Noncardiac Thoracic Surgery Research Articles

Cardiac risk assessment in noncardiac thoracic surgery.

Preoperative cardiac risk assessment for noncardiac thoracic surgery is limited by the lack of data specific to this type of surgery, especially prospective, controlled data. However, the value of clinical predictors in determining accurate postoperative cardiac outcomes is a reliable tool. Thus, the approach is similar to traditional cardiac risk assessment for noncardiac surgery. The essential elements of cardiovascular evaluation as it pertains to noncardiac thoracic surgery are reviewed with a specific focus on coronary artery disease, perioperative arrhythmias, and selected topics relevant to noncardiac thoracic surgery. The core recommendations of the clinical guidelines by the American College of Cardiology and American Heart Association are discussed in the context of noncardiac thoracic surgery.

What happens when chest tubes are removed in children?

OBJECTIVE: To evaluate the incidence, onset, and severity of complications in children after chest tube removal. DESIGN: A prospective evaluation of patients. SETTING: Pediatric intensive care unit in a tertiary care university hospital. PATIENTS: One hundred and one consecutive children requiring intraoperative placement of chest tubes for cardiac or noncardiac thoracic surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 120 chest tubes placed in 101 patients, 16 were associated with positive findings after removal. Of these 16, only six required changes in management, and only two were serious complications. There was no association of complications with duration of chest tube placement. Children who developed complications were younger. All serious complications were immediately apparent after chest tube removal. CONCLUSION: Serious complications of chest tube removal in children are very uncommon and in this series were immediately apparent.

Usefulness of hypotension during dobutamine echocardiography in predicting perioperative cardiac events

This study was undertaken to determine the prognostic significance of hypotension induced during preoperative dobutamine stress echocardiography (DSE) before vascular and noncardiac thoracic surgery. Wall motion abnormality during DSE predicts perioperative risk. Although hypotension during DSE has not been shown to correlate with the presence or severity of coronary artery disease, its significance in perioperative risk assessment is unknown. We retrospectively studied 300 patients who had DSE within 6 months of noncardiac surgery. Perioperative events including death, myocardial infarction, ischemia, and arrhythmias were recorded. Odds ratios with 95% confidence intervals were used to examine the association between clinical and echocardiographic variables and perioperative events. A hypotensive response during DSE was seen in 85 patients (28%). Forty-eight patients (16%) had 54 perioperative complications including 4 cardiac-related deaths, 10 myocardial infarctions, 12 myocardial ischemic events, and 28 arrhythmias. Hypotension during DSE was predictive of the combined end point of perioperative cardiac mortality, myocardial infarction, and ischemia (odds ratio 4.04, 95% confidence interval 1.72 to 9.51). In a multivariate logistic regression model, hypotension during DSE remained a significant predictor (odds ratio 4.10, p <0.01). DSE-related hypotension was predictive of perioperative cardiac events and therefore may have a role in risk stratification before vascular or noncardiac thoracic surgery.

Signal-averaged P-wave duration does not predict atrial fibrillation after thoracic surgery.

Atrial fibrillation (AF) is the most common dysrhythmia seen early after major thoracic surgery but occurs infrequently after minor thoracic or other operations. A prolonged signal-averaged P-wave duration (SAPWD) has been shown to be an independent predictor of AF after cardiac surgery. The authors sought to determine whether a prolonged SAPWD alone or in combination with clinical or echocardiographic correlates predicts AF after elective noncardiac thoracic surgery. Of the 250 patients enrolled, 228 were included in the final analysis. Preoperative SAPWD was obtained in 155 patients who had major thoracic surgery and in 73 patients undergoing minor thoracic or other operations who served as comparison control subjects. The SAPWD was recorded from three orthogonal leads using a sinus P-wave template. The filtered vector composite was used to measure total P-wave duration. Clinical, surgical, and echocardiographic parameters were collected and patients followed for 30 days after surgery for the development of symptomatic AF. Symptomatic AF developed in 18 of 155 (12%) patients undergoing major thoracic surgery and in 1 of 73 (1%) patients having minor thoracic or abdominal surgery, most commonly 2 or 3 days after surgery. In comparison with similar patients undergoing major thoracic surgery without AF, those who developed AF were older (66+/-8 vs. 62+/-10 yr; P = 0.04) but did not differ in SAPWD (145+/-17 vs. 147+/-16, ms) in standard electrocardiographic P-wave duration (105+/-7 vs. 107+/-10 mns), incidence of left-ventricular hypertrophy on 12-lead electrocardiography, male sex, history of hypertension, diabetes, or coronary heart disease. Thoracic-surgery patients at risk for postoperative AF did not differ from all other patients at low risk for AF in clinical or SAPWD parameters. Under the conditions of this study, SAPWD did not differentiate patients who did or did not develop AF after noncardiac thoracic surgery, and therefore its measurement cannot be recommended for the routine evaluation of these patients. Older age continues to be a risk factor for AF after thoracic surgery.

