Incidence Of Postoperative Pulmonary Complications Research Articles

Nutritional assessment in esophageal fast-track surgery: comparisons of 4 objective malnutrition screening tools.

BackgroundThis cohort study aimed to compare the performance of the 2015 diagnostic criteria for malnutrition of the European Society of Clinical Nutrition and Metabolism (ESPEN), the Nutritional Risk Screening 2002 (NRS 2002), Malnutrition Universal Screening Tool (MUST), and Short-Form of Mini-Nutritional Assessment (MNA-SF) in detecting malnutrition risk and predicting postoperative complications and the failure of early oral feeding (EOF) programs in esophageal cancer patients.MethodsThe 4 tools were used to conduct malnutrition assessments before surgery. The patients were divided into the groups of severe malnutrition and mild/moderate malnutrition and the incidences of the endpoints were observed. Multivariable logistic regression and receiver operating characteristic (ROC) curve analyses were conducted.ResultsTwo hundred and nineteen consecutive esophageal cancer patients were included in the study. The prevalence rates of severe malnutrition as determined by the ESPEN 2015 criteria, MUST, NRS 2002, and MNA-SF were 24.7%, 29.7%, 23.7%, and 16.0%, respectively. The moderate/severe malnutrition risk screened by the MUST had a high sensitivity (100.0%) with malnutrition identified by the ESPEN 2015 criteria. In total, 42 (19.2%) patients experienced major complications, and the incidence rate of EOF failure was 7.3%. The severe malnutrition identified by the ESPEN 2015 criteria, MUST, and NRS 2002 were comparable in predicting the incidence of postoperative pulmonary complications, anastomotic leakage, readmission to intensive care units (ICUs), and EOF failure, but the ESPEN 2015 criteria was better in predicting postoperative overall complications, major complications, and delayed hospital discharge.ConclusionsThe ESPEN 2015 criteria specializes in identifying severe malnutrition and is better in predicting adverse surgical outcomes; however, the MUST and NRS 2002 are better superior in detecting early malnutrition and are also valuable in the perioperative management in esophageal surgery. It is recommended that the MUST be used as the malnutrition screening tool before the ESPEN 2015 criteria is applied.

Post-Operative Complications Following Emergency Laparotomy are Common and Associated with increased Late Mortality - A Retrospective Multi-Centre study

Emergency abdominal surgery, often termed emergency laparotomy, is a common surgical procedure undertaken in the United Kingdom (U.K), with approximately 30000 procedures annually. Patients presenting for emergency abdominal surgery are heterogeneous and present with diverse pathology, resulting in challenges for the surgical, anaesthetic and critical care team that manage them. Emergency laparotomy, by its very nature is high-risk surgery, with an estimated 30-day mortality in the U.K of 11%, which is over 10 times greater than the mortality of patients undergoing major elective surgery (e.g. cardiac, vascular and oncological surgery) and a median hospital length of stay (LOS) of 12-days. Risk factors associated with poorer outcomes from emergency laparotomy have been identified by the National Emergency Laparotomy Audit (NELA) and include advancing age, with each decade above the age of 50 being associated with increasing risk. Additional risk factors include an American Society of Anaesthesia (ASA) status of 3 or more and Portsmouth- Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM) risk of death of greater than 5%. The development of post-operative pulmonary complications (PPCs) is a composite definition for a variety of respiratory complications that occur following surgery. They range from clinically significant bronchospasm and atelectasis, through to the development of pneumonia and the acute respiratory distress syndrome (ARDS). The incidence following elective major abdominal surgery has been estimated at 11.9% and is associated poorer outcomes with increased length of hospital stay, increased re-admissions and a higher mortality. Although emergency surgery is well established as a significant risk factor for the development of PPCs, the incidence is not well established. This study aimed to establish the incidence of PPCs in a cohort of patients undergoing emergency laparotomy and the consequences on patient outcomes.

Механічна вентиляція легень, керована об’ємом або тиском під час нейрохірургічних операцій. Чи є перевага?

