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Jose AM, Prabhakaran K, Rafieezadeh A, Kirsch J, Zangbar B. Analysis of pre-admission risk factors for unplanned reintubation in geriatric trauma patients. Am J Surg 2024; 238:115882. [PMID: 39098281 DOI: 10.1016/j.amjsurg.2024.115882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 07/15/2024] [Accepted: 07/29/2024] [Indexed: 08/06/2024]
Abstract
INTRODUCTION Reintubation in unplanned scenarios, carries inherent risks and potential complications particularly in vulnerable populations such as geriatric trauma patients. We sought to identify preadmission risk factors for unplanned re-intubation (URI) in geriatric trauma patients and its effects on outcomes. METHODS Analysis of TQIP (2017-2019) of intubated geriatric trauma patients, classified into two groups, those who were successfully extubated and those who required URI. We used logistic regression to assess for preadmission risk factors of URI. RESULTS Among 23,572 patients, 20.2 % underwent URI. URI had higher mortality (13.7%vs.8.1 %, p < 0.001), in-hospital complications (p < 0.05), longer hospital and ICU LOS (p < 0.001 for both). Higher age (OR = 1.017), smoking (OR = 1.418), CRF(OR = 1.414), COPD (OR = 1.410), alcohol use (OR = 1.365), functionally dependent health status (OR = 1.339), and anticoagulant use (OR = 1.148), increased the risks of URI (p < 0.05 for all). CONCLUSION Geriatric patients with comorbidities including age, smoking, CRF, COPD, alcohol use, dependent status, and anticoagulant use are at higher risks of URI that could in turn, be associated with increased rates of mortality, complications, and longer hospital and ICU length of stay. LEVEL OF EVIDENCE Level III retrospective study.
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Affiliation(s)
- Anna Mary Jose
- Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | | | - Aryan Rafieezadeh
- Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Jordan Kirsch
- Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Bardiya Zangbar
- Westchester Medical Center, New York Medical College, Valhalla, NY, USA.
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2
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Chandler D, Mosieri C, Kallurkar A, Pham AD, Okada LK, Kaye RJ, Cornett EM, Fox CJ, Urman RD, Kaye AD. Perioperative strategies for the reduction of postoperative pulmonary complications. Best Pract Res Clin Anaesthesiol 2020; 34:153-166. [PMID: 32711826 DOI: 10.1016/j.bpa.2020.04.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/17/2020] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- Debbie Chandler
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport LA 71103, USA.
| | - Chizoba Mosieri
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport LA 71103, USA.
| | - Anusha Kallurkar
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport LA 71103, USA.
| | - Alex D Pham
- Department of Anesthesiology, LSU Health New Orleans, 1542 Tulane Ave, New Orleans LA 70112, USA.
| | - Lindsey K Okada
- Tulane University School of Medicine, 1430 Tulane Ave., New Orleans, LA, 70112, USA.
| | - Rachel J Kaye
- Medical University of South Carolina, Charleston, SC, 29425, USA.
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport LA 71103, USA.
| | - Charles J Fox
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport LA 71103, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
| | - Alan D Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, LSU Health Shreveport, 1501 Kings Highway, Shreveport LA 71103, USA; Vice Chancellor of Academic Affairs, LSU Health Shreveport, 1501 Kings Highway, Shreveport LA 71103, USA.
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Huang SS, Lv WW, Liu YF, Yang SZ. Analgesic effect of parecoxib combined with ropivacaine in patients undergoing laparoscopic hepatectomy. World J Clin Cases 2019; 7:2704-2711. [PMID: 31616686 PMCID: PMC6789389 DOI: 10.12998/wjcc.v7.i18.2704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/19/2019] [Accepted: 08/26/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Currently, there is no uniform standard for analgesia during laparoscopic hepatectomy. Most of the analgesia schemes adopt epidural analgesia after laparotomy. Although the analgesia is effective, it has a great impact on the recovery of patients after laparoscopic hepatectomy and is not completely suitable for analgesia after laparoscopic hepatectomy. Although multimodal perioperative analgesia can significantly relieve postoperative pain, there is no relevant study of parecoxib combined with ropivacaine for post-laparoscopic hepatectomy analgesia.
AIM To study the analgesic effect of the preoperative intravenous injection of parecoxib combined with long-acting local anesthetic ropivacaine for incision infiltration in patients undergoing laparoscopic hepatectomy.
METHODS Forty-eight patients undergoing laparoscopic hepatectomy were randomly divided into a combined group (parecoxib combined with ropivacaine) and a control group. The visual analogue scale (VAS) at rest and during movement was used to compare the analgesic effect of the two groups. Meanwhile, the cumulative sufentanil, the recovery time for enterokinesia, the length of postoperative hospital stay, and the adverse reactions (nausea and vomiting) were recorded and compared between the two groups.
RESULTS The change tendency in VAS scores for both groups was similar after operation. At rest, the VAS scores of the combined group were significantly lower than those of the control group at 0, 6, 12, 24 and 36 h, and during movement, the VAS scores of the combined group were significantly lower than those of the control group at 0, 6, 12, and 24 h. The recovery time for enterokinesia in the combined group was 2.9 d, which was significantly shorter than that in the control group. The cumulative sufentanil in the combined group decreased significantly at 24, 36, and 48 h after operation.
CONCLUSION Preoperative intravenous injection of parecoxib combined with ropivacaine for incision infiltration is a simple and effective method for postoperative analgesia in laparoscopic hepatectomy, which could relieve pain and promote recovery.
