Effect of the amount of intraoperative fluid administration on postoperative pulmonary complications following anatomic lung resections

Risk Factors for Postoperative Pulmonary Complications in Patients Undergoing Thoracotomy for Indications Other than Primary Lung Cancer Resection: A Multicenter Retrospective Cohort Study from the German Thorax Registry

Background: Postoperative pulmonary complications (PPCs) are the most common complications following lung surgery and can lead to increased postoperative mortality. In this study, we examined the incidence of PPCs, the in-hospital mortality rate, and the risk factors associated with PPCs in patients undergoing open thoracotomy lung resection (OTLR) for reasons other than primary lung cancer. Methods: Data from this multicenter, retrospective study involving 1.368 patients were extracted from the German Thorax Registry and analyzed using univariate and multivariable statistical methods. Results: In total, 278 patients showed at least one PPC. The presence of PPCs was associated with a significantly higher in-hospital mortality rate (7.2% vs. 1.5%; p = 0.000). Multivariable stepwise logistic regression analysis showed absolute age (OR 1.02) and BMI ≤ 19 (OR 2.6) as independent patient-specific risk factors. Significant preoperative risk factors included re-thoracotomy (OR 4.0) and FEV1 < 60% (OR 2.5). Procedure-related independent risk factors for PPCs included a surgical duration surpassing 195 min (OR 2.7), the continuation of invasive ventilation post-surgery (OR 3.8), and an intraoperative infusion of crystalloids greater than 6 mL/kg/h (OR 1.8). Conclusions: Optimizing intraoperative fluid therapy and on-table extubation when possible may reduce the incidence of PPCs and associated mortality.

Perioperative fluid management: evidence-based consensus recommendations from the international multidisciplinary PeriOperative Quality Initiative

Fluid therapy is an integral component of perioperative management. In light of emerging evidence in this area, the Perioperative Quality Initiative (POQI) convened an international multiprofessional expert meeting to generate evidence-based consensus recommendations for fluid management in patients undergoing surgery. This article provides a summary of the recommendations for perioperative fluid management of surgical patients from the preoperative period until hospital discharge and for all types of elective and emergency surgery, apart from burn injuries and head and neck surgery. Where evidence was lacking, recommendations for future research were generated. Specific recommendations are made for fluid management in elective major noncardiac surgery, cardiopulmonary bypass, thoracic surgery, neurosurgery, minor noncardiac surgery under general anaesthesia, and critical illness. There are ongoing gaps in knowledge resulting in variation in practice and some disagreement with our consensus recommendations. Perioperative fluid management should be individualised, taking into account the type of surgery and important patient factors, including intravascular volume status and acute and chronic comorbidities. Recommendations are made for further research in perioperative fluid management to address important gaps.

Effect of low-dose norepinephrine combined with goal-directed fluid therapy on postoperative pulmonary complications in lung surgery: A prospective randomized controlled trial

STUDY OBJECTIVE

Postoperative pulmonary complications (PPCs), the predominant complications following lung surgery, are closely associated with intraoperative fluid therapy. This study investigates whether continuous low-dose norepinephrine infusion combined with goal-directed fluid therapy (GDFT) reduced the risk of PPCs after lung surgery relative to either GDFT alone or standard fluid treatment.

DESIGN

A prospective, randomized controlled trial.

SETTING

The First Affiliated Hospital of Anhui Medical University, Anhui, China.

PATIENTS

The study included 184 patients undergoing elective thoracoscopic lung resection surgery.

INTERVENTIONS

Patients were randomized into three groups based on different fluid treatment regimens: Group C received standard fluid treatment, Group G received GDFT, and Group N received continuous low-dose norepinephrine infusion combined with GDFT.

MEASUREMENTS

The primary outcome was the incidence of PPCs, including respiratory infection, atelectasis, pneumothorax, pleural empyema, respiratory failure, pulmonary embolism and bronchopleural fistula, during the postoperative hospital stay. Secondary outcomes were hemodynamic variables and arterial blood gases. Additional recorded parameters included other postoperative complications such as bleeding, postoperative re-intubation, re-hospitalization within 30 days, and the length of hospital stay.

MAIN RESULTS

Group N showed a significantly lower PPCs incidence during hospitalization compared to Group C (11.5 % vs 27.9 %; odds ratio, 2.98; 95 % confidence interval, 1.17-8.31; P = 0.023). No significant difference in PPCs was found between Group N and Group G (11.5 % vs 14.5 %; odds ratio, 1.31; 95 % confidence interval, 0.46-3.91; P = 0.616). Additionally, there were no significant differences among the three groups in the components of PPCs. Group N showed higher mean arterial pressure and stroke volume index intraoperatively compared to Group C.

CONCLUSIONS

Continuous low-dose norepinephrine infusion combined with GDFT reduced PPCs incidence in elective lung surgery patients compared with standard fluid management, but showed no difference compared to GDFT alone.

CLINICAL TRIAL REGISTRATION

ChiCTR2200064081.

Goal-Directed Fluid Therapy Using Pulse Pressure Variation in Thoracic Surgery Requiring One-Lung Ventilation: A Randomized Controlled Trial

Background: Intraoperative fluid management based on pulse pressure variation has shown potential to reduce postoperative pulmonary complications (PPCs) and improve clinical outcomes in various surgical settings. However, its efficacy and safety have not been assessed in patients undergoing thoracic surgery with one-lung ventilation. Methods: Patients scheduled for pulmonary lobectomy using uniportal video-assisted thoracic surgery approach were randomly assigned to two groups. In the PPV group, fluid administration was guided by the pulse pressure variation parameter, while in the near-zero group, it was guided by conventional hemodynamic parameters. The primary outcome was the partial pressure of oxygen (PaO2)/ fraction of inspired oxygen (FiO2) ratio 15 min after extubation. The secondary outcomes included extubation time, the incidence of postoperative pulmonary complications in the first three postoperative days, and the length of hospital stay. Results: The PaO2/FiO2 ratio did not differ between the two groups (364.48 ± 38.06 vs. 359.21 ± 36.95; p = 0.51), although patients in the PPV group (n = 44) received a larger amount of both crystalloids (1145 ± 470.21 vs. 890 ± 459.31, p = 0.01) and colloids (162.5 ± 278.31 vs 18.18 ± 94.68, p = 0.002) compared to the near-zero group (n = 44). No differences were found in extubation time, type and number of PPCs, and length of hospital stay. Conclusions: PPV-guided fluid management in thoracic surgery requiring one-lung ventilation does not improve pulmonary gas exchange as measured by the PaO2/FiO2 ratio and does not seem to offer clinical benefits. Additionally, it results in increased fluid administration compared to fluid management based on conventional hemodynamic parameters.

Fluid Management in Acute Respiratory Failure

Fluid management in acute respiratory failure is an area of uncertainty requiring a delicate balance of resuscitation and fluid removal to manage hypoperfusion and avoidance of hypoxemia. Overall, a restrictive fluid strategy (minimizing fluid administration) and careful attention to overall fluid balance may be beneficial after initial resuscitation and does not have major side effects. Further studies are needed to improve our understanding of patients who will benefit from a restrictive or liberal fluid management strategy.