D-Dimer Formation During Cardiac and Noncardiac Thoracic Surgery

The ability to make therapeutic decisions regarding excessive fibrinolysis in the perioperative period is limited by the lack of availability of a near site monitor of fibrinolysis.We investigated the use of a latex agglutination D-dimer assay to detect perioperative fibrinolysis in patients undergoing thoracic surgery with and without extracorporeal circulation. We studied 27 patients who underwent thoracic surgery requiring cardiopulmonary bypass (CPB; coronary artery bypass grafting, n = 12; valvular surgery, n = 15) and a cohort of 20 patients who underwent noncardiac thoracic surgical procedures not requiring CPB. The purpose of this investigation was to determine the relationship among alterations in the latex agglutination D-dimer assay, use of extracorporeal circulation, type of cardiac surgical procedure, and mediastinal and/or chest tube drainage (cardiac surgery only) in patients undergoing thoracic surgery. Perioperative D-dimer levels, measured by latex agglutination, had significant (P<or=to0.05) intragroup changes among patients undergoing cardiac surgery (requiring CPB) and the cohort of patients who underwent noncardiac thoracic surgery without CPB. Although intraoperative D-dimer levels were not increased in patients undergoing noncardiac thoracic surgery, postoperative levels were significantly (P<0.05) increased (compared with preinduction). In cardiac surgery patients requiring CPB, intraoperative D-dimer formation was significantly (P<or=to0.05) increased but did not demonstrate any intragroup (coronary artery bypass grafting versus valvular surgery) differences. Finally, D-dimer levels were not associated with postoperative mediastinal and/or chest tube accumulative drainage measured at intervals up to 48 h postoperatively in patients undergoing cardiac surgery requiring CPB. Our study indicates that the latex agglutination D-dimer assay can detect excessive fibrinolysis perioperatively, and that extracorporeal circulation can significantly influence the pattern of D-dimer formation in patients undergoing thoracic surgery. Implications: We assessed the ability of a readily available D-dimer assay to detect excessive fibrinolysis in patients undergoing thoracic surgery with and without extracorporeal circulation. The findings demonstrate that the assay used in this investigation reflected variable amounts of fibrinolysis in patients undergoing both types of thoracic surgery. (Anesth Analg 1999;88:1226-31)

Strategies and Techniques for Neuroprotection in Coronary Artery Surgery

Patients undergoing coronary artery bypass grafting are at higher risk of neurologic events than demographi cally similar patients undergoing noncardiac surgery. Postoperative stroke has been shown to occur two to three times more frequently than in age-, gender-, and education-matched patients undergoing noncardiac vas cular or thoracic surgery. The incidence of more subtle brain syndromes, giving rise to symptoms of memory loss and cognitive deterioration as documented in up to 79% of coronary bypass patients, varies depending on whether prospective or retrospective data are analyzed, and whether or not serial cognitive testing is used, and is also significantly higher in coronary bypass patients. Various factors have been identified as causative in the genesis of perioperative neurologic injury in these pa tients. Although there is evidence that microgaseous and microparticulate emboli are instrumental in the production of postoperative cognitive impairment, the role of ascending aortic atherosclerosis is increasingly recognized as being the greatest single risk factor for postoperative stroke.

