ILAs and postoperative mortality. One-way analysis of variance was performed to assess the correlation between ILAs and hospital stay duration.

Results

A total of 262 patients (median age, 73 [interquartile range, 71-76] years; 132 male) were evaluated. A multivariable logistic regression model revealed that, among several relevant risk factors, fibrotic ILAs independently predicted both overall PPCs (adjusted odds ratio [OR], 4.84; 95% confidence interval [CI], 1.35-17.38; p=0.016) and major PPCs (adjusted OR, 8.72; 95% CI, 1.71-44.38; p=0.009). Fibrotic ILAs were significantly associated with higher postoperative mortality and longer hospital stay (F=5.21, p=0.006).

Conclusion

Pretreatment fibrotic ILAs are associated with PPCs, higher postoperative mortality, and longer hospital stay.

Effect of goal-directed fluid therapy based on plasma colloid osmotic pressure on the postoperative pulmonary complications of older patients undergoing major abdominal surgery

BACKGROUND

As an important component of accelerated rehabilitation surgery, goal-directed fluid therapy (GDT) is one of the optimized fluid therapy strategies and is closely related to perioperative complications and mortality. This article aimed to study the effect of combining plasma colloid osmotic pressure (COP) with stroke volume variation (SVV) as a target for intraoperative GDT for postoperative pulmonary complications in older patients undergoing major abdominal surgery.

METHODS

In this study, older patients (n = 100) undergoing radical resection of gastroenteric tumors were randomized to three groups: Group C (n1 = 31) received a conventional infusion regimen, Group S1 (n2 = 34) received GDT based on SVV, and Group S2 (n3 = 35) received GDT based on SVV and COP. The results were recorded, including the lung injury score (LIS); PaO₂/FiO₂ ratio; lactic acid value at the times of beginning (T0) and 1 h (T1), 2 h (T2), and 3 h (T3) after liquid infusion in the operation room; the total liquid infusion volume; infusion volumes of crystalline and colloidal liquids; urine production rate; pulmonary complications 7 days after surgery; and the severity grading of postoperative pulmonary complications.

RESULTS

The patients in the S2 group had fewer postoperative pulmonary complications than those in the C group (P < 0.05) and the proportion of pulmonary complications of grade 1 and higher than grade 2 in S2 group was significantly lower than that in C group (P <0.05); the patients in the S2 group had a higher PaO₂/FiO₂ ratio than those in the C group (P < 0.05), lower LIS than those in the S1 and C groups (P < 0.05), less total liquid infusion than those in the C group (P < 0.05), and more colloidal fluid infusion than those in the S1 and C groups (P < 0.05).

CONCLUSION

The findings of our study show that intraoperative GDT based on COP and SVV can reduce the incidence of pulmonary complications and conducive to shortening the hospital stay in older patients after gastrointestinal surgery.

TRIAL REGISTRATION

Chinese Clinical Trial. no. ChiCTR2100045671. Registry at www.chictr.org.cn on April 20, 2021.

Role of Lung Ultrasound in the Detection of Postoperative Pulmonary Complications in Pediatric Patients: A Prospective Observational Study

OBJECTIVE

To evaluate the incremental benefit of lung ultrasound (LUS) over clinical examination and chest x-rays (CXR) together (clinico-radiologic examination) for the diagnosis of postoperative pulmonary complications (PPC).

DESIGN

Prospective observational study.

SETTING

Tertiary care center.

PARTICIPANTS

One hundred children after corrective congenital cardiac surgery with left-to-right shunts.

INTERVENTION

Participants were independently evaluated with clinico-radiologic examination by the treating team, as well as LUS by an investigator at 12, 24, 48, and 72 hours after surgery. After recording the diagnoses, the LUS findings were disclosed to the treating team and a final diagnosis was made. CXR scores and LUS scores were evaluated for their ability to predict PPC.

MEASUREMENTS AND MAIN RESULTS

A total of 34 cases of PPCs were observed. Of these, 32 each were detected by clinico-radiologic examination and LUS alone. Addition of LUS improved total number of PPCs detected in the early postoperative period but not in the late postoperative period. Preoperative and early postoperative LUS scores were superior to CXR scores in predicting occurrence of PPC (area under receiver operating characteristics curve [AUROC] 0.920 v 0.732; p < 0.001 preoperatively; AUROC 0.987 v 0.858, p = 0.001 at 12 hours postoperatively). Multivariate analysis suggested LUS score as an independent predictor of PPC, and LUS score along with aortic cross-clamp time as independent predictors of duration of mechanical ventilation and intensive care unit stay.