A predictive model for post-thoracoscopic surgery pulmonary complications based on the PBNN algorithm

We constructed an early prediction model for postoperative pulmonary complications after thoracoscopic surgery using machine learning and deep learning algorithms. The artificial intelligence prediction models were built in Python, primarily using artificial intelligencealgorithms including both machine learning and deep learning algorithms. Correlation analysis showed that postoperative pulmonary complications were positively correlated with age and surgery duration, and negatively correlated with serum albumin. Using the light gradient boosting machine(LGBM) algorithm, weighted feature engineering revealed that single lung ventilation duration, history of smoking, surgery duration, ASA score, and blood glucose were the main factors associated with postoperative pulmonary complications. Results of artificial intelligence algorithms for predicting pulmonary complications after thoracoscopy in the test group: In terms of accuracy, the two best algorithms were Logistic Regression (0.831) and light gradient boosting machine(0.827); in terms of precision, the two best algorithms were Gradient Boosting (0.75) and light gradient boosting machine (0.742); in terms of recall, the three best algorithms were gaussian naive bayes (0.581), Logistic Regression (0.532), and pruning Bayesian neural network (0.516); in terms of F1 score, the two best algorithms were LogisticRegression (0.589) and pruning Bayesian neural network (0.566); and in terms of Area Under Curve(AUC), the two best algorithms were light gradient boosting machine(0.873) and pruning Bayesian neural network (0.869). The results of this study suggest that pruning Bayesian neural network (PBNN) can be used to assess the possibility of pulmonary complications after thoracoscopy, and to identify high-risk groups prior to surgery.

Incidence and risk factors of postoperative pulmonary complications after oral cancer surgery with free flap reconstruction: A single center study

BACKGROUND

Postoperative pulmonary complications (PPCs) increase the risk of morbidity and mortality in patients who underwent oral cancer surgery with free flap reconstruction. The association between PPC and preoperative risk factors has been investigated; however, reports on intraoperative factors are limited. Therefore, we investigated PPC incidence and its associated preoperative and intraoperative risk factors in these patients.

METHODS

We retrospectively analyzed medical records of patients who underwent free flap reconstruction between 2009 and 2019. PPC was defined as presence of atelectasis, pneumonia, and respiratory failure based on radiological confirmation and clinical symptoms during hospitalization. Mortality, hospital stay, preoperative factors (including age and tumor stages), American Society of Anesthesiologists (ASA) classification, and intraoperative factors (including intraoperative fluids and medications) were recorded.

RESULTS

PPC incidence among the 993 patients included in this study was 25.8% (256 patients). Six patients with PPCs died; death was not observed among patients without PPCs (p < 0.001). Patients with PPCs had longer hospitalization than those without PPCs (30.3 vs 23.3 days; p < 0.001). Tumor stage (stage I: reference; stage II [OR]: 3.3, p = 0.019; stage III: 4.4, p = 0.002; stage IV: 4.8, p = 0.002), age (OR: 1.0; p < 0.001), and ASA grade >2 (OR: 1.4; p = 0.020) were independent risk factors of PPC; using labetalol was a borderline significant factor (OR: 1.4; p = 0.050).

CONCLUSION

The PPC incidence was 25.8% in patients undergoing oral cancer surgery with free flap reconstruction. Tumor stage, age, and ASA >2 were risk factors of developing PPC.

The impact of goal-directed fluid therapy on postoperative pulmonary complications in patients undergoing thoracic surgery: a systematic review and meta-analysis

BACKGROUND

Pulmonary complications after thoracic surgery are common and associated with significant morbidity and high cost of care. Goal-directed fluid therapy (GDFT) could reduce the incidence of postoperative pulmonary complications (PPCs) and facilitate recovery in patients undergoing major abdominal surgery. However, whether GDFT could reduce the incidence of PPCs in patients undergoing thoracic surgery was unclear. The present meta-analysis was designed to assess the impact of Goal-directed Fluid Therapy on PPCs in patients undergoing thoracic surgery.

METHODS

Randomized controlled trials (RCTs) comparing GDFT with other conventional fluid management strategies in adult patients undergoing thoracic surgery were identified. Databases searched included PubMed, Web of Science, Embase, and Cochrane Library databases. Review Manager 5.4 (The Cochrane Collaboration, Oxford, UK) software was used for statistical analysis. Heterogeneity was analyzed using I2 statistics, and a standardized mean difference with 95% CI and P value was used to calculate the treatment effect for outcome variables. The primary study outcomes were the incidence of PPCs. Secondary outcomes were the total volume infused, the length of hospitalization, the incidence of cardiac complications, and the incidence of renal dysfunction. Subgroup analysis was planned to verify the definite role of GDFT.

RESULTS

A total of 6 RCTs consisting of 680 patients were included in this meta-analysis, which revealed that GDFT did not reduce the incidence of PPCs in patients undergoing thoracic surgery (RR, 0.57; 95% CI 0.29-1.14). However, GDFT decreased the total intra-operative fluid input (MD, - 244.40 ml; 95% CI - 397.06 to - 91.74). There was no statistical difference in the duration of hospitalization (MD; - 1.31, 95% CI - 3.00 to 0.38), incidence of renal dysfunction (RR, 0.62; 95% CI 0.29-1.35), and incidence of cardiac complications (RR, 0.62; 95% CI 0.27-1.40).

CONCLUSIONS

The results of this meta-analysis indicate that GDFT did not reduce the postoperative incidence of pulmonary complications in individuals undergoing thoracic surgery. However, considering the small number of contributing studies, these results should be interpreted with caution.

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.

Stroke volume variation and dynamic arterial elastance predict fluid responsiveness even in thoracoscopic esophagectomy: a prospective observational study

PURPOSE

It remains unknown whether stroke volume variation (SVV), pulse pressure variation (PPV), and dynamic arterial elastance (Eadyn) are suitable for monitoring fluid management during thoracoscopic esophagectomy (TE) in the prone position with one-lung ventilation and artificial pneumothorax. Our study aimed to evaluate the accuracy of SVV, PVV, and Eadyn in predicting the fluid responsiveness in these patients.

METHODS

We recruited 24 patients who had undergone TE. Patients with a mean arterial blood pressure ≤ 65 mmHg received a 200-ml bolus of 6% hydroxyethyl starch over 10 min. Fluid responders showed the stroke volume index ≥ 15% 5 min after the fluid bolus. Receiver operating characteristic (ROC) curves were generated and area under the ROC curve (AUROC) was calculated.

RESULTS

We obtained 61 fluid bolus data points, of which 20 were responders and 41 were non-responders. The median SVV before the fluid bolus in responders was significantly higher than that in non-responders (18% [interquartile range (IQR) 13-21] vs. 12% [IQR 8-15], P = 0.001). Eadyn was significantly lower in responders than in non-responders (0.55 [IQR 0.45-0.78] vs. 0.91 [IQR 0.67-1.00], P < 0.001). There was no difference in the PPV between the groups. The AUROC was 0.76 for SVV (95% confidence interval [CI] 0.62-0.89, P = 0.001), 0.56 for PPV (95% CI 0.41-0.71, P = 0.44), and 0.82 for Eadyn (95% CI 0.69-0.95, P < 0.001).

CONCLUSIONS

SVV and Eadyn are reliable parameters for predicting fluid responsiveness in patients undergoing TE.

The effect of intraoperative goal-directed fluid therapy combined with enhanced recovery after surgery program on postoperative complications in elderly patients undergoing thoracoscopic pulmonary resection: a prospective randomized controlled study

BACKGROUND

To investigate the effect of intraoperative goal-directed fluid therapy (GDFT) combined with enhanced recovery after surgery (ERAS) program on postoperative complications in elderly patients undergoing thoracoscopic pulmonary resection.

