Intraoperative Factors and the Risk of Respiratory Complications After Pneumonectomy

The Impact of Postoperative Pulmonary Complications on Perioperative Outcomes in Patients Undergoing Pneumonectomy: A Multicenter Retrospective Cohort Study of the German Thorax Registry

Postoperative pulmonary complications have a deleterious impact in regards to thoracic surgery. Pneumonectomy is associated with the highest perioperative risk in elective thoracic surgery. The data from 152 patients undergoing pneumonectomy in this multicenter retrospective study were extracted from the German Thorax Registry database and presented after univariate and multivariate statistical processing. This retrospective study investigated the incidence of postoperative pulmonary complications (PPCs) and their impact on perioperative morbidity and mortality. Patient-specific, preoperative, procedural, and postoperative risk factors for PPCs and in-hospital mortality were analyzed. A total of 32 (21%) patients exhibited one or more PPCs, and 11 (7%) died during the hospital stay. Multivariate stepwise logistic regression identified a preoperative FEV1 < 50% (OR 9.1, 95% CI 1.9-67), the presence of medical complications (OR 7.4, 95% CI 2.7-16.2), and an ICU stay of more than 2 days (OR 14, 95% CI 3.9-59) as independent factors associated with PPCs. PPCs (OR 13, 95% CI 3.2-52), a preoperative FEV1 < 60% in patients with previous pulmonary infection (OR 21, 95% CI 3.2-52), and continued postoperative mechanical ventilation (OR 8.4, 95% CI 2-34) were independent factors for in-hospital mortality. Our data emphasizes that PPCs are a significant risk factor for morbidity and mortality after pneumonectomy. Intensified perioperative care targeting the underlying risk factors and effects of PPCs, postoperative ventilation, and preoperative respiratory infections, especially in patients with reduced pulmonary reserve, could improve patient outcomes.

Impact of fluid balance and blood transfusion during extracorporeal circulation on outcome for acute type A aortic dissection surgery

BACKGROUND

In thoracic aortic surgery, fluid replacement and blood transfusion during extracorporeal circulation (ECC) are associated with increased coagulopathy, elevated inflammatory response, and end-organ dysfunction. The optimal strategy has not been established in this regard. The aim of this study was to evaluate the effect of the fluid balance during ECC in thoracic aortic dissection surgery on outcome.

METHODS

Between 2009 and 2020, 358 patients suffering from acute type A aortic dissection (ATAAD) underwent aortic surgery at our heart center. In-hospital mortality, major complications (postoperative stroke, respiratory failure, heart failure, acute renal failure), and follow-up mortality were assessed. Logistic regression analysis was used to identify whether fluid balance and blood transfusion during ECC were risk factors for occurring adverse events.

RESULTS

The in-hospital mortality amounted to 20.4%. Major complications included temporary neurologic deficit in 13.4%, permanent neurologic deficit in 6.1%, acute renal failure in 32.7%, prolonged ventilation for respiratory failure in 17.9%, and acute heart failure in 10.9% of cases. At a mean of 42 months after discharge of 285 survivors, follow-up mortality was 13.3%. Multivariate analysis revealed major complications as well as the risk of in-hospital and follow-up mortality to increase with fluid balance and blood transfusion during ECC.

CONCLUSIONS

Fluid balance and blood transfusion during ECC present with predictive potential concerning the risk of postoperative adverse events.

Ventilation during Lung Resection and Critical Care: Comparative Clinical Outcomes

Recent evidence suggests that outcomes do not meaningfully differ between thoracic surgery patients who are ventilated with a low or higher tidal volume and the effects of low versus higher positive end-expiratory pressure are unclear.

Restricted, optimized or liberal fluid strategy in thoracic surgery: A narrative review

Perioperative fluid balance has a major impact on clinical and functional outcome, regardless of the type of interventions. In thoracic surgery, patients are more vulnerable to intravenous fluid overload and to develop acute respiratory distress syndrome and other complications. New insight has been gained on the mechanisms causing pulmonary complications and the role of the endothelial glycocalix layer to control fluid transfer from the intravascular to the interstitial spaces and to promote tissue blood flow. With the implementation of standardized processes of care, the preoperative fasting period has become shorter, surgical approaches are less invasive and patients are allowed to resume oral intake shortly after surgery. Intraoperatively, body fluid homeostasis and adequate tissue oxygen delivery can be achieved using a normovolemic therapy targeting a “near-zero fluid balance” or a goal-directed hemodynamic therapy to maximize stroke volume and oxygen delivery according to the Franck–Starling relationship. In both fluid strategies, the use of cardiovascular drugs is advocated to counteract the anesthetic-induced vasorelaxation and maintain arterial pressure whereas fluid intake is limited to avoid cumulative fluid balance exceeding 1 liter and body weight gain (~1-1.5 kg). Modern hemodynamic monitors provide valuable physiological parameters to assess patient volume responsiveness and circulatory flow while guiding fluid administration and cardiovascular drug therapy. Given the lack of randomized clinical trials, controversial debate still surrounds the issues of the optimal fluid strategy and the type of fluids (crystalloids versus colloids). To avoid the risk of lung hydrostatic or inflammatory edema and to enhance the postoperative recovery process, fluid administration should be prescribed as any drug, adapted to the patient's requirement and the context of thoracic intervention.