CONCLUSIONS

LUS improves identification of PPC over clinico-radiologic examination in the early postoperative period. Preoperative LUS scores have better predictive ability than CXR scores for the occurrence of PPC.

Difficult intubation and postoperative aspiration pneumonia associated with Moebius syndrome: a case report

Background

Moebius syndrome is a rare congenital disorder characterized by non-progressive palsy of the abducens (VI) and facial (VII) cranial nerves. Its common features include dysfunctions associated with other cranial nerves, orofacial abnormalities, skeletal muscle hypotonia, and other systemic disorders of differing severities. There are several concerns in the perioperative management of patients with Moebius syndrome.

Case presentation

We present a report on the management of general anesthesia of a 14-year-old male patient with Moebius syndrome who was scheduled for mandibular cystectomy. The patient was diagnosed with Moebius syndrome at the age of 7 years based on his clinical manifestations of nerve palsy since birth and cranial nerve palsy of the trigeminal (V), facial (VII), glossopharyngeal (IX), vagus (X), and sublingual nerves (XII). The patient’s oral morphological abnormalities made intubation difficult. He also experienced dysphagia and aspiration pneumonia on a daily basis. Oral secretions were frequently suctioned postoperatively. However, after discharge, the patient developed aspiration pneumonia and was readmitted to the hospital.

Conclusions

The main problem arising when administering general anesthesia to patients with this syndrome is difficult airway management. The oral abnormalities in these patients, such as small jaw and extreme dental stenosis, make mask ventilation and intubation difficult. Furthermore, this syndrome often involves respiratory impairment and dysphagia due to cerebral nerve palsy, so there is a high risk of postoperative respiratory complications. Since multiple organs are affected in patients with Moebius syndrome, appropriate perioperative management strategies must be prepared for these patients.

Risk factors of postoperative pulmonary complications after primary posterior fusion and hemivertebra resection in congenital scoliosis patients younger than 10 years old: a retrospective study

Background

Postoperative pulmonary complications are common and associated with morbidity and mortality. Congenital scoliosis is a failure of vertebral formation and/or segmentation arising from abnormal vertebral development. Posterior fusion and osteotomy are necessary for these patients to prevent deterioration of spine deformity. The incidence of postoperative pulmonary complications in this specific group of patients, especially young children were unknown.

Methods

A retrospective study was conducted and electronic medical records of early-onset scoliosis patients who had primary posterior fusion and hemivertebra resection at our institution from January 2014 to September 2019 were reviewed. The demographic characteristics, the intraoperative and postoperative parameters were collected to identify the predictors of postoperative pulmonary complications.

Results

A total of 174 patients (57.5% boys) with a median age of 3 years old were included for analysis. Eighteen patients (10.3%) developed perioperative pulmonary complications and pneumonia (n=13) was the most common. History of recent upper respiratory infection was not related to postoperative pulmonary complications. Multifactorial regression analysis showed thoracoplasty was the only predictive risk factor of postoperative pulmonary complications.

Conclusions

For congenital scoliosis patients younger than 10 years old, thoracoplasty determine the occurrence of postoperative pulmonary complications. Both surgeons and anesthesiologists should pay attention to patients undergoing thoracoplasty and preventive measures are necessary.

The Optimal Time of High-Intensity Pre-rehabilitation for Surgical Lung Cancer Patients: A Retrospective Cohort Study with 4452 Patients

BACKGROUND

The aim of this study was to investigate the influence of the time of pre-rehabilitation (PR) combined with respiratory training and aerobic exercise on surgical patients with lung cancer.

PATIENTS AND METHODS

A retrospective study from a 5-year database of a single center, including patients with lung cancer who underwent surgery between 1 January 2016 and 31 December 2020, was conducted. The patients were divided into the PR group, in which they received the PR regimen, and the non-PR group, in which they received routine care.

RESULTS

A total of 4452 patients were retrospectively included, 684 of whom received PR regimen. A lower postoperative pulmonary complication (PPC) rate was observed in PR group than in non-PR group before or after propensity score matching (PSM) (before: 12.6% vs 18.5%, P < 0.001; after: 12.6% vs 18.7%, P < 0.001). For the PR group, a restricted cubic spline model revealed a significant nonlinear dose‒response association between PR time and the occurrence of PPCs (P for nonlinearity = 0.002). The PR time associated with the lowest occurrence of PPCs was 7 days, and the odds ratio (OR) of PPCs decreased steeply, with an OR of 0.8 [95% confidence interval (CI) 0.66-0.97] per day until 7 days, and then remained stable with a slight increase afterward with an OR of 1.11 (95% CI 0.99-1.25) per day.