METHODS

Patients, more than 60 years old, undergoing thoracoscopic pulmonary resection for non-small cell lung cancer were randomly divided into GDFT group and restrictive fluid therapy (RFT) group. ERAS program was implemented in all patients. In GDFT group, the intraoperative fluid management was guided by stroke volume variation (SVV), cardiac index (CI), and mean arterial pressure (MAP) and maintained the SVV < 13%, CI > 2.5 L/min/m², and MAP > 65 mmHg. In RFT group, fluid maintenance with 2 ml/kg/h of balanced crystalloid solution, norepinephrine was used to maintain MAP > 65 mmHg. The incidence of postoperative acute kidney injury (AKI) and pulmonary and cardiac complications was compared.

RESULTS

Two-hundred seventy-six patients were enrolled and randomly divided into two groups (138 in each group). Compared to RFT group, the total intraoperative infusion volume, colloids infusion volume, and urine output were more; the dosage of norepinephrine was lower in GDFT group. Although there were no significant differences of postoperative AKI (GDFT vs RFT; 4.3% vs 8%; P = 0.317) and composite postoperative complications (GDFT vs RFT; 66 vs 70) between groups, but the postoperative increase degree of serum creatinine was lower in GDFT group than that in RFT group (GDFT vs RFT; 91.9 ± 25.2 μmol/L vs 97.1 ± 17.6 μmol/L; P = 0.048).

CONCLUSIONS

Under ERAS program, there was no significant difference of AKI incidence between GDFT and RFT in elderly patients undergoing thoracoscopic pulmonary resection. But postoperative increase degree of serum creatinine was lower in GDFT group.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov, NCT04302467 on 26 February 2020.

Post-operative pulmonary complications after thoracic and upper abdominal procedures at referral hospitals in Amhara region, Ethiopia: a multi-center study

Background

Thoraco-abdominal surgery cuts through muscle, disrupting the normal structure and function of the respiratory muscles, resulting in lower lung volumes and a higher risk of developing post-operative pulmonary complications (PPC). PPC remains an important cause of post-operative morbidity and mortality and impacts the long-term outcomes of patients after hospital discharge. This study was aimed at determining the incidence and factors associated with postoperative pulmonary complications among patients who underwent thoracic and upper abdominal surgery in the Amhara region of Ethiopia.

Methods

A multi-center follow-up study was conducted from April 1, 2022, to June 30, 2022, at comprehensive specialized hospitals in Amhara regional state, northwest Ethiopia. 424 patients were consecutively included in this study, with a response rate of 100%. A chart review and patient interview were used to collect data. A logistic regression analysis was performed to assess the strength of the association of independent variables with postoperative pulmonary complications.The crude odds ratio (COR) and adjusted odds ratio (AOR) with the corresponding 95% confidence interval were computed. Variables with a p-value of <0.05 were considered statistically significant predictors of the outcome variable.

Results

The incidence of postoperative pulmonary complication was 24.5%. Emergency procedures, preoperative SpO₂ < 94%, duration of surgery >2 h, patients with a nasogastric tube, intraoperative blood loss >500 ml and post-operative albumin <3.5 g/dl were factors associated with pulmonary complications. The most common complications were pneumonia (9.9%) followed by respiratory infection (4.2%).

Conclusion

The incidence of postoperative pulmonary complication after thoracic and upper abdominal surgery remains high. Preoperative SpO₂, duration of surgery, patients having a nasogastric tube, intraoperative blood loss and post-operative albumin were factors associated with post-operative pulmonary complications.

Risk Factors for Postoperative Pulmonary Complications Leading to Increased Morbidity and Mortality in Patients Undergoing Thoracic Surgery for Pleural Empyema

OBJECTIVES

Surgery for pleural empyema carries a high burden of morbidity and mortality. The authors investigated the incidence of postoperative pulmonary complications (PPCs) and their effects on perioperative morbidity and mortality. Patient-specific, preoperative, procedural, and postoperative risk factors for PPCs were analyzed.

DESIGN

Retrospective observational study.

SETTING

A single, large university hospital.

PARTICIPANTS

A total of 250 adult patients were included who underwent thoracic surgery for pleural empyema between January 2017 and December 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 250 patients with pleural empyema underwent thoracic surgery by video-assisted thoracoscopic surgery (49%; n = 122) or open thoracotomy (51%; n = 128). A proportion (42% [105]) of patients had ≥1 PPCs; 28% (n = 70) had to undergo resurgery; and 10% (n = 25) were re-admitted unexpectedly to the ICU. Preoperative respiratory failure (odds ratio [OR]: 5.8, 95% CI: 2.4-13.1), general anesthesia without regional analgesia techniques (OR: 2.9, 95% CI: 1.4-5.8), open thoracotomy and subsequent resurgery (OR: 3.9, 95% CI 1.5-9.9), surgery outside the regular working hours (OR: 3.1, 95% CI 1.2-8.2), and postoperative sepsis (OR: 2.6, 95% CI 1.1-6.8) were identified as independent risk factors for PPCs. Postoperative pulmonary complications were independent factors for unplanned intensive care unit admission (OR: 10.5, 95% CI 2.1-51 for >1 PPC), death within 360 days (OR: 4.5, 95% CI 2.2-12.3 for ≥2 PPCs), and death within 30 days for ≥1 PPCs (OR: 1.2, 95% CI 1.1-1.3).

CONCLUSIONS

The incidence of PPCs is a significant risk factor for morbidity and mortality after surgery for pleural empyema. Targeting the risk factors identified in this study could improve patient outcomes.

The ARISCAT Risk Index as a Predictor of Pulmonary Complications After Thoracic Surgeries, Almoosa Specialist Hospital, Saudi Arabia

Background

Pulmonary complications after thoracic surgery are common and are associated with prolonged hospital stay, higher costs, and increased mortality. This study aimed to evaluate the value of The Assess Respiratory risk in Surgical Patients in Catalonia (ARISCAT) risk index in predicting pulmonary complications after thoracic surgery.

Methods

This retrospective study was conducted at Almoosa Specialist Hospital, Saudi Arabia, from August 2016 to August 2019 and included 108 patients who underwent thoracic surgery during the study period. Demographic data, ARISCAT risk index score, length of hospital stay, time of chest tube removal, postoperative complications, and time of discharge were recorded.

Results

The study involved 108 patients who met the inclusion criteria. Their mean age was 42.5 ± 18.9 years, and most of them were men (67.6%). Comorbid diseases were present in 53.7%, including mainly type 2 diabetes mellitus and hypertension. FEV1% was measured in 58 patients, with a mean of 71.1 ± 7.3%. The mean ARISCAT score was 39.3 ± 12.4 and ranged from 24 to 76, with more than one-third (35.2%) having a high score grade. The most common surgical procedures were thoracotomy in 47.2%, video-assisted thoracoscopic surgery (VATS) in 28.7%, and mediastinoscopy in 17.6%. Postoperative pulmonary complications (PPCs) occurred in 22 patients (20.4%), mainly pneumonia and atelectasis (9.2%). PPCs occurred most frequently during thoracotomy (68.2%), followed by VATS (13.6%), and mediastinoscopy (9.1%). Multinomial logistic regression of significant risk factors showed that lower FEV1% (OR = 0.88 [0.79-0.98]; p=0.017), longer ICU length of stay (OR = 1.53 [1.04-2.25]; p=0.033), a higher ARISCAT score (OR = 1.22 [1.02-1.47]; p=0.040), and a high ARISCAT grade (OR = 2.77 [1.06-7.21]; p=0.037) were significant predictors of the occurrence of postoperative complications.

