Perioperative Evaluation of Patients with Pulmonary Conditions Undergoing Non-Cardiothoracic Surgery

Comprehensive Strategies for Preoperative Pulmonary Risk Evaluation and Management

Postoperative pulmonary complications (PPCs) significantly increase morbidity and mortality in surgical patients, particularly those with pulmonary conditions. PPC incidence varies widely, influenced by factors such as surgery type, patient age, smoking status, and comorbid conditions, including chronic obstructive pulmonary disease (COPD) and congestive heart failure. While preoperative pulmonary function tests and chest radiographs are crucial for lung resection surgery, their use should be judiciously tailored to individual risk profiles. Effective risk stratification models, such as the American Society of Anesthesiologists classification, Arozullah respiratory failure index, Gupta Calculators, and Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) model, play a key role in predicting PPCs. Key strategies to diminish PPCs include preoperative optimization of respiratory conditions, smoking cessation, and respiratory rehabilitation. In patients with COPD and asthma, it is crucial to maintain optimal disease control through inhaled therapies, systemic corticosteroids, and tailored preoperative respiratory exercises. Anemia and hypoalbuminemia are significant predictors of PPCs and require meticulous management. The choice and duration of anesthesia also notably influence PPC risk, with regional anesthesia being preferable to general anesthesia when possible. Comprehensive preoperative evaluations and tailored interventions are essential for enhancing surgical outcomes and reducing PPC incidence. Additional studies involving domestic patients are necessary to refine national guidelines for managing those at risk of PPCs.

Incidence and risk factors of postoperative pulmonary complications following total hip arthroplasty revision: a retrospective Nationwide Inpatient Sample database study

BACKGROUND

Postoperative pulmonary complications (PPCs) are among the most severe complications following total hip arthroplasty revision (THAR), imposing significant burdens on individuals and society. This study examined the prevalence and risk factors of PPCs following THAR using the NIS database, identifying specific pulmonary complications (SPCs) and their associated risks, including pneumonia, acute respiratory failure (ARF), and pulmonary embolism (PE).

METHODS

The National Inpatient Sample (NIS) database was used for this cross-sectional study. The analysis included patients undergoing THAR based on NIS from 2010 to 2019. Available data include demographic data, diagnostic and procedure codes, total charges, length of stay (LOS), hospital information, insurance information, and discharges.

RESULTS

From the NIS database, a total of 112,735 THAR patients in total were extracted. After THAR surgery, there was a 2.62% overall incidence of PPCs. Patients with PPCs after THAR demonstrated increased LOS, total charges, usage of Medicare, and in-hospital mortality. The following variables have been determined as potential risk factors for PPCs: advanced age, pulmonary circulation disorders, fluid and electrolyte disorders, weight loss, congestive heart failure, metastatic cancer, other neurological disorders (encephalopathy, cerebral edema, multiple sclerosis etc.), coagulopathy, paralysis, chronic pulmonary disease, renal failure, acute heart failure, deep vein thrombosis, acute myocardial infarction, peripheral vascular disease, stroke, continuous trauma ventilation, cardiac arrest, blood transfusion, dislocation of joint, and hemorrhage.

CONCLUSIONS

Our study revealed a 2.62% incidence of PPCs, with pneumonia, ARF, and PE accounting for 1.24%, 1.31%, and 0.41%, respectively. A multitude of risk factors for PPCs were identified, underscoring the importance of preoperative optimization to mitigate PPCs and enhance postoperative outcomes.

Identification of risk factors for postoperative pulmonary complications in general surgery patients in a low-middle income country

BACKGROUND

Postoperative pulmonary complications (PPCs) are an important cause of perioperative morbidity and mortality. Although risk factors for PPCs have been identified in high-income countries, less is known about PPCs and their risk factors in low- and middle-income countries, such as South Africa. This study examined the incidence of PPCs and their associated risk factors among general surgery patients in a public hospital in the province of KwaZulu-Natal, South Africa to inform future quality improvement initiatives to decrease PPCs in this clinical population.

METHODS

A retrospective secondary analysis of adult patients with general surgery admissions from January 1, 2013 to December 31, 2017 was conducted using data from the health system's Hybrid Electronic Medical Registry. The sample was comprised of 5352 general surgery hospitalizations. PPCs included pneumonia, atelectasis, acute respiratory distress syndrome, pulmonary edema, pulmonary embolism, prolonged ventilation, hemothorax, pneumothorax, and other respiratory morbidity which encompassed empyema, aspiration, pleural effusion, bronchopleural fistula, and lower respiratory tract infection. Risk factors examined were age, tobacco use, number and type of pre-existing comorbidities, emergency surgery, and number and type of surgeries. Bivariate and multivariable logistic regression models were conducted to identify risk factors for developing a PPC.

RESULTS

The PPC rate was 7.8%. Of the 418 hospitalizations in which a patient developed a PPC, the most common type of PPC was pneumonia (52.4%) and the mortality rate related to the PPC was 11.7%. Significant risk factors for a PPC were increasing age, greater number of comorbidities, emergency surgery, greater number of general surgeries, and abdominal surgery.

CONCLUSIONS

PPCs are common in general surgery patients in low- and middle-income countries, with similar rates observed in high-income countries. These complications worsen patient outcomes and increase mortality. Quality improvement initiatives that employ resource-conscious methods are needed to reduce PPCs in low- and middle-income countries.

Preoperative risk factors for postoperative pneumonia following primary Total Hip and Knee Arthroplasty

BACKGROUND

The purpose of this study is to evaluate risk factors for pneumonia following THA and TKA.