CONCLUSION

The study validated the effectiveness of a pre-rehabilitation regimen for decreasing the occurrence of PPCs. A U-shaped nonlinear relationship was found between pre-rehabilitation time and the PPC rate, indicating that both excessive and insufficient pre-rehabilitation time may increase the incidence of PPCs. Registry Number: ChiCTR1800020097.

Risk factors and predictive model for pulmonary complications in patients transferred to ICU after hepatectomy

OBJECTIVE

Postoperative pulmonary complications (PPCs) seriously harm the recovery and prognosis of patients undergoing surgery. However, its related risk factors in critical patients after hepatectomy have been rarely reported. This study aimed at analyzing the factors related to PPCs in critical adult patients after hepatectomy and create a nomogram for prediction of the PPCs.

METHODS

503 patients' data were collected form the Peking University People's Hospital. Multivariate logistic regression analysis was used to identify independent risk factors to derive the nomogram. Nomogram's discriminatory ability was assessed using the area under the receiver operating characteristic curve (AUC), and calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test and calibration curve.

RESULTS

The independent risk factor for PPCs are advanced age (odds ratio [OR] = 1.026; P = 0.008), higher body mass index (OR = 1.139; P < 0.001), lower preoperative serum albumin level (OR = 0.961; P = 0.037), and intensive care unit first day infusion volume (OR = 1.152; P = 0.040). And based on this, we created a nomogram to predict the occurrence of PPCs. Upon assessing the nomogram's predictive ability, the AUC for the model was 0.713( 95% CI: 0.668-0.758, P<0.001). The Hosmer-Lemeshow test (P = 0.590) and calibration curve showed good calibration for the prediction of PPCs.

CONCLUSIONS

The prevalence and mortality of postoperative pulmonary complications in critical adult patients after hepatectomy are high. Advanced age, higher body mass index, lower preoperative serum albumin and intensive care unit first day infusion volume were found to be significantly associated with PPCs. And we created a nomogram model which can be used to predict the occurrence of PPCs.

Comparison of Postoperative Pulmonary Complication Indices in Elective Abdominal Surgery Patients

BACKGROUND

Postoperative pulmonary complications (PPC) are important problems that prolong hospital stays by increasing morbidity and mortality of patients. Early identification of risky cases through preoperative evaluation is important for reducing the complications that may be seen in patients postoperatively. The aim of this study is to calculate, evaluate and compare the risk indices for PPC in patients who will undergo elective abdominal surgery.

MATERIALS AND METHODS

One hundred twenty-four patients who were hospitalized for elective abdominal surgery were included in this prospective observational study. American Society of Anesthesiologists (ASA), Epstein and Shapiro scores, respiratory failure index (RFI), pneumonia risk indexes (PI) and scores were calculated preoperatively. Patients were re-evaluated at the 48th postoperative hour, and one-week follow-up was performed. The patients with PPCs are recorded.

RESULTS

The mean PPC rate was 36.8%. Based on this, pleural effusion was observed in 18.5%, prolonged mechanical ventilation in 8.9%, atelectasis in 9.7%, and respiratory failure in 5.7%, bronchospasm in 4.0%, and pneumonia in 3.2% of patients. An increased risk in PPC was determined if ASA were above 3 (odds ratio, [OR], 7.06; <0.001), PI scores were above 3 (OR, 6.67; <0.001), RFI score were above 4 (OR, 6.30, p:0.001) and Shapiro score above 2 (OR, 20.01; <0.001), respectively.

CONCLUSION

The Shapiro index is the strongest predictor of pulmonary complications, whereas the PI is the strongest predictor of morbidity risk. However, RFI and the PI are equally valuable for predicting respiratory complications and may prove to be useful in abdominal surgeries for preoperative assessment.

Neutrophil extracellular traps predict postoperative pulmonary complications in paediatric patients undergoing parental liver transplantation

BACKGROUND

Parental liver transplantation (PLT) improves long-term survival rates in paediatric hepatic failure patients; however, the mechanism of PLT-induced postoperative pulmonary complications (PPCs) is unclear.