Conclusion

ARISCAT scoring system, lower FEV1% score, and longer ICU stay were significant predictors of postoperative complications. In addition, thoracotomy was also found to be associated with PPCs.

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.

Sugammadex for reversing neuromuscular blockages after lung surgery: A systematic review and meta-analysis

BACKGROUND

This study determined whether sugammadex was associated with a lower risk of postoperative pulmonary complications and improved outcomes in lung surgeries.

METHODS

A systematic literature search was conducted using PubMed, Embase, Web of Science, and the Cochrane Library from January 2000 to March 2022. The characteristics of lung surgeries using sugammadex treatment compared with control drugs and postoperative outcomes were retrieved. The primary outcome was estimated through a pooled odds ratio (OR) and its 95% confidence interval (CI) was identified using a random-effects model.

RESULTS

From 465 citations, 7 studies with 453 patients receiving sugammadex and 452 patients receiving a control were included. The risk of postoperative pulmonary complication (PPCs) was lower in the sugammadex group than in the control group. Also, it showed that the effect of sugammadex on PPCs in the subgroup analysis was significantly assessed on the basis of atelectasis or non-atelectasis. Furthermore, subgroup analysis based on the relationship between high body mass index (BMI) and PPCs also showed that sugammadex had less occurrence in both the high BMI (defined as BMI ≥ 25) and low BMI groups. No difference in length of hospital stay (LOS) between the two groups was observed.

CONCLUSION

This study observed that although reversing neuromuscular blockages with sugammadex in patients undergoing thoracic surgery recorded fewer PPCs and shorter extubation periods than conventional reversal agents, no difference in LOS, postanaesthesia care unit (PACU) stay length and chest tube insertion duration in both groups was observed.

Risk Factors for Postoperative Pulmonary Complications Leading to Increased In-Hospital Mortality in Patients Undergoing Thoracotomy for Primary Lung Cancer Resection: A Multicentre Retrospective Cohort Study of the German Thorax Registry

Postoperative pulmonary complications (PPCs) represent the most frequent complications after lung surgery, and they increase postoperative mortality. This study investigated the incidence of PPCs, in-hospital mortality rate, and risk factors leading to PPCs in patients undergoing open thoracotomy lung resections (OTLRs) for primary lung cancer. The data from 1426 patients in this multicentre retrospective study were extracted from the German Thorax Registry and presented after univariate and multivariate statistical processing. A total of 472 patients showed at least one PPC. The presence of two PPCs was associated with a significantly increased mortality rate of 7% (p < 0.001) compared to that of patients without or with a single PPC. Three or more PPCs increased the mortality rate to 33% (p < 0.001). Multivariate stepwise logistic regression analysis revealed male gender (OR 1.4), age > 60 years (OR 1.8), and current or previous smoking (OR 1.6), while the pre-operative risk factors were still CRP levels > 3 mg/dl (OR 1.7) and FEV1 < 60% (OR 1.4). Procedural independent risk factors for PPCs were: duration of surgery exceeding 195 min (OR 1.6), the amount of intraoperative blood loss (OR 1.6), partial ligation of the pulmonary artery (OR 1.5), continuing invasive ventilation after surgery (OR 2.9), and infusion of intraoperative crystalloids exceeding 6 mL/kg/h (OR 1.9). The incidence of PPCs was significantly lower in patients with continuous epidural or paravertebral analgesia (OR 0.7). Optimising perioperative management by implementing continuous neuroaxial techniques and optimised fluid therapy may reduce the incidence of PPCs and associated mortality.

The association between double-lumen tube versus bronchial blocker and postoperative pulmonary complications in patients after lung cancer surgery

Background

Both double-lumen tube (DLT) and bronchial blocker (BB) are used for lung isolation in patients undergoing lung cancer surgery. However, the effects of different devices for lung isolation remain inconclusive. Present study was designed to investigate the association between the choice of the two devices and postoperative pulmonary complications (PPCs) in patients with lung cancer.

Methods

In this retrospective cohort study, patients who underwent lung cancer surgery between January 1, 2020 and October 31, 2020 were screened. Patients were divided into two groups according to different devices for lung isolation: DLT group and BB group. Primary outcome was the incidence of a composite of PPCs during postoperative in-hospital stay.

Results

A total of 1721 were enrolled for analysis, of them, 868 received DLT and 853 BB. A composite of PPCs was less common in patients with BB (25.1%, [214/853]) than those received DLT (37.9% [329/868] OR 0.582 95% CI 0.461-0.735 P < 0.001). Respiratory infection was less common in BB group (14.4%, [123/853]) than DLT group (30.3%, [263/868], P<0.001). The incidence of non-PPCs complications was not statistically significant between the 2 groups.

Conclusions

For patients undergoing surgery for lung cancer, the use of BB for lung isolation was associated with a reduced risk of PPCs when compared with DLT.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyzes, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

MEasuring the impact of Anesthetist-administered medications volumeS on intraoperative flUid balance duRing prolonged abdominal surgEry (MEASURE Study)

BACKGROUND

The contribution of intraoperative anesthetist-administered medications (IAAMs) to the total volume of intraoperative intravenous (IV) fluid therapy and their association with postoperative outcomes has never been formally investigated.

METHODS

We performed a retrospective study of adult patients undergoing pancreaticoduodenectomy. The volume of IAAMs, crystalloids and colloids, blood and blood products, blood loss, urine output and intraoperative fluid balance were collected. The contribution of IAAMs to the total intraoperative IV fluid volume and postoperative complications was evaluated.

RESULTS

A total of 152 consecutive patients were included. The median volume of IAAMs was 363.8 mL (interquartile range [IQR], (241.0-492.5) delivered at a median rate of 0.61 mL kg hr^-1 (0.40-0.87) over a median duration of surgery of 489 minutes (416.3-605.3). This increased the total administered fluid volume by 5.2% (95% confidence intervals [CI]: 4.6, 5.9%) (Cohen's d=1.33, P<0.001). The volume of IAAMs was comparable to the intraoperative colloid volume administered (median colloid volume, 400 mL). Overall, fluid volumes correlated significantly with the severity of complications (P=0.011), and the correlation strength increased when the IAAMs volume was included (P=0.005). On addition of IAAMs, the area under the receiver operator characteristic curve for prediction of postoperative complications increased from 0.580 (95%CI: 0.458, 0.701) to 0.603 (95%CI: 0.483, 0.723), P=0.041).

CONCLUSIONS

IAAMs significantly increased the total administered fluid volume during pancreaticoduodenectomy. Their inclusion increases the accuracy of postoperative complications predictions. These findings support their inclusion in fluid volumes and balances in future interventional studies.

Should fluid management in thoracic surgery be goal directed?

PURPOSE OF REVIEW

To find a reliable answer to the question in the title: Should fluid management in thoracic surgery be goal directed?

RECENT FINDINGS

'Moderate' fluid regimen is the current recommendation of fluid management in thoracic anesthesia, however, especially in more risky patients; 'Goal-Directed Therapy' (GDT) can be a more reliable approach than just 'moderate'. There are numerous studies examining its effects in general anesthesia; albeit mostly retrospective and very heterogenic. There are few studies of GDT in thoracic anesthesia with similar drawbacks.