Актуальність. Однією з головних технологій сучасної анестезіології є механічна вентиляція легень (МВЛ). На даний час в інтенсивній терапії широко визнаною є протективна технологія МВЛ. Доцільність застосування даної технології в операційній, особливо у хворих з інтактними легенями, є не такою очевидною. Більшість наукових робіт, що висвітлюють дану проблему, стосується хворих з абдомінальною патологією, і менш висвітленою вона залишається у пацієнтів з нейрохірургічною патологією. Пацієнти, які оперуються з приводу нейрохірургічної патології, відносяться до групи хворих високого хірургічного ризику, це і змотивувало нас провести дане дослідження. Метою дослідження було вивчити доцільність застосування протективної МВЛ під час операційних втручань у нейрохірургічних хворих. Матеріали та методи. Нами обстежено 46 хворих, які знаходилися на стаціонарному лікуванні у КНП «8 МКЛ м. Львова» з приводу патології хребта та яким було виконане операційне втручання — вертебропластика із спондилодезом. Пацієнти були розподілені на дві групи: у першій групі (34 хворі) МВЛ проводили за технологією S-IPPV — синхронізована примусова вентиляція легень з контролем по об’єму, а в другій групі (12 хворих) МВЛ проводилась за технологією PCV — вентиляція, керована тиском. Результати. Ми ретроспективно визначили частоту виникнення післяопераційних легеневих ускладнень (ПОЛУ) у хворих першої та другої групи. З 34 хворих першої групи ознаки ПОЛУ були виявлені у 17 осіб (50 %), а з 12 хворих другої групи ПОЛУ було виявлено у 4 (33,3 %). Слід зауважити, що МВЛ у хворих обох груп не відрізнялася за такими параметрами, як частота дихання, кінцево-альвеолярний тиск на видиху та фракція кисню в дихальній суміші. Висновки. Порівняно невелика кількість хворих не дозволяє, очевидно, робити остаточні висновки, проте слід звернути увагу на те, що МВЛ (особливо керована об’ємом) сприяє виникненню післяопераційних легеневих ускладнень у пацієнтів з інтактними легенями в доопераційний період. А застосування МВЛ, керованої тиском, має тенденцію до зменшення частоти виявлення легеневих ускладнень в післяопераційному періоді. Якщо врахувати, що частота дихання, кінцево-альвеолярний тиск на видиху та фракція кисню в дихальній суміші були порівнянні у хворих обох груп, можна припустити, що фактором, який впливає на частоту виникнення ПОЛУ, є механіка вентиляції легень.

Postoperative Pulmonary Complications After Cardiac Surgery: The VENICE International Cohort Study

Postoperative pulmonary complications (PPC) remain a main issue after cardiac surgery. The objective was to report the incidence and identify risk factors of PPC after cardiac surgery. An international multicenter prospective study (42 international centers in 9 countries). A total of 707 adult patients who underwent cardiac surgery under cardiopulmonary bypass. None MEASUREMENTS AND MAIN RESULTS: During a study period of 2 weeks, the investigators included all patients in their respective centers and screened for PPCs. PPC was defined as the occurrence of at least 1 pulmonary complication among the following: atelectasis, pleural effusion, respiratory failure, respiratory infection, pneumothorax, bronchospasm, or aspiration pneumonitis. Among 676 analyzed patients, 373 patients presented with a PPC (55%). The presence of PPC was significantly associated with a longer intensive care length of stay and hospital length of stay. One hundred ninety (64%) patients were not intraoperatively ventilated during cardiopulmonary bypass. Ventilation settings were similar regarding tidal volume, respiratory rate, inspired oxygen. In the regression model, age, the Euroscore II, chronic obstructive pulmonary disease, preoxygenation modality, intraoperative positive end-expiratory pressure, the absence of pre- cardiopulmonary bypass ventilation, the absence of lung recruitment, and the neuromuscular blockade were associated with PPC occurrence. Both individual risk factors and ventilatory settings were shown to explain the high level of PPCs. These findings require further investigations to assess a bundle strategy for optimal ventilation strategy to decrease PPC incidence.

P-OGC46 Physiotherapy Regimens in Esophagectomy and Gastrectomy: a Systematic Review and Meta-analysis

Abstract Background Esophageal and gastric cancer surgery are associated with considerable morbidity, specifically postoperative pulmonary complications (PPC), potentially accentuated by underlying challenges with malnutrition and cachexia affecting respiratory muscle mass. Physiotherapy regimens aim to increase the respiratory muscle strength and may prevent postoperative morbidity. This meta-analysis aims to assess the impact of physiotherapy regimens following esophagectomy or gastrectomy. Methods An electronic database search was performed in MEDLINE, EMBASE, CENTRAL, CINAHL and Pedro databases. A meta-analysis was performed to assess the impact of physiotherapy on the functional capacity, incidence of PPC and postoperative morbidity, in-hospital mortality rate, the Length of Hospital Stay (LOS) and the Health-Related Quality of Life (HRQoL). Results Seven RCTs and 7 cohort studies assessing prehabilitation totalling 960 patients, and 5 RCTs and 5 cohort studies assessing peri- or postoperative physiotherapy with 703 total patients, were included. Prehabilitation resulted in a lower incidence of postoperative pneumonia and morbidity (Clavien-Dindo score >II). No difference was observed in functional exercise capacity, and in-hospital mortality following prehabilitation. Meanwhile, peri- or postoperative rehabilitation resulted in a lower incidence of pneumonia, a shorter LOS and better HRQoL scores for dyspnea and physical functioning, while no differences were found for the QoL summary score, global health status, fatigue and pain scores. Conclusions Our meta-analysis shows that implementing an exercise intervention may be beneficial in both the preoperative and peri- or postoperative period. Further investigation is needed to understand the mechanism through which exercise interventions improve clinical outcomes and which subgroup of patients will gain the most benefit.