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Affiliation(s)
- Shan-Shan Huang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Wei-Wei Lv
- Department of Radiology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Yan-Feng Liu
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Shao-Zhong Yang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
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Vogt B, Hennig V, Deuß K, Balke L, Weiler N, Frerichs I. Performance of new spirometry reference values in preoperative assessment of lung function. CLINICAL RESPIRATORY JOURNAL 2019; 13:239-246. [PMID: 30735004 DOI: 10.1111/crj.13004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 11/05/2018] [Accepted: 01/12/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Pulmonary function is not routinely assessed in patients without respiratory disease and symptoms before surgery, even if they are smokers. We aimed to check whether the new spirometric reference values of the worldwide Global Lung Initiative (GLI) affected the preoperative assessment of lung function in allegedly lung-healthy patients compared with the still commonly used old predicted values. METHODS Two hundred nineteen allegedly lung-healthy non-smokers, past and current smokers were examined by spirometry before elective surgery. The obtained values of forced expiratory volume in 1 second (FEV1 ), forced vital capacity (FVC) and FEV1 /FVC were transformed into z-scores according to the GLI guidelines. A comparison between the new and old reference values was performed. FEV1 was used for the grading of airway obstruction. RESULTS One hundred eighty-three subjects performed the ventilation manoeuvre according to the GLI recommendations and were analysed. Most non-smokers and past smokers met the new references ranges for spirometric values. Only z-scores of FEV1 /FVC distinguished among all three patient groups, FEV1 between smokers and the other two groups and FVC did not discriminate the groups, irrespective of the reference values used. Airway obstruction was identified in 24% of asymptomatic smokers by z-scores of FEV1 /FVC but in only 14% by the old predicted values. In elderly smokers (>60 years), the corresponding values rose to 50% and 30%. Old predicted values of FEV1 underestimated the degree of airway obstruction mainly in middle-aged smokers. CONCLUSION Allegedly lung-healthy current smokers showed a higher proportion of preoperatively reduced lung function when z-scores were used, especially in elderly subjects.
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Affiliation(s)
- Barbara Vogt
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Victoria Hennig
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Kathinka Deuß
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Lorenz Balke
- Department of Pneumology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Norbert Weiler
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Inéz Frerichs
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Anesthesia for Video-Assisted Thoracoscopic Surgery. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Atilla N, Arpag H, Bozkus F, Kahraman H, Cengiz E, Bulbuloglu E, Atilla S. Can We Predict the Perioperative Pulmonary Complications Before Laparoscopic Sleeve Gastrectomy: Original Research. Obes Surg 2017; 27:1524-1528. [PMID: 28074374 DOI: 10.1007/s11695-016-2522-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The increasing prevalence of obesity in worldwide is one of the most serious chronic public health problems and is considered to be a global epidemic. Bariatric surgical procedures have also been applied more often with increased prevalence of obesity. As a result, the incidence of surgical complications has increased. Preoperative evaluation is quite important for these patients. AIMS The aim of our study is to determine the predictors of perioperative pulmonary complications of laparoscopic sleeve gastrectomy. STUDY DESIGN The study is a cross-sectional study. METHODS One hundred eighty-three consecutive patients who received laparoscopic bariatric surgery were followed up during 3 months. Patients were divided into two groups A and B. Group A being the patients who had perioperative pulmonary complications (n = 28) and group B being patients who had not (n = 155). Pulmonary function test (PFT), body mass index (BMI), preoperative oxygen saturation, age, gender, comorbid diseases, and smoking history were compared between these groups. RESULTS Mean age, size, weight, BMI, PFT parameters of groups A and B were close to each other. The strongest predictors of perioperative pulmonary complications were duration of smoking in current smokers and low baseline oxygen saturation. CONCLUSIONS Preoperative oxygen saturation and smoking history may help to predict perioperative complications of laparoscopic sleeve gastrectomy.
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Affiliation(s)
- Nurhan Atilla
- Department of Chest Diseases, Kahramanmaras Sutcu Imam University Medicine Faculty, Kahramanmaras, Turkey.
| | - Huseyin Arpag
- Department of Chest Diseases, Kahramanmaras Sutcu Imam University Medicine Faculty, Kahramanmaras, Turkey
| | - Fulsen Bozkus
- Department of Chest Diseases, Kahramanmaras Sutcu Imam University Medicine Faculty, Kahramanmaras, Turkey
| | - Hasan Kahraman
- Department of Chest Diseases, Kahramanmaras Sutcu Imam University Medicine Faculty, Kahramanmaras, Turkey
| | - Emrah Cengiz
- Department of General Surgery, Kahramanmaras Sutcu Imam University Medicine Faculty, Kahramanmaras, Turkey
| | - Ertan Bulbuloglu
- Department of General Surgery, Kahramanmaras Sutcu Imam University Medicine Faculty, Kahramanmaras, Turkey
| | - Semi Atilla
- Department of Chest Diseases, Kahramanmaras Necip Fazıl State Hospital, Kahramanmaras, Turkey
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Takiguchi H, Hayama N, Oguma T, Harada K, Sato M, Horio Y, Tanaka J, Tomomatsu H, Tomomatsu K, Takihara T, Niimi K, Nakagawa T, Masuda R, Aoki T, Urano T, Iwazaki M, Asano K. Post-bronchoscopy pneumonia in patients suffering from lung cancer: Development and validation of a risk prediction score. Respir Investig 2017; 55:212-218. [PMID: 28427748 DOI: 10.1016/j.resinv.2016.12.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 12/30/2016] [Indexed: 06/07/2023]
Abstract
BACKGROUND The incidence, risk factors, and consequences of pneumonia after flexible bronchoscopy in patients with lung cancer have not been studied in detail. METHODS We retrospectively analyzed the data from 237 patients with lung cancer who underwent diagnostic bronchoscopy between April 2012 and July 2013 (derivation sample) and 241 patients diagnosed between August 2013 and July 2014 (validation sample) in a tertiary referral hospital in Japan. A score predictive of post-bronchoscopy pneumonia was developed in the derivation sample and tested in the validation sample. RESULTS Pneumonia developed after bronchoscopy in 6.3% and 4.1% of patients in the derivation and validation samples, respectively. Patients who developed post-bronchoscopy pneumonia needed to change or cancel their planned cancer therapy more frequently than those without pneumonia (56% vs. 6%, p<0.001). Age ≥70 years, current smoking, and central location of the tumor were independent predictors of pneumonia, which we added to develop our predictive score. The incidence of pneumonia associated with scores=0, 1, and ≥2 was 0, 3.7, and 13.4% respectively in the derivation sample (p=0.003), and 0, 2.9, and 9.7% respectively in the validation sample (p=0.016). CONCLUSIONS The incidence of post-bronchoscopy pneumonia in patients with lung cancer was not rare and associated with adverse effects on the clinical course. A simple 3-point predictive score identified patients with lung cancer at high risk of post-bronchoscopy pneumonia prior to the procedure.