SUMMARY

Although the evidence level is low, GDT is generally associated with fewer postoperative complications. It can be helpful in decision-making for volume-optimization, timing of fluid administration, and indication of vasoactive agents.

Effects of preoperative pulmonary function on short-term outcomes and overall survival after video-assisted thoracic surgery lobectomy

Background

Preoperative pulmonary function tests are a necessary preoperative assessment tool for non-small cell lung cancer (NSCLC) patients awaiting surgery. We studied the effects of preoperative pulmonary function on short-term outcomes and overall survival (OS).

Methods

A retrospective cohort study was undertaken with adult NSCLC patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy between May 2016 and April 2017. The primary exposure variables were the percentage of predicted peak expiratory flow (PEF%), the percentage of predicted forced vital capacity (FVC%), and the percentage of predicted forced expiratory volume in 1 s. The observation outcomes were postoperative pulmonary complications (PPCs), acute kidney injury (AKI), in-hospital mortality, readmission within 30 days, and OS. Univariate and multivariate analyses were performed.

Results

Of the 548 patients, postoperative pneumonia was observed in 206 (37.6%). The results of the binary logistics regression analysis showed that relative to the moderate PEF% group, the risk of postoperative pneumonia was significantly increased in the marginal PEF% [odds ratio (OR) 2.076; 95% confidence interval (CI): 1.211–3.558; P=0.008] and excellent PEF% (OR 1.962; 95% CI: 1.129–3.411; P=0.017) groups. Relative to the good FVC% group, the risk of postoperative pneumonia was significantly increased in the marginal FVC% (OR 2.125; 95% CI: 1.226–3.683; P=0.007) and moderate FVC% (OR 2.230; 95% CI: 1.298–3.832; P=0.004) groups. The OS analysis did not reveal any correlations among the pulmonary function parameters and OS in this cohort.

Conclusions

Preoperative PEF% and FVC% are associated with postoperative pneumonia in NSCLC patients undergoing VATS lobectomy. Preoperative PEF% is as important as FVC% in pulmonary function assessment before lung surgery.

Prospective comparison of the effects of intraoperative goal-directed fluid therapy and restrictive fluid therapy on complications in thoracoscopic lobectomy

Objective

Restrictive fluid therapy is recommended in thoracoscopic lobectomy to reduce postoperative pulmonary complications, but it may contribute to hypovolemia. Goal-directed fluid therapy (GDFT) regulates fluid infusion to an amount required to avoid dehydration. We compared the effects of GDFT versus restrictive fluid therapy on postoperative complications after thoracoscopic lobectomy.

Methods

In total, 124 patients who underwent thoracoscopic lobectomy were randomized into the GDFT group (group G, n = 62) or restrictive fluid therapy group (group R, n = 62). The fluid volume and postoperative complications within 30 days of surgery were recorded.

Results

The total fluid volume in groups G and R was 1332 ± 364 and 1178 ± 278 mL, respectively. Group R received a smaller colloid fluid volume (523 ± 120 vs. 686 ± 180 mL), had a smaller urine output (448 ± 98 vs. 491 ± 101 mL), and received more norepinephrine (120 ± 66 vs. 4 ± 18 µg) than group G. However, there were no significant differences in postoperative pulmonary complications, acute kidney injury, length of hospital stay, or in-hospital mortality between the two groups.

Conclusion

Restrictive fluid therapy performs similarly to GDFT in thoracoscopic lobectomy but is a simpler fluid strategy than GDFT.

Trial registration: This study has been registered at the Chinese Clinical Trial Registry (ChiCTR2100051339) (http://www.chictr.org.cn/index.aspx).

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.

Does laparoscopic hepatectomy offer benefits for patients with COPD? A propensity score analysis

BACKGROUND

To date, it remains unclear whether laparoscopic hepatectomy (LH) is safe and feasible for patients with chronic obstructive pulmonary disease (COPD). Thus, we compared the perioperative outcomes of LH versus open hepatectomy (OH) in this special cohort of patients.

METHODS

Between February 2014 and October 2020, 162 patients who underwent hepatectomy met the inclusion and exclusion criteria of this study. Perioperative data were compared between the two groups by propensity score matching (PSM) analysis.

RESULTS

After PSM, 55 patients with well-balanced baseline data were included in each group. Intraoperative blood loss, overall postoperative complications, and postoperative pulmonary complications (PPCs) were significantly lower in the LH group than in the OH group (P < 0.001, P = 0.047, and P = 0.020 after PSM, respectively). However, major complications, early readmission, and early mortality were comparable between the two groups. According to multivariate analysis, high stage of COPD, preoperative tobacco use, and long operative time were independent risk factors for PPCs, whereas treatment with LH was a protective factor.

CONCLUSION

LH is safe and feasible for selected patients with COPD when performed by experienced surgeons, and it has superior perioperative outcomes (especially regarding PPCs) when compared to OH.

Effect of intraoperative blood loss on postoperative pulmonary complications in patients undergoing video-assisted thoracoscopic surgery

Background

We aimed to investigate the impact of intraoperative blood loss on postoperative pulmonary complications in patients who underwent video-assisted thoracoscopic lobectomy for nonsmall cell lung cancer.

Methods

Data of a total of 409 patients (227 males, 182 females; median age: 62 years; range, 20 to 86 years) who underwent lung resection for Stage I-IIIa non-small cell lung cancer in our clinic between July 2017 and April 2018 were retrospectively analyzed. The receiver operating characteristic analysis was used to confirm the threshold value of intraoperative blood loss for the prediction of postoperative pulmonary complications. Propensity score matching was performed to compare between high-intraoperative blood loss and low-intraoperative blood loss groups. A post-matching conditional logistic regression was conducted to determine the independent risk factors for postoperative pulmonary complications.

Results

Of the patients, 86 (21.03%) developed postoperative pulmonary complications. In the propensity score matching analysis, intraoperative blood loss was shown to be a predictive factor of postoperative pulmonary complications (3.992; 95% confidence interval [CI]: 1.54-10.35; p=0.004). The rate of postoperative pulmonary complications in high-intraoperative blood loss group was significantly higher than that the low-intraoperative blood loss group (37.5% vs. 13.9%, respectively; p=0.003). The postoperative length of stay and duration of postoperative antibiotic use were significantly prolonged in the high-intraoperative blood loss group.

Conclusion

Intraoperative blood loss serves as a significant risk factor for postoperative pulmonary complications after lung resection for non-small cell lung cancer. Surgeons should strive to reduce intraoperative blood loss for better surgical outcomes.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Risk factors of middle lobe bronchus kinking following right upper lobectomy

Background

The incidence rate of kinking of the middle lobe bronchus following right upper lobectomy is higher compared to that with residual lung bronchus following other lobectomies. Bronchial kinking was presumed to be caused by the displacement of the residual lung lobes, but its etiology is unclear. Moreover, prevention methods and effective treatments have not yet been established. The purpose of this study was to investigate the risk factors and etiology of middle lobe bronchus kinking and discuss prevention methods.

Methods

Patients who underwent right upper lobectomy in our hospital were retrospectively evaluated. Patient clinical characteristics, lung function, and lung lobe volume, surgical procedure were analyzed in association with the incidence of middle lobe bronchus kinking. The association between the displacement of residual lung lobes after operation and the incidence of middle lobe bronchus kinking was analyzed to assess the etiology.