Do ARISCAT scores help to predict the incidence of postoperative pulmonary complications in elderly patients after upper abdominal surgery? An observational study at a single university hospital

BackgroundThe incidence of postoperative pulmonary complications (PPCs) is increasing in line with the rise in the number of surgical procedures performed on geriatric patients. In this study, we determined the incidence and risk factors of PPCs in elderly Thai patients who underwent upper abdominal procedures, and we investigated whether the Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score helps to predict PPCs in Thais.MethodsA retrospective study was conducted on upper abdominal surgical patients aged over 65 years who had been admitted to the surgical ward of Siriraj Hospital, Mahidol University, Thailand, between January 2016 and December 2019. Data were collected on significant PPCs using the European Perioperative Clinical Outcome definitions. To identify risk factors, evaluations were made of the relationships between the PPCs and various preoperative, intraoperative, and postoperative factors, including ARISCAT scores.ResultsIn all, 1100 elderly postoperative patients were analyzed. Their mean age was 73.6 years, and 48.5% were male. Nearly half of their operations were laparoscopic cholecystectomies. The incidence of PPCs was 7.7%, with the most common being pleural effusion, atelectasis, and pneumonia. The factors associated with PPCs were preoperative oxygen saturation less than 96% (OR = 2.6, 1.2–5.5), albumin level below 3.5 g/dL (OR = 1.7, 1.0–2.8), duration of surgery exceeding 3 h (OR = 2.0, 1.0–4.2), and emergency surgery (OR = 2.8, 1.4–5.8). There was a relationship between ARISCAT score and PPC incidence, with a correlation coefficient of 0.226 (P < 0.001). The area under the curve was 0.72 (95% CI, 0.665–0.774; P < 0.001).ConclusionsPPCs are common in elderly patients. They are associated with increased levels of postoperative morbidities and extended ICU and hospital stays. Using the ARISCAT score as an assessment tool facilitates the classification of Thai patients into PPC risk groups. The ARISCAT scoring system might be able to be similarly applied in other Southeast Asian countries.

Adding autogenic drainage to chest physiotherapy after upper abdominal surgery: effect on blood gases and pulmonary complications prevention. Randomized controlled trial.

Hypoxemia and pulmonary complications are common after upper abdominal surgery (UAS). To examine whether inclusion of autogenic drainage (AD) in chest physiotherapy after UAS confers additional benefits in improving blood gases and reducing postoperative pulmonary complications (PPCs). Randomized controlled study conducted at Kasr Al-Ainy teaching hospital, Egypt. A randomized controlled trial was conducted on 48 subjects undergoing elective UAS with high risk of developing PPCs. The study group received AD plus routine chest physiotherapy (deep diaphragmatic breathing, localized breathing and splinted coughing) and the control group received routine chest physiotherapy only. The outcomes included arterial blood gases measured at the first and seventh postoperative days, incidence of PPCs within the first seven days and length of hospital stay. Baseline characteristics were similar between groups. In the AD group, SaO2, PaO2, PaCO2 and HCO3 significantly improved (P < 0.05) while in the physiotherapy group, only SaO2 and PaO2 significantly improved (P < 0.05). Nonetheless, significant differences in post-treatment SaO2 and PaO2 between the groups were observed. The overall incidence of PPCs was 16.66% (12.5% in the AD group and 20.8% in the physiotherapy group) (absolute risk reduction -8.3%; 95% confidence interval, CI, -13.5 to 29.6%), with no significant difference between the groups. The AD group had a significantly shorter hospital stay (P = 0.0001). Adding AD to routine chest physiotherapy after UAS provided a favorable blood gas outcome and reduced the length of hospital stay. It tended to reduce the incidence of PPCs. ClinicalTrials.gov: NCT04446520.