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Affiliation(s)
- Hiroto Takiguchi
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan.
| | - Naoki Hayama
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan.
| | - Tsuyoshi Oguma
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan.
| | - Kazuki Harada
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan.
| | - Masako Sato
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan.
| | - Yukihiro Horio
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan.
| | - Jun Tanaka
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan.
| | - Hiromi Tomomatsu
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan.
| | - Katsuyoshi Tomomatsu
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan.
| | - Takahisa Takihara
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan.
| | - Kyoko Niimi
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan.
| | - Tomoki Nakagawa
- Department of Thoracic Surgery, Tokai University School of Medicine, Kanagawa, Japan.
| | - Ryota Masuda
- Department of Thoracic Surgery, Tokai University School of Medicine, Kanagawa, Japan.
| | - Takuya Aoki
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan.
| | - Tetsuya Urano
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan.
| | - Masayuki Iwazaki
- Department of Thoracic Surgery, Tokai University School of Medicine, Kanagawa, Japan.
| | - Koichiro Asano
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan.
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Kim NY, Kwon TD, Bai SJ, Noh SH, Hong JH, Lee H, Lee KY. Effects of dexmedetomidine in combination with fentanyl-based intravenous patient-controlled analgesia on pain attenuation after open gastrectomy in comparison with conventional thoracic epidural and fentanyl-based intravenous patient-controlled analgesia. Int J Med Sci 2017; 14:951-960. [PMID: 28924366 PMCID: PMC5599918 DOI: 10.7150/ijms.20347] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 06/18/2017] [Indexed: 12/13/2022] Open
Abstract
Background: This study was investigated the effects of dexmedetomidine in combination with fentanyl-based intravenous patient-controlled analgesia (IV-PCA) on pain attenuation in patients undergoing open gastrectomy in comparison with conventional thoracic epidural patient-controlled analgesia (E-PCA) and IV-PCA. Methods: One hundred seventy-one patients who planned open gastrectomy were randomly distributed into one of the 3 groups: conventional thoracic E-PCA (E-PCA group, n = 57), dexmedetomidine in combination with fentanyl-based IV-PCA (dIV-PCA group, n = 57), or fentanyl-based IV-PCA only (IV-PCA group, n = 57). The primary outcome was the postoperative pain intensity (numerical rating scale) at 3 hours after surgery, and the secondary outcomes were the number of bolus deliveries and bolus attempts, and the number of patients who required additional rescue analgesics. Mean blood pressure, heart rate, and adverse effects were evaluated as well. Results: One hundred fifty-three patients were finally completed the study. The postoperative pain intensity was significantly lower in the dIV-PCA and E-PCA groups than in the IV-PCA group, but comparable between the dIV-PCA group and the E-PCA group. Patients in the dIV-PCA and E-PCA groups needed significantly fewer additional analgesic rescues between 6 and 24 hours after surgery, and had a significantly lower number of bolus attempts and bolus deliveries during the first 24 hours after surgery than those in the IV-PCA group. Conclusions: Dexmedetomidine in combination with fentanyl-based IV-PCA significantly improved postoperative analgesia in patients undergoing open gastrectomy without hemodynamic instability, which was comparable to thoracic E-PCA. Furthermore, this approach could be clinically more meaningful owing to its noninvasive nature.
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Affiliation(s)
- Na Young Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae Dong Kwon
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sun Joon Bai
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Hoon Noh
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Hwa Hong
- Department of Policy Research Affairs National Health Insurance Service Ilsan Hospital, Goyang, Gyeonggi-do, Republic of Korea
| | - Haeyeon Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ki-Young Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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Zheng X, Feng X, Cai XJ. Effectiveness and safety of continuous wound infiltration for postoperative pain management after open gastrectomy. World J Gastroenterol 2016; 22:1902-1910. [PMID: 26855550 PMCID: PMC4724622 DOI: 10.3748/wjg.v22.i5.1902] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 10/28/2015] [Accepted: 11/19/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To prospectively evaluate the effectiveness and safety of continuous wound infiltration (CWI) for pain management after open gastrectomy.