Results

A total of 175 patients were enrolled in the risk analysis. Middle lobe bronchus kinking was observed in 5 patients (2.9%). The low percentage of forced expiratory volume percentage in 1 second (P=0.021), the low volume ratio of the right middle lobe (RML) to the right thoracic cavity (RTC) (P=0.016), and the low volume ratio of RML to right upper lobe (RML/RUL) (P=0.006) were significant risk factors of middle lobe bronchus kinking. In the patients who underwent CT at 6 months after surgery, the degree of the cranial displacement of RML was associated with the incidence of middle lobe bronchus kinking (P=0.025).

Conclusions

The risk of middle lobe bronchus kinking could be assessed preoperatively by calculating the volume ratio of RML/RTC and RML/RUL. The displacement of RML could be associated with the incidence of middle lobe bronchus kinking.

Transesophageal echocardiography for perioperative management in thoracic surgery

PURPOSE OF REVIEW

Perioperative transesophageal echocardiography (TEE) is most often employed during cardiac surgery. This review will summarize some of the recent findings relevant to TEE utilization during thoracic surgical procedures.

RECENT FINDINGS

Hemodynamic monitoring is a key component of goal-directed fluid therapy, which is also becoming more common for management of thoracic surgical procedures. Although usually not required for the anesthetic management of common thoracic surgeries, TEE is frequently used during lung transplantation and pulmonary thromboendarterectomy. Few clinical studies support current practice patterns, and most recommendations are based on expert opinion.

SUMMARY

Currently, routine use of TEE in thoracic surgery is often limited to specific high-risk patients and/or procedures. As in other perioperative settings, TEE may be utilized to elucidate the reasons for acute hemodynamic instability without apparent cause. Contraindications to TEE apply and have to be taken into consideration before performing a TEE on a thoracic surgical patient.

Guidelines on enhanced recovery after pulmonary lobectomy

OBJECTIVE

To establish recommendations for optimisation of the management of patients undergoing pulmonary lobectomy, particularly Enhanced Recovery After Surgery (ERAS).

DESIGN

A consensus committee of 13 experts from the French Society of Anaesthesia and Intensive Care Medicine (Soci,t, franOaise d'anesth,sie et de r,animation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Soci,t, franOaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Five domains were defined: 1) patient pathway and patient information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for lobectomy; 4) surgical strategy for lobectomy; and 5) enhanced recovery after surgery. For each domain, the objective of the recommendations was to address a number of questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). An extensive literature search on these questions was carried out and analysed using the GRADE® methodology. Recommendations were formulated according to the GRADE® methodology, and were then voted by all experts according to the GRADE grid method.

RESULTS

The SFAR/SFCTCV guideline panel provided 32 recommendations on the management of patients undergoing pulmonary lobectomy. After two voting rounds and several amendments, a strong consensus was reached for 31 of the 32 recommendations and a moderate consensus was reached for the last recommendation. Seven of these recommendations present a high level of evidence (GRADE 1+), 23 have a moderate level of evidence (18 GRADE 2+ and 5 GRADE 2-), and 2 correspond to expert opinions. Finally, no recommendation was provided for 2 of the questions.

CONCLUSIONS

A strong consensus was expressed by the experts to provide recommendations to optimise the whole perioperative management of patients undergoing pulmonary lobectomy.

Minimizing postoperative pulmonary complications in thoracic surgery patients

PURPOSE OF REVIEW

Quantification and optimization of perioperative risk factors focusing on anesthesia-related strategies to reduce postoperative pulmonary complications (PPCs) after lung and esophageal surgery.

RECENT FINDINGS

There is an increasing amount of multimorbid patients undergoing thoracic surgery due to the demographic development and medical progress in perioperative medicine. Nevertheless, the rate of PPCs after thoracic surgery is still up to 30-50% with a significant influence on patients' outcome. PPCs are ranked first among the leading causes of early mortality after thoracic surgery. Although patients' risk factors are usually barely modifiable, current research focuses on procedural risk factors. From the surgical position, the minimal-invasive approach using video-assisted thoracoscopy and laparoscopy leads to a decreased rate of PPCs. The anesthesiological strategy to reduce the incidence of PPCs after thoracic surgery includes neuroaxial anesthesia, lung-protective ventilation, and goal-directed hemodynamic therapy.

SUMMARY

The main anesthesiological strategies to reduce PPCs after thoracic surgery include the use of epidural anesthesia, lung-protective ventilation: PEEP (positive end-expiratory pressure) of 5-8 mbar, tidal volume of 5 ml/kg BW (body weight) and goal-directed hemodynamics: CI (cardiac index) ≥ 2.5 l/min per m2, MAD (Mean arterial pressure) ≥ 70 mmHg, SVV (stroke volume variation) < 10% with a total amount of perioperative crystalloid fluids ≤ 6 ml/kg BW (body weight) per hour.

Effects of intraoperative goal-directed fluid therapy and restrictive fluid therapy combined with enhanced recovery after surgery protocol on complications after thoracoscopic lobectomy in high-risk patients: study protocol for a prospective randomized controlled trial

BACKGROUND

Acute kidney injury (AKI) is a common complication after thoracoscopic lobectomy in high-risk patients due to insufficient intraoperative infusion. Goal-directed fluid therapy (GDFT) is an individualized fluid infusion strategy; the fluid infusion strategy is adjusted according to the patient's fluid response. GDFT during operation can reduce the incidence of AKI after major surgery. Enhanced recovery after surgery (ERAS) protocol optimizes perioperative interventions to decrease the postoperative complications after surgery. In ERAS protocol of lobectomy, intraoperative restrictive fluid therapy is recommended. In this study, we will compare the effects of intraoperative GDFT with restrictive fluid therapy combined with an ERAS protocol on the incidence of AKI after thoracoscopic lobectomy in high-risk patients.

METHODS/DESIGN

This is a prospective single-center single-blind randomized controlled trial. Two hundred seventy-six patients scheduled for thoracoscopic lobectomy are randomly allocated to receive either GDFT or restrictive fluid therapy combined with an ERAS protocol at a 1:1 ratio. The primary outcome is the incidence of AKI after operation. The secondary outcomes include (1) the incidence of renal replacement therapy, (2) the length of intensive care unit stay after operation, (3) the length of hospital stay after operation, and (4) the incidence of other complications including infection, acute lung injury, pneumonia, arrhythmia, heart failure, myocardial injury after noncardiac surgery, and cardiac infarction.

DISCUSSION

This is the first study to compare intraoperative GDFT with restrictive fluid therapy combined with an ERAS protocol on the incidence of AKI after thoracoscopic lobectomy in high-risk patients. The hypothesis is that the restrictive fluid therapy is noninferior to GDFT in reducing the incidence of AKI, but restrictive fluid therapy is simpler to apply than GDFT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04302467 . Registered on 26 February 2020.

A Tool to Predict Readmission to the Intensive Care Unit in Surgical Critical Care Patients-The RISC Score

BACKGROUND

Readmission to the Intensive Care Unit (ICU) is associated with a high risk of in-hospital mortality and higher health care costs. Previously published tools to predict ICU readmission in surgical ICU patients have important limitations that restrict their clinical implementation. We sought to develop a clinically intuitive score that can be implemented to predict readmission to the ICU after surgery or trauma. We designed the score to emphasize modifiable predictors.