Asymptomatic Patients with Airflow Limitation are at Higher Risk of Postoperative Pulmonary Complications After Lung Surgeries: An Ambispective Cohort Study.

PurposeWith the use of pulmonary function tests (PFTs) as a preoperative examination, it is not rare to screen out airflow limitation (AFL) in asymptomatic patients undergoing lung surgeries. This study aims to elucidate whether there is a difference in the prevalence and prognosis of postoperative pulmonary complications (PPCs) between asymptomatic patients with newly diagnosed AFL and the normal population undergoing lung surgeries.Patients and MethodsThe medical records of asymptomatic patients undergoing lung surgeries who were spirometrically diagnosed with AFL between January and October 2017 were collected in Qilu hospital. These patients were subsequently followed up until February 2021. The diagnosis of PPCs was based on a recommended consensus definition. The incidence of PPCs between the newly diagnosed AFL group and the normal group was compared and a propensity score-matched analysis (PSM) was performed. The survival analysis was performed to investigate the long-term prognosis of the two groups.ResultsOverall, 535 asymptomatic subjects were recruited and 126 subjects (11.4%) were spirometrically diagnosed as AFL. The incidence of PPCs was significantly higher in the newly diagnosed AFL group than in the normal population (28.6%VS 14.4%, P < 0.001), especially in the FEV1/FVC≤65% group (P < 0.001), which were all confirmed by PSM analysis. Furthermore, these patients were at a higher risk of ICU admissions (P < 0.001) and 90-day hospital readmissions secondary to PPCs (P < 0.001). No significant differences were found in the overall, in-hospital and 90-day mortality between the AFL group and the normal group (P values >0.05).ConclusionAsymptomatic patients with AFL are at higher risk of PPCs than the general population after lung surgeries, along with an increase in ICU admissions and 90-day hospital readmissions secondary to PPCs. Although these patients tended to report worse current conditions, they were similar in the in-hospital, 90-day and overall mortality during the follow-up.

The effect of age on short-term and mid-term outcomes after thoracoscopic Ivor Lewis esophagectomy: a propensity score-matched analysis

BackgroundThe number of elderly patients diagnosed with esophageal cancer rises. Current information about outcomes in elderly patients undergoing thoracoscopic Ivor Lewis esophagectomy is limited. The objective of this study was to evaluate the influence of age on short-and mid-term outcomes after thoracoscopic Ivor Lewis esophagectomy.MethodsA retrospective review of 188 patients with esophageal cancer undergoing thoracoscopic Ivor Lewis esophagectomy between August 2014 and July 2019 was performed. Patients were divided into patients aged > 75 years (elderly group (EG), n = 37) and patients ≤ 75 years (younger group (YG), n = 151) and matched using propensity-score matching. Baseline characteristics, length of hospital stay, mortality and major postoperative complications (Clavien-Dindo ≥ grade III) were compared.ResultsAfter matching 74 patients remained (n = 37 in each group). Postoperatively, no significant differences in major and overall complications, intra-hospital and 30-day mortality, disease-free or overall survival up to 3 years after surgery were noted. The incidence of pulmonary complications (65% vs. 38%) and pneumonia (54% vs. 30%) was significantly higher and the median hospital length of stay (12 vs. 14 days) significantly longer in the EG versus YG.ConclusionThoracoscopic Ivor Lewis esophagectomies resulted in acceptable postoperative major morbidity and mortality without compromising 3-years overall and disease-free survival in elderly compared to younger patients with esophageal cancer. However, the incidence of postoperative pulmonary complications was higher in patients aged over 75 years.

Spirometric lung age for predicting the risk of pulmonary complications after thoracic surgeries

Annotation. Surgical interventions for diseases of the thoracic cavity are one of the most invasive surgical procedures, which are often accompanied by postoperative complications, which increase mortality, prolong hospital stays, require additional costs and correlate with poor long-term survival. However, respiratory complications remain the most common of non-surgical complications and their frequency varies from 13 to 38%. So far, several studies have shown that respiratory dysfunction is an independent risk factor for postoperative pneumonia. The aim – investigate whether it is possible to use spirometric lung age to predict the occurrence of postoperative pneumonia after thoracic surgeries. The study was performed on 192 patients with diseases of the thoracic cavity (esophagus, lungs, mediastinum), underwent surgery in the thoracoabdominal department of the Shalimov’s National Institute of Surgery and Transplantation. Statistical software EZR v.1.54 was used for statistical calculations (graphical user interface for statistical software R version 4.0.3, R Foundation for Statistical Computing, Vienna, Austria). We found a very strong association between the risk of developing pulmonary complications and the age of the lungs, AUC=0.97 (95% confidence interval from 0.94 to 0.99). When choosing the optimal point for predicting the risk of pulmonary complications obtained: Lung age critical = 99.6 years. Thus, at Lung age &gt;99.6 years, the development of postoperative pulmonary complications is predicted. At Lung age &lt;99.6 years, the absence of postoperative pulmonary complications is predicted. When choosing this decision point, the sensitivity is 93.5% (82.1-98.6%), specificity – 95.9% (91.3-98.5%). Therefore, spirometric age of the lungs was associated with the incidence of postoperative pulmonary complications in patients undergoing surgery for thoracic disease. This parameter deserves attention as a predictor of the probability of developing postoperative pneumonia after thoracic surgeries and can help in assessing the state of respiratory function of patients.