METHODS

Patients were identified from the American College of Surgeons National Quality Improvement Database (NSQIP) who experienced postoperative pneumonia after undergoing primary THA and TKA.

RESULTS

Many characteristics including old age, anemia, diabetes, cardiac comorbidities, dialysis, and smoking were independent risk factors for postoperative pneumonia after THA or TKA.

CONCLUSION

This analysis offers new evidence on risk factors associated with the development of pneumonia after THA and TKA. These risk factors can help guide clinicians in preventing postoperative pneumonia after THA and TKA.

Perioperative strategies for the reduction of postoperative pulmonary complications

Postoperative pulmonary complications (PPCs), estimated between 2.0% and 5.6% in the general surgical population and 20-70% for upper abdominal and thoracic surgeries, are a significant factor leading to poor patient outcomes. Efforts to decrease the incidence of PPCs such as bronchospasm, atelectasis, exacerbations of underlying chronic lung conditions, infections (bronchitis and pneumonia), prolonged mechanical ventilation, and respiratory failure, begins with a detailed preoperative risk evaluation. There are several available preoperative tests to estimate the risk of PPCs. However, the value of some of these studies to estimate PPCs remains controversial and is still debated. In this review, the preoperative risk assessment of PPCs is examined along with preoperative pulmonary tests to estimate risk, intraoperative, and procedure-associated risk factors for PPCs, and perioperative strategies to decrease PPCs. The importance of minimizing these events is reflected in the fact that nearly 25% of postoperative deaths occurring in the first week after surgery are associated with PPCs. This review provides important information to help clinical anesthesiologists to recognize potential risks for pulmonary complications and allows strategies to create an appropriate perioperative plan for patients.

Volume-Controlled Versus Dual-Controlled Ventilation during Robot-Assisted Laparoscopic Prostatectomy with Steep Trendelenburg Position: A Randomized-Controlled Trial

Dual-controlled ventilation (DCV) combines the advantages of volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV). Carbon dioxide (CO₂) pneumoperitoneum and steep Trendelenburg positioning for robot-assisted laparoscopic radical prostatectomy (RALRP) has negative effects on the respiratory system. We hypothesized that the use of autoflow as one type of DCV can reduce these effects during RALRP. Eighty patients undergoing RALRP were randomly assigned to receive VCV or DCV. Arterial oxygen tension (PaO₂) as the primary outcome, respiratory and hemodynamic data, and postoperative fever rates were compared at four time points: 10 min after anesthesia induction (T1), 30 and 60 min after the initiation of CO₂ pneumoperitoneum and Trendelenburg positioning (T2 and T3), and 10 min after supine positioning (T4). There were no significant differences in PaO₂ between the two groups. Mean peak airway pressure (Ppeak) was significantly lower in group DCV than in group VCV at T2 (mean difference, 5.0 cm H₂O; adjusted p < 0.001) and T3 (mean difference, 3.9 cm H₂O; adjusted p < 0.001). Postoperative fever occurring within the first 2 days after surgery was more common in group VCV (12%) than in group DCV (3%) (p = 0.022). Compared with VCV, DCV did not improve oxygenation during RALRP. However, DCV significantly decreased Ppeak without hemodynamic instability.

Trending Towards Safer Breast Cancer Surgeries? Examining Acute Complication Rates from A 13-Year NSQIP Analysis

As breast cancer surgery continues to evolve, this study highlights the acute complication rates and predisposing risks following partial mastectomy (PM), mastectomy(M), mastectomy with muscular flap reconstruction (M + MF), mastectomy with implant reconstruction (M + I), and oncoplastic surgery (OPS). Data was collected from the American College of Surgeons NSQIP database (2005⁻2017). Complication rate and trend analyses were performed along with an assessment of odds ratios for predisposing risk factors using adjusted linear regression. 226,899 patients met the inclusion criteria. Complication rates have steadily increased in all mastectomy groups (p < 0.05). Cumulative complication rates between surgical categories were significantly different in each complication cluster (all p < 0.0001). Overall complication rates were: PM: 2.25%, OPS: 3.2%, M: 6.56%, M + MF: 13.04% and M + I: 5.68%. The most common predictive risk factors were mastectomy, increasing operative time, ASA class, BMI, smoking, recent weight loss, history of CHF, COPD and bleeding disorders (all p < 0.001). Patients who were non-diabetic, younger (age < 60) and treated as an outpatient all had protective OR for an acute complication (p < 0.0001). This study provides data comparing nationwide acute complication rates following different breast cancer surgeries. These can be used to inform patients during surgical decision making.

Preoperative Assessment for Ambulatory Surgery

PURPOSE OF REVIEW

Ambulatory surgery has grown in recent decades in volume and represents a significant number of anesthetics delivered throughout the USA. Preoperative anesthetic assessment in the ambulatory setting has become important because patients with numerous complex comorbidities are now commonplace in this arena. Disease states involving the lungs, the heart, the kidneys, and subpopulations including those who are obese and the elderly commonly receive anesthetics in an ambulatory setting.

RECENT FINDINGS

This review presents key aspects of current thinking with regard to preoperative assessment and considerations for different critical disease states and subpopulations that are now being managed under ambulatory surgery. Same day surgery centers require patient safety, and expectations are high for patient satisfaction. Advancements in surgical and anesthetic technique have allowed for more complex patients to partake in ambulatory surgery. Anesthesiologists must be familiar with guidelines, state-of-the-art pain management, and standards of preoperative patient evaluation to accurately stratify patient risk and to advocate for patient safety.