METHODS

In this retrospective cohort study, we included surgical patients requiring critical care between June 2015 and January 2019 at Beth Israel Deaconess Medical Center, Harvard Medical School, MA, USA. We used logistic regression to fit a prognostic model for ICU readmission from a priori defined, widely available candidate predictors. The score performance was compared with existing prediction instruments.

RESULTS

Of 7,126 patients, 168 (2.4%) were readmitted to the ICU during the same hospitalization. The final score included 8 variables addressing demographical factors, surgical factors, physiological parameters, ICU treatment and the acuity of illness. The maximum score achievable was 13 points. Potentially modifiable predictors included the inability to ambulate at ICU discharge, substantial positive fluid balance (>5 liters), severe anemia (hemoglobin <7 mg/dl), hyperglycemia (>180 mg/dl), and long ICU length of stay (>5 days). The score yielded an area under the receiver operating characteristic curve of 0.78 (95% CI 0.74-0.82) and significantly outperformed previously published scores. The performance of the underlying model was confirmed by leave-one-out cross-validation.

CONCLUSION

The RISC-score is a clinically intuitive prediction instrument that helps identify surgical ICU patients at high risk for ICU readmission. The simplicity of the score facilitates its clinical implementation across surgical divisions.

Intraoperative Anesthetic Management of the Thoracic Patient

The intraoperative anesthetic management for thoracic surgery can impact a patient's postoperative course, especially in patients with significant lung disease. One-lung ventilation poses an inherent risk to patients, including hypoxemia, acute lung injury, and right ventricular dysfunction. Patient-specific ventilator management strategies during one-lung ventilation can reduce postoperative morbidity.

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.

Individualized lung protective ventilation vs. conventional ventilation during general anesthesia in laparoscopic total hysterectomy

Laparoscopic total hysterectomy is performed by carbon dioxide insufflation, Trendelenburg position and mechanical ventilation of patients under general anesthesia. However, this may induce pulmonary atelectasis and/or hyperdistention of the lungs. Multiple studies have indicated that mechanical ventilation with the use of low tidal volumes, moderate positive end-expiratory pressure (PEEP) and regular alveolar recruitment maneuvers may improve post-operative outcomes. However, the benefits of an individualized level of PEEP have not been clearly established. In the present study, it was hypothesized that a moderate fixed PEEP may not suit all patients and an individually-titrated PEEP during anesthesia may improve the peri-operative pulmonary oxygenation function. The aim of the present study was to compare the pulmonary oxygenation function and post-operative pulmonary complications (PPCs) in patients receiving individualized lung-protective mechanical ventilation (LPV) vs. conventional ventilation (CV) during laparoscopic total hysterectomy. The present study was a randomized double-blinded clinical trial on 87 patients who were randomly divided to receive CV or protective ventilation (PV). An optimal individualized PEEP value was determined using a static pulmonary compliance-directed PEEP titration procedure. Pulmonary oxygenation function, serum inflammatory factors, including interleukin-8 and Clara cell protein 16, the incidence of PPCs and the post-operative length of stay were also determined. Patients in the PV group exhibited improved pulmonary oxygenation function during and after the operation. The total percentage of PPCs during the first 7 days after surgery was significantly lower in the PV group compared with those in the CV group. In conclusion, as compared to CV, intra-operative individualized LPV significantly improved pulmonary oxygenation function and reduced the incidence of PPCs during the first 7 days after laparoscopic total hysterectomy (Clinical trial registration no. ChiCTR1900027738).

Intraoperative fluid therapy and postoperative complications during minimally invasive esophagectomy for esophageal cancer: a single-center retrospective study

PURPOSE

Compared with open thoracotomy, minimally invasive esophagectomy (MIE) methods, such as transhiatal or thoracoscopic esophagectomy, likely have lower morbidity. However, the relationship between intraoperative fluid management and postoperative complications after MIE remains unclear. Thus, we investigated the association of cumulative intraoperative fluid balance and postoperative complications in patients undergoing MIE.

METHODS

This single-center retrospective cohort study examined patients undergoing thoracoscopic esophagectomy for esophageal cancer in the prone position. Postoperative complications included pneumonia, arrhythmia, thrombotic events and acute kidney injury (AKI). We compared patients with higher and lower intraoperative fluid balance (higher and lower than the median). Multivariable logistic regression analyses were performed to estimate the odds ratio of intraoperative fluid balance status on the incidence of postoperative complications.

RESULTS

In total, 135 patients were included in the study. Postoperative complications occurred in 43 (32%), including cardiac arrhythmia (n = 12, 9%), thrombosis (n = 20, 15%), pneumonia (n = 13, 10%), and AKI required hemodialysis (n = 1, 1%). Patients with a higher fluid balance had higher incidence of complications than those with a lower fluid balance (46% vs. 18%, p < 0.001). After adjusting for age, ASA-PS ≥ III, blood loss, and the use of radical surgery, the higher intraoperative fluid balance group was significantly and independently associated with postoperative complications (adjusted OR 5.31, 95% CI 2.26-13.6, p < 0.0001).

CONCLUSIONS

In patients undergoing thoracoscopic esophagectomy in the prone position, a greater intraoperative positive fluid balance was independently associated with a higher incidence of complications.

Validation study of the dynamic parameters of pulse wave in pulmonary resection surgery

INTRODUCTION

In lung resection surgery, restrictive fluid therapy is recommended due to the risk of acute lung injury. In contrast, this recommendation increases the risk of hypoperfusion. Guided fluid therapy allows individualization of fluid intake. The use of dynamic volume response parameters is not validated during one-lung ventilation. The main objective is the validation of dynamic parameters, stroke volume variation (SVV) and pulse pressure variation (PPV), during lung resection surgery as fluid response predictors, after the administration of 250ml crystalloid volume loads, if IC<2.5ml/min/m² and if SVV≥8% and/or PPV≥10%.

MATERIAL AND METHODS

Pilot, prospective, observational and single centre study. Twenty-five patients monitored with the PiCCO system were included during open lung resection surgery with the patient in a lateral position, one lung ventilation with tidal volume (TV): 6ml/kg and open chest. Hemodynamic variables were collected before and after volume loading. The results were classified into two groups: volume responders (increase IC≥10% and/or VSI≥10% after volume loading) and non-responders (no increase or increase IC<10% and/or VSI<10% after volume loading). We assess the diagnostic efficacy of SVV and PPV by analyzing the AUC (area under curve) in the ROC curves.

RESULTS

In the analysis of ROC curves, SVV and PPV did not reach a discriminative value (AUCSVV: 0.47; AUCPPV: 0.50), despite the decrease in the threshold value of SVV and PPV to initiate an overload of volume during one-lung ventilation, in lateral position and open chest.

CONCLUSIONS

The results obtained show that the values of the dynamic parameters of volume response (SVV≥8% and PPV≥10%) do not discriminate against responders patients and non-responders during open lung resection surgery.

Impact of paravertebral blockade use in geriatric patients undergoing thoracic surgery on postoperative adverse outcomes

Background

While it is known that thoracic paravertebral blockade (TPVB) could reduce pain undergoing thoracic surgery, it has not been confirmed whether this reduction in pain reduces pulmonary complications in an elderly population.