Nosocomial pneumonia and bacteremia in intensive care: results from the Belgian national surveillance, 1996-1998

In 1996 the Scientific Institute of Public Health — Louis Pasteur (IPH), in collaboration with the Belgian Society of Intensive Medicine and Emergency Medicine, started a multicentre surveillance of intensive care units (ICU) acquired pneumonias and bacteremia. From January 1996 to June 1998, 60% of Belgian acutecare hospitals (n = 101) participated during at least one surveillance period (3 months), and 64% of those participated more than one period. A total of 31 374 patients were included for the analysis. In 4.7% (95% CI 4.5—5.0) of the patients a pneumonia with onset later than 48 h of ICU stay and matching CDC criteria for nosocomial pneumonia was registered. In 89% of those at least one ventilation-day had preceded the onset of the infection (RR 10.4%; 8.9—12.2). The number of ventilator-associated pneumonias per 1000 ventilation-days was 19.0/1000 ventilation-days, varying from 11.9 in coronary surgery patients to more than 25 in patients having undergone neurosurgery, non-cardiac thoracic surgery, vascular surgery and transplantation. The predominant micro-organisms were Pseudomonas aeruginosa (recovered in 18.0% of the episodes), Staphylococcus aureus (17.7%), Escherichia coli (12.6%), Candida spp. (12.1%) and Enterobacter spp. (9.5%). Bacteremia was reported in 2.4% of the patients. Five percent of bacteremia occurred within the first 48 h. Forty percent (n = 301) were secondary to another infection site and 55% (1.3% of the patients and 2.3 BSIs per 1000 patient-days) matched the CDC case definition of laboratory-confirmed primary bacteremia. The device-adjusted primary bacteremia rate was 3.1/1000 catheter-days and varied between 1.5 in coronary surgery to 4.8 in patients with multiple trauma and 6.0 in neurosurgical patients. The five predominant micro-organisms in primary bacteremia were Staphylococus epidermidis (in 33.3% of the episodes), Staphylococcus aureus (12.8%), Enterococcus faecalis (7.1%), Pseudomonas aeruginosa (6.1 %) and Enterobacter aerogenes (5.7%). The frequent participation to the national surveillance led to an important national database that allows to study the risk factors of ICU-acquired infections, to identify areas for prevention and to improve the inter-ICU comparability of infection rates according to the risk profile of the different ICU populations. International comparisons remain a delicate matter by lack of internationally standardised surveillance methods.

Noncardiac Thoracic Surgery in Children: A Retrospective Study

A retrospective study of noncardiac thoracic surgery in children (age < 16 years) comprised 126 patients consecutively operated on over a 10-year period. The surgical procedures included chest-tube insertion for neonatal pneumothorax in 33 children, 12 of whom died within 5 days after birth. Primary intrathoracic disorders were treated in 55 cases, mainly congenital pulmonary malformations in the youngest and traumatic conditions in the oldest. There were no early postoperative deaths in this group, but seven children were dead at the time of follow-up. In 38 children surgery was performed for involvement of intrathoracic organs secondary to other, often malignant diseases. Eleven of these children were dead at follow-up. Noncardiac thoracic surgery is thus required for a number of reasons in children and is well tolerated, although serious primary disease can increase mortality.

Anesthetic management of the cancer patient undergoing noncardiac thoracic surgery.

The scope of this article is necessarily limited, but we have addressed preoperative assessment, monitoring, and intraoperative support that might be required for surgical patients with lung, mediastinal, and esophageal cancer. The development of the subspecialty of thoracic anesthesia has been responsible for reducing mortality and improving care of all patients undergoing noncardiac thoracic surgery and has been one of the forces behind the surgeon's ability to handle bigger challenges with better results.

Coronary artery calcification at CT as a predictor for cardiac complications of thoracic surgery.

Our goal was to determine the predictive value of coronary artery calcification (CAC) on preoperative CT of the thorax for cardiac complications of noncardiac thoracic surgery. Of 117 patients undergoing noncardiac thoracic surgical procedures between January 1, 1993, and June 1, 1995, at our institution, 75 had inpatient records and chest CTs available for retrospective review. Inpatient records were reviewed for postoperative cardiac complications (arrhythmia, hypotension with ECG changes, myocardial infarction, congestive heart failure, stroke, and death). The CT scans were scored for the presence and extent of CAC by an independent observer. Six of the 75 patients had cardiac complications including 1 death. Thirty-nine of the 75 patients had a CAC score of > or = 7. The sensitivity, specificity, positive predictive value, and negative predictive value of a CAC score of > or = 7 for cardiac complications were 100, 71, 23, and 100%, respectively. The presence of CAC on preoperative CT scanning is associated with cardiac complications of noncardiac thoracic surgery; however, the positive predictive value is low. The absence of CAC was a reliable predictor of a favorable postoperative cardiac course.