METHODS

A total of 133 paediatric patients undergoing PLT were included. Serum levels of NET components, including circulating free DNA (cfDNA), DNA-histone complex, and myeloperoxidase (MPO)-DNA complex, were detected. The occurrence of PPCs post-PLT, prolonged intensive care unit (ICU) stay and death within one year were recorded as the primary and secondary outcomes.

RESULTS

The overall rate of PPCs in the hospital was 47.4%. High levels of serum cfDNA, DNA-histone complexes and MPO-DNA complexes were associated with an increased risk of PPCs (for cfDNA, OR 2.24; for DNA-histone complex, OR 1.64; and for MPO-DNA, OR 1.94), prolonged ICU stay (OR 1.98, 4.26 and 3.69, respectively), and death within one year (OR 1.53, 2.65 and 1.85, respectively). The area under the curve of NET components for the prediction of PPCs was 0.843 for cfDNA, 0.813 for DNA-histone complexes, and 0.906 for MPO-DNA complexes. During the one-year follow-up, the death rate was higher in patients with PPCs than in patients without PPCs (14.3% vs. 2.9%, P = 0.001).

CONCLUSIONS

High serum levels of NET components are associated with an increased incidence of PPCs and death within one year in paediatric patients undergoing PLT. Serum levels of NET components serve as a biomarker for post-PLT PPCs and a prognostic indicator.

Association of preoperative spirometry with postoperative pulmonary complications and prolonged length of hospital stay following coronary artery graft surgery

PURPOSE

Ventilatory function measured by spirometry is commonly performed preoperatively in people undergoing coronary artery graft surgery (CAGS). Minimal information exists on the associations between spirometry parameters, postoperative pulmonary complications (PPC), and prolonged (≥7 days) length of hospital stay (LOHS) following cardiac surgery. This study aims to investigate the relationships between preoperative spirometry values with both PPC and prolonged LOHS in patients undergoing CAGS, and to compare the predictive value of preoperative spirometry against other known PPC risk factors.

METHODS

This retrospective observational cohort study analysed patients undergoing preoperative spirometry and CAGS at Royal Prince Alfred Hospital between January 2017 and December 2021. Forced expiratory volume in the first one second (FEV1) and forced vital capacity (FVC) were measured. For each patient, both were converted to percentage of predicted value for a healthy person with matched characteristics termed FEV1%pred and FVC%pred respectively. The association between FEV1%pred and FVC%pred against the incidence of PPC and prolonged LOHS was determined using multivariate logistic regression analysis.

RESULTS

956 patients [773 male, mean (SD): age 65 (10) years; BMI 29 (6)] were analysed. Lower FEV1%pred was associated with PPC (odds ratio: 0.99; 95% CI: 0.98 to 0.99, P = 0.009) and prolonged LOHS (odds ratio: 0.99; 95% CI: 0.98 to 0.99, P = 0.003). FVC%pred was not associated with PPC or prolonged LOHS in multivariate analyses.

CONCLUSIONS

Preoperative spirometry could be valuable in predicting risk of PPC and prolonged LOHS in people undergoing CAGS and therefore could be useful in identifying at risk patients preoperatively. CONTRIBUTION OF THE PAPER.

Postoperative esketamine improves ventilation after video-assisted thoracoscopic lung resection: A double-blinded randomized controlled trial

Background

Pain management after lung resection plays a crucial role in reducing postoperative pulmonary complications (PPCs). This study aimed to examine the effect of postoperative esketamine infusion as an adjunct to opioid analgesia on ventilation and pulmonary complications in patients underwent lung resection.

Methods

Patients undergoing video-assisted thoracoscopic lung resection were randomly assigned to either the esketamine group or the control group. The esketamine group received a 24-h infusion of 1.5 mcg/ml sufentanil combined with 0.75 mcg/ml esketamine after surgery, while the control group received 1.5 mcg/ml sufentanil alone. The primary outcome measure was low minute ventilation, and the secondary outcome measures were hypoxemia, PaO2/FiO2 levels, postoperative pulmonary complications, hospital stay duration, ambulation time, Visual Analogue Scale (VAS) score, depression and anxiety levels, sleep quality, and analgesia satisfaction.

Results

80 patients were randomly divided into two groups: the esketamine group (n = 40) and the control group (n = 40). The esketamine group exhibited notably reduced incidence of low minute ventilation (P = 0.014), lower occurrence of postoperative pulmonary complications (PPCs) compared to the control group (P = 0.039), and decreased incidence of hypoxemia (P = 0.003). Furthermore, the esketamine group showed improved outcomes with lower VAS scores on the second postoperative day and enhanced sleep quality (P < 0.001) after the surgery.