Methods

We performed a monocentric retrospective analysis for a prospectively collected patients receiving thoracic surgery with or without intraoperative TPVB between November 7, 2018 and April 1, 2019, at Shanghai Chest Hospital. Whether or not to use TPVB depending on anesthesiologists' preference, the chances of harm and benefit of each patients after discussed with their anesthetist. Chest wall resection, bilateral lung resection, conversion to thoracotomy and ipsilateral reoperation were excluded. A total of 154 patients with lung operations were included in the final analysis, 34 of whom received general anesthesia combined with TPVB (GA-TPVB). The primary outcome was the incidence of postoperative pulmonary complications (PPCs). The secondary outcomes were the incidence of cardiovascular and other complications, required analgesia in post anesthesia care unit (PACU), patient controlled analgesia (PCA) pressing frequency in 24h, chest tube duration, ICU stay and the hospital length of stay (LOS).

Results

The incidence of PPCs undergoing thoracic surgery was about 21.4% (33/154). Compared with GA, GA-TPVB could reduce the incidence of PPCs (25% vs. 9%, P=0.042), mostly reduce postoperative atelectasis (19% vs. 3%, P=0.021). TPVB could reduce the rate of required analgesia in PACU, PCA pressing frequency in 24 h and chest tube duration. However, there were no significant differences on the rate of cardiovascular and other complications, ICU stay and LOS between the two groups (P>0.05). Multivariable logistic regression analysis identified preoperative DLCO% ≥92% (OR =0.293, P=0.006), duration of surgery <75 min (OR =0.278, P=0.008) and GA-TPVB (OR =0.270, P=0.048) was associated with fewer PPCs.

Conclusions

Our study shows that general anesthesia combined with TPVB may reduce PPCs by reducing postoperative pain in geriatric patients undergoing thoracic surgery compared with general anesthesia alone.

Trial registration

Chinese Clinical Trial Registry number, ChiCTR1800019526. Registered on Nov 7, 2018.

Effect of postoperative haemoglobin variation on major cardiopulmonary complications in high cardiac risk patients undergoing anatomical lung resections

OBJECTIVES

Recent evidence shows that permissive anaemia strategies are safe in different surgical settings. However, effects of variations in haemoglobin (Hb) levels could have a negative impact in high-risk patients. We investigated the combined effect of postoperative Hb concentration and cardiac risk status on major cardiopulmonary complications after anatomical lung resections.

METHODS

We retrospectively analysed the records, collected in a prospective clinical database, of 154 consecutive patients undergoing anatomical lung resections at our institution (February 2017-February 2019). Hb levels were displayed as preoperative concentration, nadir Hb level before onset of complications and delta Hb (ΔHb). Cardiac risk was stratified according to the Thoracic Revised Cardiac Risk Index (ThRCRI). Univariable and multivariable logistic regression analyses were used to test the associations between patients, surgical variables and cardiopulmonary complications according to the European Society of Thoracic Surgeons definitions.

RESULTS

Cardiopulmonary complications occurred in 63 patients (17%). In the fully adjusted multivariable model, higher values of ΔHb were associated with increased risk of complications [odds ratio (OR) 1.07; P < 0.001], along with higher ThRCRI classes (classes A-B versus C-D: OR 0.09; P < 0.001). Interaction terms with transfusion were not statistically significant, indicating that the harmful effect of ΔHb was independent. According to receiver operating characteristic curve analysis, a ΔHb of 29 g/l was found to be the best cut-off value for predicting complications.

CONCLUSIONS

In our series, ΔHb, rather than nadir Hb, was associated with an increased risk of complications, particularly in patients with higher cardiac risk. Restrictive transfusion strategies should be carefully applied in patients undergoing lung resections and balanced according to individual clinical status.

Excessive intravenous crystalloid infusion after video-assisted thoracoscopic surgery lobectomy is associated with postoperative pneumonia

Background

Video-assisted thoracoscopic surgery has been widely used in thoracic surgery worldwide. Our goal was to identify the risk factors for postoperative pneumonia in patients undergoing video-assisted thoracoscopic surgery lobectomy.

Methods

A retrospective analysis of adult patients undergoing video-assisted thoracoscopic surgery lobectomy between 2016 and 05 and 2017–04 was performed. We used univariate analyses and multivariate analyses to examine risk factors for postoperative pneumonia after lobectomy.

Results

The incidence of postoperative pneumonia was 19.7% (n = 143/727). Patients with postoperative pneumonia had a higher postoperative length of stay and total hospital care costs when compared to those without postoperative pneumonia. Multivariate analysis showed that body mass index grading ≥24.0 kg/m² (vs. <24.0 kg/m²: odds ratio 1.904, 95% confidence interval 1.294–2.802, P = 0.001) and right lung lobe surgery (vs. left lung lobe surgery: odds ratio 1.836, 95% confidence interval 1.216–2.771, P = 0.004) were independent risk factors of postoperative pneumonia. Total intravenous crystalloid infusion grading in the postoperative 24 h ≥ 1500 mL was also identified as the risk factors (vs. 1000 to < 1500 mL: odds ratio 2.060, 95% confidence interval 1.302–3.260, P = 0.002).

Conclusions

Major risk factors for postoperative pneumonia following video-assisted thoracoscopic surgery lobectomy are body mass index grading ≥24.0 kg/m², right lung lobe surgery and total intravenous crystalloid infusion grading in the postoperative 24 h ≥ 1500 mL.

Risk factors for post-operative pulmonary complications in lung cancer patients after video-assisted thoracoscopic lung resection: Results of the German Thorax Registry

OBJECTIVE

Post-operative pulmonary complications (PPCs) represent the most frequent complications after lung surgery. The aim of this study was to identify the modifiable risk factors for PPCs after video-assisted thoracoscopic surgery (VATS) in lung cancer patients.

METHODS

Data of this retrospective study were extracted from the German Thorax Registry, an interdisciplinary and multicenter database of the German Society of Anesthesiology and Intensive care medicine and the German Society of Thoracic Surgery. Univariate and multivariate stepwise logistic regression analysis of patient-specific and procedural risk factors for PPCs were conducted.

RESULTS

We analyzed 376 patients with lung cancer who underwent VATS bilobectomy (n = 2), lobectomy (n = 258) or segmentectomy (n = 116) in 2016 and 2017. One-hundred fourteen patients (114/376; 30%) developed PPCs. Two patients died within 30 days after surgery. In the univariate analysis, patients of the PPC group showed significantly more often a body mass index (BMI) ≤ 19 kg/m² ; a pre-operative forced expiratory volume in 1 second (FEV₁ ) ≤ 60%; a pre-operative arterial oxygen partial pressure (p_a O₂ ) ≤ 60 mm Hg; a higher rate of prolonged duration of surgery (≥2 hours [h]) and a higher frequency of intraoperative blood loss ≥500 mL. The multivariate stepwise logistic regression analysis revealed 4 independent risk factors: FEV₁ ≤ 60% (1.9[1.1-3.4] OR [95% CI], P = 0.029); p_a O₂ ≤ 60 mm Hg (4.6[1.7-12.8] OR [95% CI], P = 0.003; duration of surgery ≥2 hours (2.7[1.5-4.7] OR [95% CI], P = 0.001) and intraoperative crystalloids ≥6 mL/kg/h (2.9[1.2-7.5] OR [95% CI], P = 0.023).

CONCLUSION

Intraoperative amount of crystalloid fluids should be kept below 6 mL/kg/h and duration of surgery should be below 2 hours to avoid an increased risk for PPCs.