METHODS: Seventy-five adult patients with American Society of Anesthesiologists (ASA) Physical Status Classification System (ASA) grade 1-3 undergoing open gastrectomy were randomized to three groups. Group 1 patients received CWI with 0.3% ropivacaine (group CWI). Group 2 patients received 0.5 mg/mL morphine intravenously by a patient-controlled analgesia pump (PCIA) (group PCIA). Group 3 patients received epidural analgesia (EA) with 0.12% ropivacaine and 20 µg/mL morphine with an infusion at 6-8 mL/h for 48 h (group EA). A standard general anesthetic technique was used for all three groups. Rescue analgesia (2 mg bolus of morphine, intravenous) was given when the visual analogue scale (VAS) score was ≥ 4. The outcomes measured over 48 h after the operation were VAS scores both at rest and during mobilization, total morphine consumption, relative side effects, and basic vital signs. Further results including time to extubation, recovery of bowel function, surgical wound healing, mean length of hospitalization after surgery, and the patient’s satisfaction were also recorded.
RESULTS: All three groups had similar VAS scores during the first 48 h after surgery. Group CWI and group EA, compared with group PCIA, had lower morphine consumption (P < 0.001), less postoperative nausea and vomiting (1.20 ± 0.41 vs 1.96 ± 0.67, 1.32 ± 0.56 vs 1.96 ± 0.67, respectively, P < 0.001), earlier extubation (16.56 ± 5.24 min vs 19.76 ± 5.75 min, P < 0.05, 15.48 ± 4.59 min vs 19.76 ± 5.75 min, P < 0.01), and earlier recovery of bowel function (2.96 ± 1.17 d vs 3.60 ± 1.04 d, 2.80 ± 1.38 d vs 3.60 ± 1.04 d, respectively, P < 0.05). The mean length of hospitalization after surgery was reduced in groups CWI (8.20 ± 2.58 d vs 10.08 ± 3.15 d, P < 0.05) and EA (7.96 ± 2.30 d vs 10.08 ± 3.15 d, P < 0.01) compared with group PCIA. All three groups had similar patient satisfaction and wound healing, but group PCIA was prone to higher sedation scores when compared with groups CWI and EA, especially during the first 12 h after surgery. Group EA had a lower mean arterial pressure within the first postoperative 12 h compared with the other two groups.
CONCLUSION: CWI with ropivacaine yields a satisfactory analgesic effect within the first 48 h after open gastrectomy, with lower morphine consumption and accelerated recovery.
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Evaluation of spirometric testing as a routine preoperative assessment in patients undergoing bariatric surgery. Obes Surg 2015; 25:530-6. [PMID: 25240391 DOI: 10.1007/s11695-014-1420-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The value of spirometry as a routine preoperative test for bariatric surgery is debatable. The aim of this study was to assess the relationship between spirometry results and the frequency of postoperative pulmonary complications in 602 obese patients. METHODS Clinical files of patients undergoing bariatric surgery between 2004 and 2013 were reviewed. Demography, risk factors, respiratory symptoms, and spirometry results (forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), FEV1/FVC) were recorded, and their relationship with postoperative pulmonary complications was evaluated. RESULTS There were 256 males and 346 females with a mean age of 40.2 ± 11.6 years and a mean BMI of 42.1 ± 6.4 kg/m2. History of smoking was found in 408 patients (68 %). Preoperative respiratory symptoms were present in 328 (54.5 %). Most frequent symptoms were snoring (288), dyspnea (119), bronchospasm [6], and chronic productive cough [6]. In 153 patients, history of respiratory disease was documented. The obstructive sleep apnea syndrome (OSAS) was present in 124, 20 requiring continuous positive airway pressure (CPAP). Asthma was present in 27 and chronic obstructive pulmonary disease (COPD) in 2. Variables associated to a higher risk of pulmonary complications were OSAS (OR 2.3), an abnormal spirometry (OR 2.6), male gender (OR 1.9), and preoperative respiratory symptoms (OR 1.9). Using multivariate logistic regression, an abnormal spirometry was a significant predictor of postoperative pulmonary complications in patients with respiratory symptoms and/or OSAS. However, it lost prognostic significance when both conditions were subtracted. CONCLUSIONS In obese patients undergoing bariatric surgery, abnormal preoperative spirometry predicts postoperative respiratory complications only in patients with OSAS.
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11
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[Cardiac surgery in underlying chronic pulmonary disease. Prognostic implications and efficient preoperative evaluation]. Herz 2015; 39:45-52. [PMID: 24452760 DOI: 10.1007/s00059-013-4034-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Cardiac surgery in patients with chronic pulmonary diseases carries a high risk of postoperative pulmonary complications (ppc) because both are known to cause ppc. Autopsy studies have revealed ppc as the main cause of mortality in approximately 5-8% of patients after cardiac surgery. Not all pulmonary diseases are high risk comorbidities in cardiac surgery: whereas chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea significantly increase the risk of ppc, a well controlled asthma does not carry an additional risk of ppc. A thorough preoperative risk stratification is crucial for risk estimation and some validated risk calculators, such as the Canet risk score exist. Surprisingly the additional value of pulmonary function testing beyond a thorough patient history and physical examination is low. No validated thresholds exist in pulmonary function testing below which cardiac surgery should be denied if clearly indicated. Perioperative strategies for risk reduction should be applied to all patients whenever possible.
