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Carr ZJ, Li J, Agarkov D, Gazura M, Karamchandani K. Estimates of 30-day postoperative pulmonary complications after gastrointestinal endoscopic procedures: A retrospective cohort analysis of a health system population. PLoS One 2024; 19:e0299137. [PMID: 38394250 PMCID: PMC10889900 DOI: 10.1371/journal.pone.0299137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
The incidence of 30-day postoperative pulmonary complications (PPC) of gastrointestinal endoscopic procedures (GIEP) are not well characterized in the literature. The primary aim of this study was to identify the incidence of 30-day PPC after GIEP within a large healthcare system. We conducted a retrospective cohort study of 5377 patients presenting for GIEP between January 2013 and January 2022. Our primary outcome was the Agency for Healthcare Research and Quality PPC composite (AHRQ-PPC). Secondary outcomes were sub-composites derived from the AHRQ-PPC; including pneumonia (AHRQ-PNA), respiratory failure (AHRQ-RF), aspiration pneumonia/ pneumonitis (AHRQ-ASP) and pulmonary emboli (AHRQ-PE). We performed propensity score matching (PSM) followed by multivariable logistic regression to analyze primary and secondary outcomes. Inpatients had higher 30-day AHRQ-PPC (6.0 vs. 1.2%, p<0.001), as well as sub-composite AHRQ-PNA (3.2 vs. 0.7%, p<0.001), AHRQ-RF (2.4 vs. 0.5%, p<0.001), and AHRQ-ASP (1.9 vs. 0.4%, p<0.001). After PSM adjustment, pre-procedural comorbidities of electrolyte disorder [57.9 vs. 31.1%, ORadj: 2.26, 95%CI (1.48, 3.45), p<0.001], alcohol abuse disorder [16.7 vs. 6.8%, ORadj: 2.66 95%CI (1.29, 5.49), p = 0.01], congestive heart failure (CHF) [22.3 vs. 8.7%, ORadj: 2.2 95%CI (1.17, 4.15), p = 0.02] and pulmonary circulatory disorders [21 vs. 16.9%, ORadj: 2.95, 95%CI (1.36, 6.39), p = 0.01] were associated with 30-day AHRQ-PPC. After covariate adjustment, AHRQ-PPC was associated with upper endoscopy more than lower endoscopy [5.9 vs. 1.0%, ORadj: 3.76, 95%CI (1.85, 7.66), p<0.001]. When compared to gastroenterologist-guided conscious sedation, anesthesia care team presence was protective against AHRQ-PPC [3.7 vs. 8.4%, ORadj: 0.032, 95%CI (0.01, 0.22), p<0.001] and AHRQ-ASP [1.0 vs. 3.37%, ORadj: 0.002, 95%CI (0.00, 0.55), p<0.001]. In conclusion, we report estimates of 30-day PPC after GIEP across inpatient and outpatient settings. Upper endoscopic procedures confer a higher risk, while the presence of an anesthesia care team may be protective against 30-day PPC.
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Affiliation(s)
- Zyad J. Carr
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Judy Li
- Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Daniel Agarkov
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Makenzie Gazura
- Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, Connecticut, United States of America
| | - Kunal Karamchandani
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
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2
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Hamamah S, Gheorghita R, Lobiuc A, Sirbu IO, Covasa M. Fecal microbiota transplantation in non-communicable diseases: Recent advances and protocols. Front Med (Lausanne) 2022; 9:1060581. [PMID: 36569149 PMCID: PMC9773399 DOI: 10.3389/fmed.2022.1060581] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/21/2022] [Indexed: 12/13/2022] Open
Abstract
Fecal microbiota transplant (FMT) is a therapeutic method that aims to restore normal gut microbial composition in recipients. Currently, FMT is approved in the USA to treat recurrent and refractory Clostridioides difficile infection and has been shown to have great efficacy. As such, significant research has been directed toward understanding the potential role of FMT in other conditions associated with gut microbiota dysbiosis such as obesity, type 2 diabetes mellitus, metabolic syndrome, neuropsychiatric disorders, inflammatory bowel disease, irritable bowel syndrome, decompensated cirrhosis, cancers and graft-versus-host disease. This review examines current updates and efficacy of FMT in treating conditions other than Clostridioides difficile infection. Further, protocols for administration of FMT are also discussed including storage of fecal samples in stool banks, inclusion/exclusion criteria for donors, fecal sample preparation and methods of treatment administration. Overall, understanding the mechanisms by which FMT can manipulate gut microbiota to provide therapeutic benefit as well as identifying potential adverse effects is an important step in clarifying its long-term safety and efficacy in treating multiple conditions in the future.