Postoperative Pulmonary Complications after Transcatheter Aortic Valve Implantation under Monitored Anesthesia Care versus General Anesthesia: Retrospective Analysis at a Single Large Volume Center.

Few studies to date have assessed the postoperative pulmonary complications after transcatheter aortic valve implantation (TAVI) according to the anesthesia method. The present study aims to compare the effects of general anesthesia (GA) or monitored anesthesia care (MAC) on postoperative outcomes in patients undergoing TAVI. This retrospective cohort study included 578 patients who underwent TAVI through the trans-femoral approach between August 2011 and May 2019 at a single tertiary academic center. The primary outcome was postoperative pulmonary complications, which were defined as the occurrence of one or more pulmonary complications, such as respiratory failure, respiratory infection, and radiologic findings, within 7 days after TAVI. Secondary outcomes included postoperative delirium, all-cause 30-day mortality rate, 30-day readmission rate, reoperation rate, vascular complications, permanent pacemaker/implantable cardioverter-defibrillator insertion, length of stay in the ICU, hospital stay, and incidence of stroke. Of the 589 patients, 171 underwent TAVI under general anesthesia (GA), and 418 under monitored anesthesia care (MAC). The incidence of postoperative pulmonary complications was significantly higher in the GA than in the MAC group (17.0% vs. 5.3%, p < 0.001). Anesthetic method significantly affected the occurrence of postoperative pulmonary complications, but not of delirium. ICU stay was significantly shorter in the MAC group, as were operation time, the volume of fluid administered during surgery, heparin dose, transfusion, and inotrope requirements. TAVI under MAC can increase the efficiency of medical resources, reducing the lengths of ICU stay and the occurrence of postoperative pulmonary complications, compared with TAVI under GA.

Active cycle of breathing technique may reduce pulmonary complications after esophagectomy: A randomized clinical trial.

BackgroundThe purpose of the study was to determine whether the active cycle of breathing technique (ACBT) has an impact on postoperative pulmonary complication (PPC) after esophagectomy.MethodsIn this prospective randomized trial, patients who were candidates for esophagectomy were randomized into groups, wherein they received either ACBT (n = 146) or conventional chest physiotherapy (control group, n = 145) on postoperative days (POD) 1–3. The primary outcome was PPC. The secondary outcomes included the incidence of anastomotic leakage (AL), efficacy of airway clearance, and postoperative hospital length of stay (LOS).ResultsAfter esophagectomy, the PPC rate was significantly lower in the ACBT group (15.2%) than in the control group (31.0%) (p = 0.001). The incidences of AL were 5.5% and 12.4% in the ACBT and control groups, respectively (p = 0.042). Mean hospital LOS was 12.3 days for the ACBT group and 16.8 days for the control group (p = 0.008). ACBT significantly increased the mean sputum wet weight (g) on POD 1–3 when compared with conventional therapy (POD 1 9.08 vs. 6.47, POD 2 16.86 vs. 10.92, POD 3 24.65 vs. 13.52, all p < 0.001). Multivariable analysis revealed that ACBT decreased the rates of PPC (odds ratio [OR] 0.403, p = 0.003), AL (OR 0.379，p = 0.038)，arrhythmia (OR 0.397, p = 0.028), and bronchoscopy aspiration (OR 0.362, p = 0.016).ConclusionACBT is an effective airway clearance technique that significantly reduces the incidence of PPC after esophagectomy. ACBT could also significantly reduce both AL and LOS.

Intraoperative lung protective ventilation in peritonitis patients undergoing emergency laparotomy: A randomised controlled trial.