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12
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Bablekos GD, Michaelides SA, Analitis A, Lymperi MH, Charalabopoulos KA. Comparative changes in tissue oxygenation between laparoscopic and open cholecystectomy. J Clin Med Res 2015; 7:232-41. [PMID: 25699119 PMCID: PMC4330015 DOI: 10.14740/jocmr2086w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2015] [Indexed: 01/30/2023] Open
Abstract
Background Previous studies examined the effect of laparoscopic cholecystectomy (LC) versus open cholecystectomy (OC) on physiological variables of the respiratory system. In this study we compared changes in arterial blood gases-related parameters between LC and OC to assess their comparative influence on gas exchange. Methods We studied 28 patients, operated under identical anesthetic protocol (LC: 18 patients, OC: 10 patients). Measurements were made on the morning before surgery (BS), the second (AS2) and the eighth (AS8) postoperative day. Studied parameters, including alveolar-arterial difference in PO2 ((A-a)DO2) and oxygen content (Oct in vol%), were statistically compared. Results On AS2 a greater increase was found in ((A-a)DO2) for the OC compared to LC (4.673 ± 0.966 kPa versus 3.773 ± 1.357 kPa, respectively). Between BS and AS2, Oct in vol% decreased from 17.55 ± 1.90 to 15.69 ± 1.88 in the LC and from 16.99 ± 2.37 to 14.62 ± 2.23 in the OC, whilst a reduction (P = 0.093) between AS2 and AS8 was also found for the open method. Besides, on AS2, SaO2% decrease was greater in OC compared to LC (P = 0.096). Conclusions On AS2, the greater increase in OC-((A-a)DO2) associated with Oct in vol% and SaO2% findings also in OC group suggest that LC might be associated with lower risk for impaired tissue oxygenation.
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Affiliation(s)
- George D Bablekos
- Department of Experimental Physiology, Medical School, Democritous University of Thrace, 68100 Dragana, Alexandroupolis, Greece ; Technological Educational Institute (T.E.I.) of Athens, Agiou Spyridonos 28 Street, 12243 Egaleo, Athens, Greece
| | - Stylianos A Michaelides
- "Sismanogleio" General Hospital, First Thoracic Medicine Department, Sismanogleiou 1 Street, 15126 Maroussi, Athens, Greece
| | - Antonis Analitis
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Mikras Asias 75 Street, 11527 Goudi, Athens, Greece
| | - Maria H Lymperi
- Department of Experimental Physiology, Medical School, National and Kapodistrian University of Athens, Mikras Asias 75 Street, 11527 Goudi, Athens, Greece
| | - Konstantinos A Charalabopoulos
- Department of Experimental Physiology, Medical School, Democritous University of Thrace, 68100 Dragana, Alexandroupolis, Greece
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Sahni S, Molmenti E, Bhaskaran MC, Ali N, Basu A, Talwar A. Presurgical pulmonary evaluation in renal transplant patients. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2015; 6:605-12. [PMID: 25599047 PMCID: PMC4290048 DOI: 10.4103/1947-2714.147974] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Patients with chronic renal failure (CRF) due to various mechanisms are prone to significant pulmonary comorbidities. With the improvements in renal replacement therapy (RRT), patients with CRF are now expected to live longer, and thus may develop complications in the lung from these processes. The preferred treatment of CRF is kidney transplantation and patients who are selected to undergo transplant must have a thorough preoperative pulmonary evaluation to assess pulmonary status and to determine risk of postoperative pulmonary complications. A MEDLINE®/PubMed® search was performed to identify all articles outlining the course of pre-surgical pulmonary evaluation with an emphasis on patients with CRF who have been selected for renal transplant. Literature review concluded that in addition to generic pre-surgical evaluation, renal transplant patients must also undergo a full cardiopulmonary and sleep evaluation to investigate possible existing pulmonary pathologies. Presence of any risk factor should then be aggressively managed or treated prior to surgery.
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Affiliation(s)
- Sonu Sahni
- Department of Pulmonary, Critical Care and Sleep Medicine, North Shore-Long Island Jewish Health System, New York, USA
| | - Ernesto Molmenti
- Department of Transplant Surgery, North Shore-Long Island Jewish Health System, New York, USA
| | - Madhu C Bhaskaran
- Department of Nephrology, North Shore-Long Island Jewish Health System, New York, USA
| | - Nicole Ali
- Department of Nephrology, North Shore-Long Island Jewish Health System, New York, USA
| | - Amit Basu
- Department of Transplant Surgery, North Shore-Long Island Jewish Health System, New York, USA
| | - Arunabh Talwar
- Department of Pulmonary, Critical Care and Sleep Medicine, North Shore-Long Island Jewish Health System, New York, USA
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Bablekos GD, Michaelides SA, Analitis A, Charalabopoulos KA. Effects of laparoscopic cholecystectomy on lung function: A systematic review. World J Gastroenterol 2014; 20:17603-17617. [PMID: 25516676 PMCID: PMC4265623 DOI: 10.3748/wjg.v20.i46.17603] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 03/17/2014] [Accepted: 06/17/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To present and integrate findings of studies investigating the effects of laparoscopic cholecystectomy on various aspects of lung function.
METHODS: We extensively reviewed literature of the past 24 years concerning the effects of laparoscopic cholecystectomy in comparison to the open procedure on many aspects of lung function including spirometric values, arterial blood gases, respiratory muscle performance and aspects of breathing control, by critically analyzing physiopathologic interpretations and clinically important conclusions. A total of thirty-four articles were used to extract information for the meta-analysis concerning the impact of the laparoscopic procedure on lung function and respiratory physiopathology. The quality of the literature reviewed was evaluated by the number of their citations and the total impact factor of the corresponding journals. A fixed and random effect meta-analysis was used to estimate the pooled standardized mean difference of studied parameters for laparoscopic (LC) and open (OC) procedures. A crude comparison of the two methods using all available information was performed testing the postoperative values expressed as percentages of the preoperative ones using the Mann-Whitney two-sample test.