Diagnostic value of routine chest tube tip culture in surgery for noninfectious lung disease

BACKGROUND

Evaluation of the diagnostic value of routine chest tube tip culture for detection of postoperative infection after surgery for noninfectious lung disease.

METHODS

Included subjects were patients who underwent lung surgery between January 1st 2013 and January 1st 2018 in University Medical Centre Utrecht and of whom a chest tube tip was cultured. Postoperative outcomes included pneumonia, surgical site infection, and empyema within 30 days after surgery. Univariable analysis for diagnostic accuracy of chest tube tip culture results predicting these postoperative outcomes was performed, as well as multivariable analysis using penalized firth logistic regression.

RESULTS

Patients developed one or more postoperative infections in 42 out of 210 (20%) lung surgeries. Pneumonia, surgical site infection, and empyema were found in 36 (17%), 8 (4%), and 2 (1%) cases respectively. Chest tube tip culture had a sensitivity of 31%, a specificity of 83%, a positive predictive value of 32%, and a negative predictive value of 83% for postoperative infections. In the subgroup of patients who did not have evidence of postoperative infection at the time of chest tube removal, the drain tip culture's positive and negative predictive value changed to 18% and 92% respectively. Adding additional variables to chest tube tip culture in a prediction model resulting in only limited improvement in diagnostic performance.

CONCLUSIONS

We found insufficient diagnostic performance to support the practice of routine chest tube tip culture after surgery for noninfectious lung disease. Therefore, routine chest tube tip culture is not advisable and should be omitted to unburden the healthcare process and prevent low value care together with extra costs.

Restrictive intraoperative fluid management was associated with higher incidence of composite complications compared to less restrictive strategies in open thoracotomy: A retrospective cohort study

Restrictive fluid management has been recommended for thoracic surgery. However, specific guidelines are lacking, and there is always concern regarding impairment of renal perfusion with a restrictive policy. The objective of this study was to find the net intraoperative fluid infusion rate which shows the lowest incidence of composite complications (either pulmonary complications or acute kidney injury) in open thoracotomy. We hypothesized that a certain range of infusion rate would decrease the composite complications within postoperative 30 days. All patients (n = 1,031) who underwent open thoracotomy at a tertiary care university hospital were included in this retrospective study. The time frame of fluid monitoring was from the start of operation to postoperative 24 hours. The cutoff value of the intraoperative net fluid amount was 4–5 ml.kg⁻¹.h⁻¹ according to the minimum p-value method, thus, patients were divided into Low (≤3 ml.kg⁻¹.h⁻¹), Cutoff (4–5 ml.kg⁻¹.h⁻¹) and High (≥6 ml.kg⁻¹.h⁻¹) groups. The Cutoff group showed the lowest composite complication rate (19%, 12%, and 13% in the Low, Cutoff, and High groups, respectively, P = 0.0283; Low vs. Cutoff, P = 0.0324, Bonferroni correction). Acute respiratory distress syndrome occurred least frequently in the Cutoff group (7%, 3%, and 6% for the Low, Cutoff, and High groups, respectively, P = 0.0467; Low vs. Cutoff, P = 0.0432, Bonferroni correction). In multivariable analysis, intraoperative net fluid infusion rate was associated with composite complications, and the Cutoff group decreased risk (odds ratio 0.54, 95% confidence interval: 0.35–0.81, P = 0.0035). In conclusion, maintaining intraoperative net fluid infusion at 4–5 ml.kg⁻¹.h⁻¹ was associated with better results in open thoracotomy, in terms of composite complications, compared to more restrictive fluid management.

RBC transfusion is associated with increased risk of respiratory failure after pneumonectomy

BACKGROUND AND OBJECTIVES

Pneumonectomy is associated with high risk of respiratory complications. Our objective was to determine if transfusions are associated with increased rate of ARDS and respiratory failure in adults undergoing elective pneumonectomy.

METHODS

Retrospective cohort study of consecutive pneumonectomies undertaken at a tertiary hospital (2003-2013). Multivariable logistic regression was performed to adjust for confounding factors.