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Affiliation(s)
- Sevag Hamamah
- Department of Basic Medical Sciences, College of Osteopathic Medicine, Western University of Health Sciences, Pomona, CA, United States
| | - Roxana Gheorghita
- Department of Medicine and Biomedical Sciences, College of Medicine and Biological Science, University of Suceava, Suceava, Romania,Department of Biochemistry, Victor Babeş University of Medicine and Pharmacy Timisoara, Timişoara, Romania
| | - Andrei Lobiuc
- Department of Medicine and Biomedical Sciences, College of Medicine and Biological Science, University of Suceava, Suceava, Romania
| | - Ioan-Ovidiu Sirbu
- Department of Biochemistry, Victor Babeş University of Medicine and Pharmacy Timisoara, Timişoara, Romania,Center for Complex Network Science, Victor Babeş University of Medicine and Pharmacy Timisoara, Timişoara, Romania
| | - Mihai Covasa
- Department of Basic Medical Sciences, College of Osteopathic Medicine, Western University of Health Sciences, Pomona, CA, United States,Department of Medicine and Biomedical Sciences, College of Medicine and Biological Science, University of Suceava, Suceava, Romania,*Correspondence: Mihai Covasa,
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3
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Alexander J, Castelow C, Cieker C, Wilbanks D, Asbeutah AA, Khouzam RN, Melton CD. Is NPO (Nil Per Os) order helping or hindering elective cardiac procedures? Curr Probl Cardiol 2022:101179. [PMID: 35341803 DOI: 10.1016/j.cpcardiol.2022.101179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 03/22/2022] [Indexed: 11/26/2022]
Abstract
The practice of fasting before elective cardiac procedures including cardiac catheterization and transesophageal echocardiography is commonly implemented but evidence for these requirements is lacking. Fasting periods often exceed the intended length of time, increasing the risk of irritability, dehydration, acute kidney injury, hypoglycemia, and length of hospitalization. The practice of perioperative fasting relies on the premise that aspiration during general anesthesia can be mitigated by minimizing the volume of gastric contents, and stomach acidity. But the evidence has shown that fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. Elective cardiac procedures are performed using procedural sedation, where the risk of serious aspiration is small. In most patients, we argue, that strict fasting requirements should be reduced, and a more nuanced fasting protocol based on individual patient characteristics and risk factors should be utilized given the overall low risk of aspiration with elective procedures utilizing procedural sedation. In this review, we examine the historical origins and current evidence relating to the practice of fasting as it relates to cardiac catheterization and transesophageal echocardiography.
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Affiliation(s)
- John Alexander
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN.
| | | | | | - David Wilbanks
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Abdul Aziz Asbeutah
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Rami N Khouzam
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN
| | - Charles D Melton
- Baylor Scott and White Health, All Saints Medical Center, Fort Worth, TX
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4
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Pfaff KE, Tumin D, Miller R, Beltran RJ, Tobias JD, Uffman JC. Perioperative aspiration events in children: A report from the Wake Up Safe Collaborative. Paediatr Anaesth 2020; 30:660-666. [PMID: 32319164 DOI: 10.1111/pan.13893] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 04/02/2020] [Accepted: 04/15/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Perioperative aspiration, while rare, is a serious complication of anesthetic care. Consequences of aspiration may include physical obstruction, wheezing, and pneumonia, resulting in mild to severe hypoxemia and even death. AIM We used a multi-institutional registry of pediatric patients to identify factors that influence the rate and resulting harm of perioperative pulmonary aspiration. METHODS The Wake Up Safe registry was queried for all severe adverse events reported from 29 institutions from 2010 to 2017. Aspiration events were identified through the "respiratory adverse event" data entry form or through free text search. Multivariable regression was used to predict aspiration events, and contributory factors were identified by reviewing free text case comments. RESULTS Analysis included 2 440 810 anesthetics administered involving patients ≤18 years of age. There were 135 pulmonary aspiration events, for an incidence of 0.006%. Within these 135 cases, 110 cases (82%) resulted in escalation of care and 51 (38%) resulted in patient harm, including 2 deaths (1.5%). In multivariable analysis, patients undergoing emergency surgery (OR 2.0 [1.2-3.5]) or with higher ASA status were more likely to experience aspiration (ASA 3 (OR 5.0 [2.6-9.1]); ASA ≥ 4 (OR 5.5 [3.8-16.8])). Noted causes of aspiration included gastrointestinal comorbid conditions (19%), postcoughing event or laryngospasm (14%), nil per os (NPO) violation (11%), blood or secretions in the airway following or during the procedure (6%), and oral premedication reaction (3%). CONCLUSION Although infrequent, death was reported as a consequence of perioperative aspiration in two patients. The frequency with which NPO violations were identified as a potential cause of aspiration highlights the struggles institutions face with adherence to NPO regulations, as these cases may be preventable. Furthermore, preventive measures may be needed to address other common causes of aspiration, such as gastrointestinal comorbid conditions.