RESULTS: Most of the relevant studies have investigated and compared changes in spirometric parameters.The median percentage and interquartile range (IQR) of preoperative values in forced vital capacity (FVC), forced expiratory volume in 1 s and forced expiratory flow (FEF) at 25%-75% of FVC (FEF25%-75%) expressed as percentage of their preoperative values 24 h after LC and OC were respectively as follows: [77.6 (73.0, 80.0) L vs 55.4 (50.0, 64.0) L, P < 0.001; 76.0 (72.3, 81.0) L vs 52.5 (50.0, 56.7) L, P < 0.001; and 78.8 (68.8, 80.9) L/s vs 60.0 (36.1, 66.1) L/s, P = 0.005]. Concerning arterial blood gases, partial pressure of oxygen [PaO2 (kPa)] at 24 or 48 h after surgical treatment showed reductions that were significantly greater in OC compared with LC [LC median 1.0, IQR (0.6, 1.3); OC median 2.4, IQR (1.2, 2.6), P = 0.019]. Fewer studies have investigated the effect of LC on respiratory muscle performance showing less impact of this surgical method on maximal respiratory pressures (P < 0.01); and changes in the control of breathing after LC evidenced by increase in mean inspiratory impedance (P < 0.001) and minimal reduction of duty cycle (P = 0.01) compared with preoperative data.
CONCLUSION: Laparoscopic cholecystectomy seems to be associated with less postoperative derangement of lung function compared to the open procedure.
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Lati J, Pellow V, Sproule J, Brooks D, Ellerton C. Examining interrater reliability and validity of a paediatric cardiopulmonary physiotherapy discharge tool. Physiother Can 2014; 66:153-9. [PMID: 24799752 DOI: 10.3138/ptc.2013-23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To determine the interrater reliability (IRR) of the individual items in the Paediatric Cardiopulmonary Physiotherapy (CPT) Discharge Tool. This tool identifies six critical items that physiotherapists should consider when determining a paediatric patient's readiness for discharge from CPT after upper-abdominal, cardiac, or thoracic surgery: oxygen saturation, mobility, secretion retention, discharge planning, auscultation, and signs of respiratory distress. METHODS A total of 33 paediatric patients (ages 2 to <19 years) who received at least 1 day of CPT following cardiac, thoracic, or upper-abdominal surgery were independently assessed using the Paediatric CPT Discharge Tool by two designated assessors, who assessed each patient within 4 hours of each other. RESULTS Kappa analysis showed the following levels of interrater agreement for the six items of the Paediatric CPT Discharge Tool: Oxygen Saturation, excellent (κ=0.80); Mobility, substantial (κ=0.62); Secretion Clearance, moderate (κ=0.39); Discharge Planning, fair (κ=0.37); and Auscultation and Respiratory Distress, poor (κ=0.24 and κ=-0.08, respectively). CONCLUSION Several of the items in the Paediatric CPT Discharge Tool demonstrate good IRR. The discharge tool is ready for further psychometric testing, specifically validity testing.
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Affiliation(s)
- Jamil Lati
- Department of Rehabilitation Services, The Hospital for Sick Children
| | - Vanessa Pellow
- Department of Rehabilitation Services, The Hospital for Sick Children
| | - Jeannine Sproule
- Department of Rehabilitation Services, The Hospital for Sick Children
| | - Dina Brooks
- Department of Physical Therapy, University of Toronto, Toronto
| | - Cindy Ellerton
- Department of Physical Therapy, University of Toronto, Toronto
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Chen P, A Y, Hu Z, Cun D, Liu F, Li W, Hu M. Risk factors and bacterial spectrum for pneumonia after abdominal surgery in elderly Chinese patients. Arch Gerontol Geriatr 2014; 59:186-9. [PMID: 24742774 DOI: 10.1016/j.archger.2014.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 03/20/2014] [Accepted: 03/22/2014] [Indexed: 11/17/2022]
Abstract
Postoperative pneumonia is a common complication of abdominal surgery in the elderly. The aim of this study was to determine risk factors and bacterial spectrum for pneumonia after abdominal surgery in elderly Chinese patients. We performed a case-control study in a total of 5431 patients aged 65 years and over who had undergone abdominal surgery at the 2nd affiliated hospital of Kunming medical college between June 2003 and June 2011. Postoperative pneumonia developed in 86 patients (1.58%). Gram-negative bacilli were the principal microorganisms (82.86%) isolated from patients. The most common organisms isolated were Klebsiella spp. (28.57%), Acinetobacter spp. (17.14%) and Pseudomonas aeruginosa (17.14%). Multivariate analysis confirmed the following to be independent risk factors for postoperative pneumonia in the elderly after abdominal surgery: age ≥70 (OR 1.93, 95% CI 1.16-3.22, p=0.01), upper abdominal surgery (OR 2.07, 95% CI 1.18-3.64, p=0.01) and duration of operation >3 h (OR 2.48, 95% CI 1.49-4.15, p=0.00). Identifying these risk factors may help achieve better prevention and treatment for postoperative pneumonia in elderly patients after abdominal surgery.
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Affiliation(s)
- Peng Chen
- Department of General Surgery, the 2nd Affiliated Hospital of Kunming Medical College, Kunming 650101, China
| | - Yongjun A
- Department of General Surgery, the 2nd Affiliated Hospital of Kunming Medical College, Kunming 650101, China
| | - Zongqiang Hu
- Department of General Surgery, the 2nd Affiliated Hospital of Kunming Medical College, Kunming 650101, China
| | - Dongyun Cun
- Department of General Surgery, the 2nd Affiliated Hospital of Kunming Medical College, Kunming 650101, China
| | - Feng Liu
- Department of General Surgery, the 2nd Affiliated Hospital of Kunming Medical College, Kunming 650101, China
| | - Wen Li
- Department of General Surgery, the 2nd Affiliated Hospital of Kunming Medical College, Kunming 650101, China
| | - Mingdao Hu
- Department of General Surgery, the 2nd Affiliated Hospital of Kunming Medical College, Kunming 650101, China.