RESULTS

ARDS and respiratory failure occurred in 12.4% (n = 20) and 19.2% (n = 31) of 161 pneumonectomy patients, respectively, and were more likely to occur in transfused patients (P = 0.03, P < 0.001). pRBCs, FFP and platelets were transfused in 27% (n = 43), 6% (n = 9), and 2% (n = 3), respectively. On multivariable analyses utilizing blood products as continuous and binary variables, pRBC use was the only independent predictor of ARDS with odds ratio (OR) = 1.23 (95%CI:1.08-1.39, P = 0.002) and OR = 2.45 (95%CI:1.10-5.49, P = 0.03), respectively. On multivariable analyses utilizing blood products as continuous and binary variables, pRBCs were the only independent predictor of respiratory failure with OR = 1.37 (95%CI:1.16-1.60, P < 0.001) and OR = 3.17 (95%CI:1.25-8.02, P = 0.02), respectively.

CONCLUSIONS

Peri-operative pRBC use appears to be an independent risk factor for ARDS and respiratory failure after pneumonectomy. There is a significant dose-response relationship. Platelets and FFP did not appear to increase ARDS risk but this may be due to low utilization.

[Consequences of pneumonectomy in the early and late phases]

Pneumonectomy can represent the appropriate surgical treatment option in advanced or centrally localized non-small cell lung cancer (NSCLC). A satisfactory oncologic tumor surgery can be reached in these cases although pneumonectomy is associated with a significantly higher mortality and morbidity than less extensive resection of the lung parenchyma.The aim of this article is a systematic review and the presentation of possible postoperative consequences of pneumonectomy in the early and late phases, which depend not only on the underlying disease but are also primarily affected by the state and function of the remaining contralateral lung parenchyma. Cardiopulmonary complications, especially pneumonia, pulmonary embolism, cardiac arrhythmia or myocardial infarction lead to increased 30-day mortality in the early postoperative period. Moreover, advanced ages over 70 years can be identified as a significant risk factor for poor quality of life after pneumonectomy.

Perioperative fluid management for pulmonary resection surgery and esophagectomy

Perioperative fluid management is of significant importance during pulmonary resection surgery and esophagectomy. Excessive fluid administration has been consistently shown as a risk factor for lung injury after thoracic procedures. Probable causes of this serious complication include fluid overload, lung lymphatics and pulmonary endothelial damage. Along with new insights regarding the Starling equation and the absence of a third space, current evidence supports a restrictive fluid regimen for patients undergoing pulmonary resection surgery and esophagectomy. Multiple minimally invasive hemodyamic monitoring devices, including pulse pressure/stroke volume variation, esophageal Doppler, and extravascular lung water measurement, were evaluated for optimizing perioperative fluid therapy. Further research regarding the prevention, diagnosis, and treatment of acute lung injury after pulmonary resection and esophagectomy is required.

Does a conservative fluid management strategy in the perioperative management of lung resection patients reduce the risk of acute lung injury?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether a conservative fluid management strategy in the perioperative management of lung resection patients is associated with a reduced incidence of postoperative acute lung injury (PALI) and/or acute respiratory distress syndrome (ARDS) in the recovery period. Sixty-seven papers were found using the reported search, of which 13 level III and 1 level IV evidence studies represented the best evidence to answer the question. Two retrospective case-control studies demonstrated a direct association between liberal fluid intake and the incidence of PALI/ARDS following lung resection on multivariate analysis (MVA) with odds ratios (ORs) of 1.42 (95% CI 1.09-4.32, P = 0.011) and 2.91 (1.9-7.4, P = 0.001). In non-PALI/ARDS cases, the mean intraoperative fluid infusion volume was significantly less [1.22 l (1.17-1.26) vs 1.68 l (1.46-1.9) P = 0.005], the fluid balance over the first 24 postoperative hours was significantly less [1.52 l positive (1.44-1.60) vs 2.0 l positive (1.6-2.4) P = 0.026] and cumulated intra- and postoperative fluid infusion was significantly less [2.0 ml/kg/h (1.7-2.3) vs 2.6 ml/kg/h (2.3-2.9) P = 0.003]. These data show that the difference between fluid regimes associated with an increased incidence of PALI/ARDS (i.e. 'liberal') and those which are not (i.e. 'conservative') is narrow but significant. However, this does not prove a causative role for liberal fluid in the multifactorial development of PALI/ARDS. On this best evidence, we recommend intra- and postoperative maintenance fluid to be administered at 1-2 ml/kg/h and that a positive fluid balance of 1.5 l should not be exceeded in the perioperative period with caution being exercised with regard to the adequacy of oxygen delivery. If the fluid balance exceeds this threshold, a high index of suspicion for PALI/ARDS should be adopted and escalation of the level of care should be considered. If a patient develops signs of hypoperfusion after these thresholds are exceeded, inotropic/vasopressor support should be considered.