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Affiliation(s)
- Kayla E Pfaff
- Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA.,Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Dmitry Tumin
- Brody School of Medicine East Carolina University, Greenville, NC, USA
| | - Rebecca Miller
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ralph J Beltran
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joshua C Uffman
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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Eltorai AS. Periprocedural pulmonary aspiration: An analysis of medical malpractice cases and alleged causative factors. J Eval Clin Pract 2019; 25:739-743. [PMID: 30548370 DOI: 10.1111/jep.13086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/07/2018] [Accepted: 11/09/2018] [Indexed: 12/18/2022]
Abstract
RATIONALE AIMS AND OBJECTIVES Pulmonary aspiration is a feared complication of anaesthesia that is associated with significant morbidity and mortality. Within the small existing body of literature on medical malpractice claims related to periprocedural aspiration, very little information is available regarding the case-specific factors that were alleged to contribute to each aspiration event. METHODS This study searched an extensive nationwide database of medical malpractice claims and identified 43 relating to periprocedural pulmonary aspiration. RESULTS The most common mechanism of causation cited in these claims (37%) was the failure to secure the airway with an endotracheal tube (ETT) when an elevated aspiration risk existed, most commonly because endotracheal intubation was not originally selected as part of the anaesthetic plan. The second most common alleged category of causation (33%) was the failure to perform a proper rapid-sequence induction and/or place a nasogastric tube (NGT) for decompression prior to induction. An equal amount of cases resulted in defendant versus plaintiff verdicts (44.2% each), while a settlement was reached in the remaining 11.6% of cases. CONCLUSION These findings are generalizable to clinical practice improvement on a broader scale. They demonstrate the need to develop reliable, high-sensitivity tests for detecting elevated risk before clinicians can be expected to take special steps to protect susceptible patients, and they also show that medical malpractice can be alleged because of failure to uphold currently accepted standards of care even when the published evidence for those standards is weak. This study demonstrates that careful review of medical malpractice litigation can elucidate common contributory factors and facilitate improvements in clinical practice and decision-making.
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Affiliation(s)
- Ashley Szabo Eltorai
- Department of Anesthesiology, Cardiac Division, Yale University School of Medicine, New Haven, Connecticut
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6
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Attard TM, Miller M, Walker AA, Lee B, McGuire SR, Thomson M. Pediatric elective therapeutic procedure complications: A multicenter cohort analysis. J Gastroenterol Hepatol 2019; 34:1533-1539. [PMID: 30729573 DOI: 10.1111/jgh.14626] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 01/30/2019] [Accepted: 01/31/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND AIM Current understanding of specific, therapeutic procedure-associated complications in pediatric patients remains limited. This study aims to determine the frequency of significant complications in pediatric age-range subjects following the principal therapeutic endoscopic procedures. METHODS This study used retrospective multi-institutional, ICD-9-CM, Clinical Transaction Classification, and Current Procedural Terminology based database (Pediatric Hospital Information System) analysis. This study included demographic, chronic comorbidity, procedure type, and post-procedure outcomes defined through mortality, unplanned direct admission, emergency room, and inpatient admission and inpatient therapeutic events. RESULTS During the study period, 18 018 patients underwent therapeutic endoscopy; 132 required direct (0.16%) or emergency room/inpatient (0.58%) admission within 5 days following the procedure; mortality was 0.01%. Most (50.75%) complications presented on the day of or 1 day post-procedure. Hispanic race and coexisting chronic comorbidities, especially gastrointestinal conditions, were identified risk factors for significant complications. Endoscopic dilatation and variceal ablation were most frequently associated with complications. Abdominal pain, gastrointestinal bleeding, and esophageal stricture were the most common diagnoses: 9.0% required intravenous antibiotics, 36.63% underwent chest imaging, 27.27% abdominal imaging, and 0.75% required blood transfusion. Readmission following esophageal dilatation was most likely to result in prolonged admission. CONCLUSION In the pediatric population undergoing therapeutic endoscopy in the ambulatory setting, significant postoperative complications resulting in unplanned admission are rare. Complications can be anticipated in medically frail patients especially with gastrointestinal chronic illness. Procedures involving variceal ablation and esophageal dilatation entail the highest risk.