Conclusions

Postoperative esketamine infusion with opioids improved ventilation and reduced PPCs after lung resection, warranting further clinical studies.

Trial registration

This study was registered on ClinicalTrials.gov (Trial ID: NCT05458453, https://clinicaltrials.gov/ct2/show/NCT05458453).

The effectiveness of postoperative rehabilitation interventions that include breathing exercises to prevent pulmonary atelectasis in lung cancer resection patients: a systematic review and meta-analysis

BACKGROUND

The main aim of this systematic review was to determine the effectiveness of postoperative rehabilitation interventions that include breathing exercises as a component to prevent atelectasis in lung cancer resection patients.

METHODS

In this review, we systematically and comprehensively searched the Cochrane Library, PubMed, EMBASE, and Web of Science in English and CNKI and Wanfang in Chinese from 2012 to 2022. The review included any randomized controlled trials focusing on the effectiveness of postoperative rehabilitation interventions that include breathing exercises to prevent pulmonary atelectasis in lung cancer patients. Participants who underwent anatomic pulmonary resection and received postoperative rehabilitation interventions that included breathing exercises as a component were included in this review. The study quality and risks of bias were measured with the GRADE and Cochrane Collaboration tools, and statistical analysis was performed utilizing RevMan 5.3 software.

RESULTS

The incidence of atelectasis was significantly lower in the postoperative rehabilitation intervention group (OR = 0.35; 95% CI, 0.18 to 0.67; I2 = 0%; P = 0.67) than in the control group. The patients who underwent the postoperative rehabilitation program that included breathing exercises (intervention group) had higher forced vital capacity (FVC) scores (MD = 0.24; 95% CI, 0.07 to 0.41; I² = 73%; P = 0.02), forced expiratory volume in one second (FEV1) scores (MD = 0.31; 95% CI, 0.03 to 0.60; I² = 98%; P < 0.01) and FEV1/FVC ratios (MD = 9.09; 95% CI, 1.50 to 16.67; I² = 94%; P < 0.01).

CONCLUSION

Postoperative rehabilitation interventions that included breathing exercises decreased the incidence rate of atelectasis and improved lung function by increasing the FVC, FEV1, and FEV1/FVC ratio.

Mortality risk of patients with intestinal obstruction

BACKGROUND

Intestinal obstruction represents a severe intestinal disease associated with higher mortality rates. However, the determinants of mortality in patients with intestinal obstruction remain inadequately understood. This study sought to elucidate the potential risk factors associated with mortality in the context of intestinal obstruction during the COVID-19 pandemic.

METHODS

A retrospective analysis was performed on a cohort of 227 patients diagnosed with intestinal obstruction at the First Hospital of Hebei Medical University, spanning the period from September 7, 2022, to January 7, 2023. The primary endpoint of the study was mortality within four weeks following discharge. Univariate and multivariable logistic regression models were utilized to evaluate the risk factors associated with mortality outcomes.

RESULTS

A cohort of 227 patients diagnosed with intestinal obstruction (median age, 59.02 years [IQR, 48.95-70.85 years]) was included in our study. Malignant bowel obstruction (MBO) and COVID-19 were identified as independent risk factors for mortality among these patients. Notably, the mortality rate increased significantly to 38.46% when MBO was concomitant with COVID-19. Furthermore, postoperative pulmonary complications (PPC) (OR, 54.21 [death]; 95% CI, 3.17-926.31), gastric cancer (OR, 9.71 [death]; 95% CI, 1.38-68.18), VTE (Caprini Score ≥ 5) (OR, 7.64 [death]; 95% CI, 1.37-42.51), and COVID-19 (OR, 5.72 [death]; 95% CI, 1.01-32.29) were all determined to be independent risk factors for postoperative mortality. Additionally, gastric cancer could have emerged as one of the most severe risk factors for mortality in individuals with intestinal obstruction within the cohort of cancer patients, of which gastric cancer exhibited higher mortality rates compared to individuals with other forms of cancer.

CONCLUSION

The study identifies MBO, gastric cancer, COVID-19, PPC, and VTE as potential risk factors for mortality in cases of intestinal obstruction. These findings highlight the necessity for continuous monitoring of indicators related to these mortality risk factors and their associated complications, thereby offering valuable insights for the management and treatment of intestinal obstruction.