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Choi SM, Lee J, Park YS, Cho YJ, Lee CH, Lee SM, Yoon HI, Yim JJ, Lee JH, Yoo CG, Lee CT, Kim YW, Park JS. Postoperative pulmonary complications after surgery in patients with interstitial lung disease. Respiration 2014; 87:287-93. [PMID: 24577160 DOI: 10.1159/000357046] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 10/19/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with interstitial lung disease (ILD) have a high incidence of postoperative pulmonary complications (PPCs) after lung resection, but there is little data about these complications in ILD after other types of surgery. OBJECTIVES The aim of this study was to examine the characteristics and predictors of PPCs after major surgery in patients with ILD. METHODS We included 336 patients with ILD who underwent major surgery between January 2005 and December 2010 at two tertiary hospitals in Korea. All types of surgery that had been performed under general anesthesia were included. Demographic characteristics, preoperative lung function, and operative conditions including anesthesia time and estimated blood loss were compared between patients with and without PPCs. RESULTS PPCs occurred in 37 patients (11%). Thirteen patients developed pneumonia, the most common PPC, and 11 had acute exacerbation of ILD. In multivariable analysis, BMI <23 (OR = 2.488, 95% CI: 1.084-5.710, p = 0.031), emergency surgery (OR = 23.992, 95% CI: 2.629-218.949, p = 0.005), lung surgery (OR = 5.090, 95% CI: 1.391-18.628, p = 0.014), and longer anesthesia time (OR = 1.595, 95% CI: 1.143-2.227, p = 0.006) were statistically significant risk factors. CONCLUSIONS The incidence of PPCs detected over all surgeries was not as high as that reported for lung surgery alone in ILD patients. Lower BMI, emergency surgery, lung surgery, and longer anesthesia time were risk factors. Operative conditions as well as lung function should be considered in preoperative planning and management for ILD patients undergoing major surgery.
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Affiliation(s)
- Sun Mi Choi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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Exploring National Surgical Quality Improvement Program respiratory comorbidities: developing a predictive understanding of postoperative respiratory occurrences, Clavien 4 complications, and death. J Surg Res 2013; 183:663-7. [DOI: 10.1016/j.jss.2013.01.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Revised: 12/22/2012] [Accepted: 01/17/2013] [Indexed: 11/30/2022]
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Graybill WS, Frumovitz M, Nick AM, Wei C, Mena GE, Soliman PT, dos Reis R, Schmeler KM, Ramirez PT. Impact of smoking on perioperative pulmonary and upper respiratory complications after laparoscopic gynecologic surgery. Gynecol Oncol 2012; 125:556-60. [PMID: 22433464 DOI: 10.1016/j.ygyno.2012.03.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 03/09/2012] [Accepted: 03/11/2012] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To determine the impact of smoking on the rate of pulmonary and upper respiratory complications following laparoscopic gynecologic surgery. METHODS We retrospectively identified all patients who underwent laparoscopic gynecologic surgery at one institution between January 2000 and January 2009. Pulmonary and upper respiratory complications were defined as atelectasis, pneumonia, upper respiratory infection, acute respiratory failure, hypoxemia, pneumothorax, or pneumomediastinum occurring within 30 days after surgery RESULTS Nine hundred three patients underwent attempt at laparoscopic surgery. Fifty-four were excluded because of conversion to laparotomy and 31 because of insufficient data. Of the 818 patients included, 356 (43%) had cancer. A total of 576 (70%) patients were never smokers, 156 (19%) were past smokers, and 86 (10%) were current smokers (smoked within 6 weeks before surgery). These three groups were similar with regard to median body mass index, operative time, and length of hospital stay. Compared to never and past smokers, current smokers were more likely to undergo high-complexity laparoscopic procedures (10.4%, 15.4%, and 19.8%, respectively; p=0.015) and had younger median age 49 years, 51 years, and 46 years, respectively; p=0.035. Nineteen (2.3%) patients experienced pulmonary complications - symptomatic atelectasis (n=9), pneumonia (n=5), acute respiratory failure (n=2), hypoxemia (n=1), pneumomediastinum (n=1), and pneumothorax (n=2). The rate of pulmonary complications was 2.1% (12 of 564 patients) in never smokers, 4.5% (7 of 156 patients) in past smokers, and zero in current smokers. CONCLUSION In this cohort, smoking history did not appear to impact postoperative pulmonary and upper respiratory complications. In smokers scheduled for operative procedures, laparoscopy should be considered when feasible.