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Affiliation(s)
- Thomas M Attard
- Departments of Gastroenterology, Children's Mercy Hospital, Kansas, Missouri, USA
| | - Mikaela Miller
- Clinical Decision Support, Children's Mercy Hospital, Kansas, Missouri, USA
| | - A Adjowa Walker
- Departments of Gastroenterology, Children's Mercy Hospital, Kansas, Missouri, USA
| | - Brian Lee
- Health Services and Outcomes Research, Children's Mercy Hospital, Kansas, Missouri, USA
| | - Stephanie R McGuire
- Department of Anesthesiology, Children's Mercy Hospital, Kansas, Missouri, USA
| | - Mike Thomson
- Department of Gastroenterology, Sheffield Children's Hospital, Western Bank, Sheffield, UK
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7
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Gacouin A, Tadié JM, Le Tulzo Y. Infections bronchopulmonaires chez le patient cirrhotique. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s13546-015-1046-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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8
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Gong EJ, Kim DH, Jung HY, Lim H, Ahn JY, Choi KS, Lee JH, Choi KD, Song HJ, Lee GH, Kim JH, Baek S. Pneumonia after endoscopic resection for gastric neoplasm. Dig Dis Sci 2014; 59:2742-8. [PMID: 25023226 DOI: 10.1007/s10620-014-3223-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 05/21/2014] [Indexed: 01/15/2023]
Abstract
BACKGROUND Pneumonia following endoscopic procedures may affect the clinical course and prolong hospital stay. AIM To investigate the incidence and risk factors for pneumonia after endoscopic resection (ER) for gastric neoplasm. METHODS Subjects who underwent ER for gastric neoplasm at the Asan Medical Center from January 1997 to March 2013 were included. To investigate risk factors, control patients were randomly selected from these subjects. RESULTS Of the 7,149 subjects who underwent ER for gastric neoplasm, 44 (0.62 %) developed pneumonia. The median age of these 44 patients was 68 years (range 31-82 years), and the male to female ratio was 3:1. Twenty-five of the pneumonia patients (56.8 %) were smokers, and 8 (18.2 %) had underlying pulmonary diseases. The median procedure time was 23 min (range 2-126 min), and pathologic diagnoses included adenocarcinoma (n = 29), dysplasia (n = 10), and hyperplastic polyp (n = 5). Compared with the control group, smoking (current smoker vs. never smoker, odds ratio [OR] 2.366, p = 0.021), total procedure time (OR 1.011, p = 0.048), and hemostasis time (OR 1.026, p = 0.028) were risk factors for the development of pneumonia. In multivariate analysis, age >65 years (OR 2.073, p = 0.031), smoking (current smoker vs. never smoker, OR 2.324, p = 0.023), and hemostasis time (OR 1.025, p = 0.038) were independent risk factors. All patients recovered from pneumonia, and the duration of hospital stay did not differ between patients with pneumonia and the control group (p = 0.077). CONCLUSIONS Whereas old age, smoking, and longer hemostasis time are risk factors for pneumonia, its incidence after ER is not associated with clinically significant adverse outcomes.
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Affiliation(s)
- Eun Jeong Gong
- Department of Gastroenterology, Asan Medical Center, Asan Digestive Disease Research Institute, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea
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Nam OO, Jang JS, Noh MH, Park JI, Kim HJ, Lee JS, Oh SY, Ryu SH. A Case of Aspiration Pneumonia after Upper Gastrointestinal Endoscopy. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2014. [DOI: 10.7704/kjhugr.2014.14.3.215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Oun Ouk Nam
- Department of Internal Medicine, Dong-Eui Medical Center, Busan, Korea
| | - Jin Seok Jang
- Department of Internal Medicine, Dong-A University College of Medine, Busan, Korea
| | - Myung Hwan Noh
- Department of Internal Medicine, Dong-A University College of Medine, Busan, Korea
| | - Jung Ik Park
- Department of Internal Medicine, Dong-Eui Medical Center, Busan, Korea
| | - Hyo Jong Kim
- Department of Internal Medicine, Dong-Eui Medical Center, Busan, Korea
| | - Jeong Seok Lee
- Department of Internal Medicine, Dong-Eui Medical Center, Busan, Korea
| | - Sang Yu Oh
- Department of Internal Medicine, Dong-Eui Medical Center, Busan, Korea
| | - Seung Hee Ryu
- Department of Internal Medicine, Dong-A University College of Medine, Busan, Korea
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