Background and Aims:Lung protective ventilation (LPV) is recommended in acute respiratory distress syndrome. However, role of intraoperative LPV in elective laparotomy is controversial and it has not been evaluated in emergency laparotomy (EL). The aim of the study was to identify whether use of intraoperative LPV in EL in peritonitis patients reduces postoperative pulmonary complications (POPC).Methods:After institutional ethics committee approval and informed written consent, 98 adult patients undergoing EL for peritonitis were randomised into two groups. Patients in group 1 received LPV (tidal volume 6–8 ml/kg, positive end expiratory pressure (PEEP) 6–8 cm H2O and recruitment manoeuvre every 30 min) and patients in group 2 received conventional ventilation (tidal volume 10-12 ml/kg, without PEEP/recruitment). Primary outcome was incidence of POPC on day 7.Results:Data of 94 patients (n = 45 in group 1 & n = 49 in group 2) were available. Baseline demographic & laboratory parameters were comparable. Incidence of POPC was similar in both the groups [42.9% in group 1 vs. 53.3% in group 2; risk difference -10.4% (-30.6%, 9.6%); P = 0.31]. Mortality during hospital stay was 26.7% patients in group 1 and 26.5% patients in group 2 [risk difference (95% CI) 0.14%, (-17.7, 18.0); P = 0.98]. Length of hospital stay [median interquartile range (IQR) 13 (9–18) days in group 1 vs. 13 (8–21) days in group 2; P = 0.82] and length of intensive care unit stay [median (IQR) 7 (4–10) days vs. 6 (3–12) days; P = 0.88] were also similar in both groups.Conclusion:LPV during EL in peritonitis patients does not reduce the incidence of POPC compared to conventional ventilation.

Effect of ventilation strategy during cardiopulmonary bypass on postoperative pulmonary complications after cardiac surgery: a randomized clinical trial

BackgroundTo determine whether maintaining ventilation during cardiopulmonary bypass (CPB) with a different fraction of inspired oxygen (FiO2) had an impact on the occurrence of postoperative pulmonary complications (PPCs).MethodsA total of 413 adult patients undergoing elective cardiac surgery with CPB were randomly assigned into three groups: 138 in the NoV group (received no mechanical ventilation during CPB), 138 in the LOV group (received a tidal volume (VT) of 3–4 ml/kg of ideal body weight with the respiratory rate of 10–12 bpm, and the positive end-expiratory pressure of 5–8 cmH2O during CPB; the FiO2 was 30%), and 137 in the HOV group (received the same ventilation parameters settings as the LOV group while the FiO2 was 80%).ResultsThe primary outcomes were the incidence and severity of PPCs during hospitalization. The composite incidence of PPCs did not significantly differ between the NoV (63%), LOV (49%) and HOV (57%) groups (P = 0.069). And there was also no difference regarding the incidence of PPCs between the non-ventilation (NoV) and ventilation (the combination of LOV and HOV) groups. The LOV group was observed a lower proportion of moderate and severe pulmonary complications (grade ≥ 3) than the NoV group (23.1% vs. 44.2%, P = 0.001).ConclusionMaintaining ventilation during CPB did not reduce the incidence of PPCs in patients undergoing cardiac surgery.Trial registration: Chinese Clinical Trial Registry ChiCTR1800015261. Prospectively registered 19 March 2018. http://www.chictr.org.cn/showproj.aspx?proj=25982

Development and validation of a novel nomogram for postoperative pulmonary complications following minimally invasive esophageal cancer surgery.

Postoperative pulmonary complications (PPCs) are the most common complications following minimally invasive esophagectomy (MIE) and can be associated with adverse outcomes. This study aims to construct a nomogram based on clinical factors to predict PPCs and investigate related early outcomes. Clinical data of 969 consecutive patients receiving MIE were retrospectively collected. Univariate and multivariate analysis were performed to select independent predictors. Using independent predictors to develop a nomogram and using a bootstrap-resampling approach to conduct internal verification. Early outcomes of PPCs were analyzed. The incidence of PPCs following MIE was 39.6% (384 out of 969). In multivariate analysis, older age (Odds ratio (OR) 1.034, P < 0.001), higher body mass index (OR 0.993, P = 0.003), heavy smoking (OR 1.396, P = 0.027), FEV1/FVC < 105% (OR 1.958, P < 0.001), chemoradiotherapy (OR 0.653, P = 0.039), estimated blood loss ≥ 400mL (OR 2.582, P = 0.018), general anesthesia (vs Combined thoracic paravertebral blockade, OR 1.578, P = 0.014), operative time ≥ 240min (OR 1.388, P = 0.027), squamous cell carcinoma (OR 2.099, P = 0.036) and conversion to thoracotomy (OR 2.820, P = 0.026) were independent predictors for PPCs. These ten independent predictors were used to develop a nomogram, with concordance index (C index) value of 0.662 and good calibration. After internal validation, similarly good calibration and discrimination (C index, 0.654; 95% CI 0.614-0.690) were observed. Patients developing PPCs had higher rates of anastomotic leakage, reoperation, ICU and 30-day readmissions, and prolonged ICU and hospital stays (P < 0.05). Our study identified ten predictors for PPCs, which were associated with poor early outcomes. The proposed nomogram can be a useful tool to identify patients at high risk of PPCs after MIE.