Comparison of two preoperative indices to predict perioperative mortality in non-cardiac thoracic surgery.

The preoperative classifications: physical status of the American Society of Anesthesiologists (ASA-PS) and/or cardiac risk index (CRI) of Goldman are widely used to estimate the perioperative risk in patients undergoing noncardiac throacic surgery. We tried to determine the validity of both methods in predicting the perioperative mortality in 845 consecutive patients scheduled for major elective noncardiac thoracic surgery. Preoperatively, each patient was assigned 2 independent estimations of risk according to the ASA-score (ASA grade, I-IV) and CRI score (CRI grade, I-IV), respectively. Twenty-five patients died within 4 weeks after the operation, the others survived the perioperative period. The grading according to ASA as well as to the CRI score showed a direct correlation with the outcome: The higher the preoperative score, the higher was the mortality rate. When various combinations of ASA and CRI were tested, the lowest mortality rate was found in presence of ASA < or = III and CRI = I. Multivariate regression analysis showed that the ASA score had an independent correlation with perioperative mortality, whereas such a relationship was absent for CRI. The subjective assessment by an experienced anesthesiologist as expressed by the ASA-score is a valid method in the determination of the perioperative risk. CRI does not contribute additional information for the general perioperative risk.

Cirurgia torácica geral em pacientes com revascularização miocárdica prévia

É analisada a experiência da Disciplina de Cirurgia Torácica da Faculdade de Medicina da Universidade de São Paulo, em 24 pacientes submetidos a cirurgia torácica com revascularização miocárdica prévia. Estudaram-se variáveis em termos de morbi-mortalidade deste grupo de doentes. Os resultados mostraram que o melhor prognóstico foi encontrado nos pacientes submetidos a revascularização entre seis meses e cinco anos antes da cirurgia torácica. Notou-se, ainda, que os pacientes com infarto agudo do miocárdio apresentam um prognóstico tardio pior. O porte da cirurgia torácica e idade maior do que 70 anos foram fatores de risco tanto imediatos, quanto tardios

Alterations of the beta-adrenergic receptor system after thoracic and abdominal surgery.

We studied perioperative regulation of the beta-adrenergic receptor (beta AR) in lymphocytes obtained from 12 patients undergoing noncardiac thoracic surgery and 12 patients undergoing abdominal surgery. beta AR number (Bmax) and dissociation constant (KD) were determined from [125I]iodopindolol saturation binding curves. Function of the beta AR/adenylyl cyclase system was assessed by measuring cyclic adenosine monophosphate (cAMP) production in the unstimulated state and in response to maximal stimulation by isoproterenol (ISO) and prostaglandin E1 (PGE1). In thoracic surgery patients, basal and ISO-stimulated cAMP production were significantly decreased postoperatively, by 44% and 45%, respectively, with no change in PGE1-stimulated cAMP. Bmax decreased from 1369 +/- 138 (mean +/- SE) sites/cell to 891 +/- 82 sites/cell postoperatively, while the KD increased from 26.7 +/- 5.6 pM to 37.8 +/- 5.1 pM. In the abdominal surgery patients, there were no significant alterations in cAMP production, but Bmax decreased, from 1235 +/- 146 sites/cell preoperatively to 888 +/- 65 sites/cell postoperatively, while the KD increased from 18.8 +/- 3.6 pM to 58.1 +/- 12.5 pM. The beta AR and its associated effector system are altered during the perioperative period of abdominal and thoracic surgery.

Surgical flaps in the chest: anatomic considerations, applications, and radiologic appearance.