Progress in Clinical Application of Positive End-Expiratory Pressure

In the surgery patient under general anesthesia doesn’t breathe spontaneously, and lung movement is completely dependent on the mechanical ventilation of the anesthesia machine. In order to achieve effective and safe mechanical ventilation of the patient’s lungs during the operation, the concept of lung protective ventilation strategy (LPVS) was proposed, that is, the use of a low tidal volume and an appropriate level of positive end expiratory pressure (PEEP) to reduce alveolar overexpansion and prevent alveolar collapse. In the past, PEEP was an important measure to treat acute lung injury(ALI) or acute respiratory distress syndrome(ARDS) by improving oxygenation and reducing pulmonary edema. Subsequent studies found that PEEP not only be used to treat patients with ALI or ARDS, but also can reduce the incidence of postoperative pulmonary complications(PPCs) in some thoracoabdominal operations. Moreover, PEEP can prevent atelectasis during and after surgery in patients undergoing thoracic and abdominal surgery under general anesthesia, and decrease the incidence of postoperative infection. However, PEEP can affect venous return by increasing intrathoracic pressure, thereby causing changes in heart function and hemodynamics, and indirectly affecting intracranial pressure and renal function. Therefore, with the widespread clinical application of PEEP, more and more people are starting to focus on how to choose the appropriate PEEP. This article reviews the research progress of PEEP selection method, the influence of PEEP on physiological function and the clinical application of PEEP during mechanical ventilation.

Effects of individualized PEEP obtained by two different titration methods on postoperative atelectasis in obese patients: study protocol for a randomized controlled trial

BackgroundThe incidence of postoperative pulmonary complications (PPCs) is higher in obese patients undergoing general anesthesia and mechanical ventilation due to the reduction of oxygen reserve, functional residual capacity, and lung compliance. Individualized positive end-expiratory pressure (iPEEP) along with other lung-protective strategies is effective in alleviating postoperative atelectasis. Here, we compared the best static lung compliance (Cstat) titration of iPEEP with electrical impedance tomography (EIT) titration to observe their effects on postoperative atelectasis in obese patients undergoing laparoscopic surgery.MethodsA total number of 140 obese patients with BMI ≥ 32.5kg/m2 undergoing elective laparoscopic gastric volume reduction and at moderate to high risk of developing PPCs will be enrolled and randomized into the optimal static lung compliance-directed iPEEP group and EIT titration iPEEP group. The primary endpoint will be pulmonary atelectasis measured and calculated by EIT immediately after extubation and 2 h after surgery. Secondary endpoints will be intraoperative oxygenation index, organ dysfunction, incidence of PPCs, hospital expenses, and length of hospital stay.DiscussionMany iPEEP titration methods effective for normal weight patients may not be appropriate for obese patients. Although EIT-guided iPEEP titration is effective in obese patients, its high price and complexity limit its application in many clinical facilities. This trial will test the efficacy of iPEEP via the optimal static lung compliance-guided titration procedure by comparing it with EIT-guided PEEP titration. The results of this trial will provide a feasible and convenient method for anesthesiologists to set individualized PEEP for obese patients during laparoscopic surgery.Trial registrationClinicalTrials.govChiCTR2000039144. Registered on October 19, 2020

Incidence of postoperative pulmonary complications in patients undergoing minimally invasive versus median sternotomy valve surgery: propensity score matching

ObjectivePostoperative pulmonary complications (PPCs) are common incidents associated with an increased hospital stay, readmissions into the intensive care unit (ICU), increased costs, and mortality after cardiac surgery. Our study aims to analyze whether minimally invasive valve surgery (MIVS) can reduce the incidence of postoperative pulmonary complications compared to the full median sternotomy (FS) approach.MethodsWe reviewed the records of 1076 patients who underwent isolated mitral or aortic valve surgery (80 MIVS and 996 FS) in our institution between January 2015 and December 2019. Propensity score-matching analysis was used to compare outcomes between the groups and to reduce selection bias.ResultsPropensity score matching revealed no significant difference in hospital mortality between the groups. The incidence of PPCs was significantly less in the MIVS group than in the FS group (19% vs. 69%, respectively; P < 0.0001). The most common PPCs were atelectasis (P = 0.034), pleural effusions (P = 0.042), and pulmonary infection (P = 0.001). Prolonged mechanical ventilation time (> 24 h) (P = 0.016), blood transfusion amount (P = 0.006), length of hospital stay (P < 0.0001), and ICU stay (P < 0.0001) were significantly less in the MIVS group. Cardiopulmonary bypass (CBP), aortic cross-clamping, and operative time intervals were significantly longer in the MIVS group than in the matched FS group (P < 0.001). A multivariable analysis revealed a decreased risk of PPCs in patients undergoing MIVS (odds ratio, 0.25; 95% confidence interval, 0.006–0.180; P < 0.0001).ConclusionMIVS for isolated valve surgery reduces the risk of PPCs compared with the FS approach.

Second-generation laryngeal mask airway as an alternative to endotracheal tube in prolonged laparoscopic abdominal surgery: a comparative analysis of intraoperative gas exchanges.

Laryngeal mask airway (LMA), which is used in difficult airway maintenance conditions during emergencies, is rarely used in prolonged surgery despite its advantages over endotracheal tube (ETT). In this study, we conducted a comparative analysis of intraoperative gas exchanges between second-generation LMA and ETT during prolonged laparoscopic abdominal surgery. Prolonged surgery was defined as a surgery lasting more than 2 h. In total, 394 patients who underwent laparoscopic liver resection via either second-generation LMA or ETT were retrospectively analysed. The following parameters were compared between the two groups of patients: end-tidal pressure of carbon dioxide (ETCO2), tidal volume (TV), respiratory rate (RR), peak inspiratory pressure (PIP), arterial partial pressure of carbon dioxide (PaCO2), pH and ratio of arterial partial pressure of oxygen to fractional inspired oxygen (PFR) during surgery. In addition, the incidence of postoperative pulmonary complications (PPCs), including pulmonary aspiration, was compared. The values of ETCO2, TV, RR and PIP during pneumoperitoneum were comparable between the two groups. Although PaCO2 at 2 h after induction was higher in patients in the LMA group (40.5 vs. 38.5 mmHg, P < 0.001), the pH and PFR values of the two groups were comparable. The incidence of PPC was similar. During prolonged laparoscopic abdominal surgery, second-generation LMA facilitates adequate intraoperative gas exchange and may serve as an alternative to ETT.

Intra-operative ventilator mechanical power as a predictor of postoperative pulmonary complications in surgical patients: A secondary analysis of a randomised clinical trial.

BACKGROUNDStudies in critically ill patients suggest a relationship between mechanical power (an index of the energy delivered by the ventilator, which includes driving pressure, respiratory rate, tidal volume and inspiratory pressure) and complications.OBJECTIVEWe aimed to assess the association between intra-operative mechanical power and postoperative pulmonary complications (PPCs).DESIGNPost hoc analysis of a large randomised clinical trial.SETTINGUniversity-affiliated academic tertiary hospital in Melbourne, Australia, from February 2015 to February 2019.PATIENTSAdult patients undergoing major noncardiothoracic, nonintracranial surgery.INTERVENTIONDynamic mechanical power was calculated using the power equation adjusted by the respiratory system compliance (C RS). Multivariable models were used to assess the independent association between mechanical power and outcomes.MAIN OUTCOME MEASURESThe primary outcome was the incidence of PPCs within the first seven postoperative days. The secondary outcome was the incidence of acute respiratory failure.RESULTSWe studied 1156 patients (median age [IQR]: 64 [55 to 72] years, 59.5% men). Median mechanical power adjusted by C RS was 0.32 [0.22 to 0.51] (J min−1)/(ml cmH2O−1). A higher mechanical power was also independently associated with increased risk of PPCs [odds ratio (OR 1.34, 95% CI, 1.17 to 1.52); P < 0.001) and acute respiratory failure (OR 1.40, 95% CI, 1.21 to 1.61; P < 0.001).CONCLUSIONIn patients receiving ventilation during major noncardiothoracic, nonintracranial surgery, exposure to a higher mechanical power was independently associated with an increased risk of PPCs and acute respiratory failure.TRIAL REGISTRATIONAustralia and New Zealand Clinical Trials Registry no: 12614000790640.