To determine the frequency of use of surgical flaps--tissue that is transposed from its normal location to promote healing and prevent complications--in noncardiac thoracic surgery and to demonstrate the typical radiologic appearances of such flaps. The surgical records of 200 patients who underwent thoracotomy or median sternotomy for noncardiac thoracic surgery were reviewed. Postoperative radiologic studies of randomly selected cases were also reviewed. A total of 213 surgical flaps were used in these patients, including 80 pericardial fat pad flaps (37.6%), 78 greater omental flaps (36.6%), 21 intercostal muscle flaps (9.9%), 16 anterior serratus muscle flaps (7.5%), and 18 greater pectoral muscle, latissimus dorsi muscle, pleural, thymic, or mediastinal fat flaps (8.5%). The flaps produced unusual opacity or attenuation and/or contour of the mediastinum, hilum, or chest wall. Knowledge of common thoracic surgical flaps is helpful in interpretation of postoperative radiologic studies.

A Clinical Prediction Rule for Delirium After Elective Noncardiac Surgery

To develop and validate a clinical prediction rule for postoperative delirium using data available to clinicians preoperatively. Prospective cohort study. General surgery, orthopedic surgery, and gynecology services at Brigham and Women's Hospital, Boston, Mass. Consenting patients older than 50 years admitted for major elective noncardiac surgery between November 1, 1990, and March 15, 1992 (N = 1341). All patients underwent preoperative evaluations, including a medical history, physical examination, laboratory tests, and assessments of physical and cognitive function using the Specific Activity Scale and the Telephone Interview for Cognitive Status. Postoperative delirium was diagnosed using the Confusion Assessment Method or using data from the medical record and the hospital's nursing intensity index. Patients were followed up for the duration of hospitalization to determine major complication rates, length of stay, and discharge disposition. Postoperative delirium occurred in 117 (9%) of the 1341 patients studied. Independent correlates included age 70 years or older; self-reported alcohol abuse; poor cognitive status; poor functional status; markedly abnormal preoperative serum sodium, potassium, or glucose level; noncardiac thoracic surgery; and aortic aneurysm surgery. Using these seven preoperative factors, a simple predictive rule was developed. In an independent population, the rule stratified patients into groups with low (2%), medium (8%, 13%), and high (50%) rates of postoperative delirium. Patients who developed delirium had higher rates of major complications, longer lengths of stay, and higher rates of discharge to long-term care or rehabilitative facilities. Using data available preoperatively, clinicians can stratify patients into risk groups for the development of delirium. Since delirium is associated with a variety of adverse outcomes, patients with substantial risk for this complication could be candidates for interventions to reduce the incidence of postoperative delirium and potentially improve overall surgical outcomes.

Survey of guidelines for antimicrobial prophylaxis in surgery

One method of making optimal use of prophylactic antibiotics is for interested parties to agree on guidelines. A postal survey was undertaken to determine the prevalence of this practice within UK hospitals and details of any guidelines used. Eighty-one of the 160 respondents (51%) stated that guidelines were available or in preparation. Prophylaxis was recommended by 100% of respondents for colorectal surgery and prosthetic joint replacement and by 96% for gastro-oesophageal surgery, procedures where it has been proven to be of benefit. Prophylaxis was recommended for the following procedures for which its efficacy remains controversial: cholecystectomy (100%); peripheral vascular grafting (93%); hysterectomy (95%) and non-cardiac thoracic surgery (63%). Although 35 combinations of 22 different antimicrobials were recommended, 63% included a cephalosporin; the greatest variety of antibiotics recommended was for peripheral vascular grafting. In 88% of policies it was advocated that prophylaxis be started preoperatively and in 79% that it be continued for less than 24 h. When surgery involved the implantation of a prosthesis the duration of prophylaxis tended to be prolonged. Policies for the prescribing of antimicrobial prophylaxis in surgery are available in many hospitals and for the most part conform with established principles.

Pharmacokinetics and tissue penetration of a single dose of ceftriaxone (1,000 milligrams intravenously) for antibiotic prophylaxis in thoracic surgery.

The pharmacokinetics and tissue penetration of ceftriaxone after a single intravenous injection of 1,000 mg to 17 patients for antibiotic prophylaxis in thoracic surgery were studied. The patients were scheduled for elective noncardiac thoracic surgery. Adequate levels in serum (higher than or equal to the MIC for 90% of isolates of Staphylococcus aureus, Streptococcus spp., Escherichia coli, Haemophilus influenzae, and Klebsiella pneumoniae) were found for all patients throughout the surgical procedures. Mean maximal (5-min) and final (24-h) ceftriaxone levels in serum were 157 +/- 42 and 8.6 +/- 4.5 mg/liter, respectively. The beta-phase elimination half-life was 8.6 +/- 3 h, the plasma clearance was 18.4 +/- 6.25 ml/min, and the apparent volume of distribution at steady state was 0.21 +/- 0.07 liters/kg. At the time of the thoracotomy, the ceftriaxone concentrations were 13.5 +/- 7.8 micrograms/g in thoracic wall fat and 27 +/- 9 micrograms/g in lung tissue. At the time of closure, the ceftriaxone concentration was 15 +/- 9 micrograms/g in thoracic wall fat. During the different steps of the surgical procedures, 100% of patients had adequate levels in tissue (higher than or equal to the MIC for 90% of isolates of Streptococcus spp., E. coli, H. influenzae, and K. pneumoniae). For S. aureus, 90 to 100% of patients had adequate tissue ceftriaxone levels.

Antibiotic prophylaxis in non-cardiac thoracic surgery: Cefazolin versus placebo

A total of 127 patients (57 given placebo and 70 given a single preoperative dose of 1 g cefazolin) undergoing thoracic surgery were included in a randomized double-blind trial. The two groups were similar in regard to mean age, sex ratio, in-hospital stay before surgery, underlying disease, risk factors, type of surgery, mean duration of surgical procedure, and mean duration of chest tube drainage. The relative risk of wound infection of the patients from the placebo group was 3.27 (range 1.5-11.5; 95% confidence interval). Cefazolin significantly reduced (p less than 0.01) the wound infection rate--1 case (1.5%) in the cefazolin group versus 8 cases (14%) in the placebo group--but not the incidence of postoperative pleural empyema--5 (7%) versus 8 cases (14%)--or nosocomial pneumonia--3 (4%) versus 5 cases (9%). Cultures were made from 3 out of 9 wound infections and Staphylococcus aureus or S. epidermidis was isolated in all 3. In addition, cultures were made from 6 out of 13 pleural cavity infections and S. aureus (1 case) or other microorganisms (5 cases) were isolated in all 6. Mortality was similar in both groups and all deaths unrelated to the infections. No adverse side effects of the drug were encountered. In conclusion, a single preoperative dose of 1 g cefazolin proved to be effective for reducing the wound infection rate in non-cardiac thoracic surgery.

Antibiotic Prophylaxis in Non-Cardiac Thoracic Surgery: A Double-blind Study of Penicillin vs. Cefuroxime

Patients referred for elective pulmonary surgery were enrolled in a prospective, randomized, double-blind study comparing the prophylactic efficacy of four-dose regimens of penicillin-G 5 million IU and cefuroxime 1.5 g. the first dose given immediately preoperatively. The treatment groups were comparable preoperatively with regard to all tested demographic factors. No significant intergroup difference was found concerning postoperative empyema, wound infection, septicaemia, pneumonia or fever of unknown origin, or any other complication or parameter tested in connection with pulmonary surgery. No side effects were observed, and no effects on the patients normal bacterial flora. Penicillin is recommended as prophylaxis in this type of surgery.

Effect of thiazide on rates of bone mineral loss: a longitudinal study.

To determine the effect of thiazide diuretic drugs on rates of bone mineral loss. Longitudinal, observational study with a mean follow up of five years. Hawaii Osteoporosis Center, Honolulu. 1017 Japanese-American men born between 1900 and 1920, of whom 378 were treated for hypertension (study group) and 639 did not have hypertension (control group). Thiazide diuretics were taken by 325 men for a mean of 11.9 years; 53 men took antihypertensive drugs other than thiazides. Rate of bone loss estimated from serial photon absorptiometric scanning at three skeletal sites (calcaneus, distal radius, and proximal radius). Rates of bone loss at all three sites were significantly reduced among thiazide users when compared with controls. The reductions in loss rate ranged from 28.8% (p = 0.02) (distal radius) to 49.2% (p = 0.0005) (calcaneus) relative to the controls. At all three sites the men taking other antihypertensive drugs had faster loss rates (22.6-43.1%) than those of the controls but the difference was significant only for the distal radius. Thiazide diuretics slow the rate of bone loss in elderly men.