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Affiliation(s)
- Whitney S Graybill
- Department of Gynecologic Oncology, Medical University of South Carolina, Charleston, South Carolina, USA
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20
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Hong CM, Cartagena R, Passannante AN, Rock P. Respiratory Diseases. ANESTHESIA AND UNCOMMON DISEASES 2012. [PMCID: PMC7151791 DOI: 10.1016/b978-1-4377-2787-6.00004-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Pulmonary arteriovenous fistulas have congenital and hereditary etiology, and patients are at risk for life-threatening rupture requiring surgery. Wegener's granulomatosis can affect any organ system, although renal and pulmonary involvement is most common; men ages 40 to 50 are at increased risk. Lymphomatoid granulomatosis affects cardiopulmonary, neurologic, and myeloproliferative systems; may result from opportunistic infection, and frequently progresses to lymphoma; men age 50 to 60 are at increased risk. Spontaneous remission occurs in some cases; mortality is 60% to 90% at 5 years. Churg-Strauss syndrome is usually associated with long-standing asthma, with men and women affected equally, and can affect any organ system; major cause of death is cardiac related. Primary pulmonary hypertension is a diagnosis of exclusion; women are affected twice as likely as men; right-to-left shunt may occur in 30%, secondary to patent foramen ovale; hypoxia with resultant heart failure is typical cause of death. Cystic fibrosis is an autosomal recessive disease, eventually fatal, with increased risk for airway obstruction, fluctuating pulmonary function, and chronic hypoxia; risk for spontaneous pneumothorax is 20%. Bronchiolitis obliterans organizing pneumonia is a pulmonary obstructive disease that may be reversible and usually resolves spontaneously. Idiopathic pulmonary hemosiderosis is associated with autoimmune disorders; patients have recurrent hemorrhage, pulmonary fibrosis, restrictive lung disease, and pulmonary hypertension, with some cases of spontaneous remission. Chronic eosinophilic pneumonia may be preceded by adult-onset asthma; women are at increased risk; prognosis is good. Goodpasture's syndrome is a genetic autoimmune disorder involving the pulmonary and renal systems. Pulmonary alveolar proteinosis, a lipoprotein-rich accumulation in alveoli, has three forms: congenital, decreased alveolar macrophage activity, and idiopathic; some cases of spontaneous remission occur. Sarcoidosis may affect any organ system; African American, northern European, and females are at greater risk; many patients are asymptomatic. Systemic lupus erythematosus may affect any organ system; women of childbearing age are at increased risk. Idiopathic pulmonary fibrosis is a rare interstitial lung disease, with smokers at increased risk for pulmonary malignancy; survival is usually 2 to 3 years from diagnosis; no effective treatment exists, with lung transplant the only therapeutic option. Acute respiratory distress syndrome (ARDS) is associated with underlying critical illness or injury, developing acutely in 1 to 2 days; mortality is 25% to 35%. Pulmonary histiocytosis X is an interstitial lung disease associated with cigarette smoking and an unpredictable course; some spontaneous remission occurs. Lymphangioleiomyomatosis involves progressive deterioration of lung function, associated with tuberous sclerosis and exacerbated by pregnancy, with women at increased risk; possible spontaneous pneumothorax and chylothorax; death usually results from respiratory failure. Ankylosing spondylitis is a genetic inflammatory process resulting in fusion of axial skeleton and spinal deformities, with men at increased risk; radiologic bamboo spine, sacral to cervical progression, and restrictive lung disease with high reliance on diaphragm; extraskeletal manifestations may occur. Kyphosis (exaggerated anterior flexion) and scoliosis (lateral rotational deformity) are spinal/rib cage deformities with idiopathic, congenital, or neuromuscular etiology; corrective surgery done if Cobb thoracic angle >50% lumbar angle >40%. Bleomycin is an antineoplastic antibiotic used in combination chemotherapy, with no myelosuppressive effect; toxicity can cause life-threatening pulmonary fibrosis. Influenza A is highly infectious, presenting with flulike symptoms and possible progression to ARDS; human-to-human exposure is through droplets or contaminated surfaces, with high risk for infants, children, pregnancy, chronically ill, or renal replacement therapy patients. No prophylactic treatment exists; treat patients with high index of suspicion without definitive testing; rRT-PCR and viral cultures are sensitive for pandemic H1N1 strain. Severe acute respiratory syndrome (SARS) is highly infectious, transmitted by coronavirus with human-to-human exposure via droplets or surfaces, and may progress to ARDS. Echinococcal disease of lung is from canine tapeworm, transmitted by eggs from feces; rupture of cyst may result in anaphylactic reaction or spread of disease to other organs; children are at increased risk. No transthoracic needle aspiration is done; surgery is only option.
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Tewari D. Preoperative Evaluation. Gynecol Oncol 2011. [DOI: 10.1002/9781118003435.ch5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Berman M, Goldsmith K, Jenkins D, Sudarshan C, Catarino P, Sukumaran N, Dunning J, Sharples LD, Tsui S, Parmar J. Comparison of Outcomes From Smoking and Nonsmoking Donors: Thirteen-Year Experience. Ann Thorac Surg 2010; 90:1786-92. [DOI: 10.1016/j.athoracsur.2010.07.073] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Revised: 07/21/2010] [Accepted: 07/23/2010] [Indexed: 10/18/2022]
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Smoking in trauma patients: the effects on the incidence of sepsis, respiratory failure, organ failure, and mortality. ACTA ACUST UNITED AC 2010; 69:308-12. [PMID: 20699738 DOI: 10.1097/ta.0b013e3181e1761e] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND There is a high percentage of smokers among trauma patients. Cigarette smoking has been associated with the development of acute lung injury and the adult respiratory distress syndrome in critically ill patients. It is also known that nicotine exerts immunosuppressive and anti-inflammatory effects with chronic use. Trauma patients who are smokers usually go through acute nicotine withdrawal after the traumatic event and during their stay in ICU. How the smoking status and acute nicotine withdrawal affect outcomes after trauma is unknown. This question was addressed in this study by analyzing the incidence of sepsis, septic shock and multiple organ dysfunction syndrome, and other outcomes in smoking and nonsmoking trauma patients. METHODS A retrospective cohort of trauma patients who met the criteria was randomly selected from the trauma registry. Individual charts were reviewed to confirm documented smoking status. Criteria for selection included the following: Injury Severity Score >or=20, age 18 to 65 years, hospital length of stay >72 hours. Patients with COPD/emphysema, diabetes mellitus, cardiac disease, malignancy, pregnancy, or steroid use were excluded. RESULTS Overall, 327 patient charts were reviewed: 156 smokers and 171 nonsmokers. Men outnumbered women in the smoking group fourfold (p = 0.003 versus nonsmokers). Age, Injury Severity Score, the presence of shock on admission, the type of trauma (blunt or penetrating), ICU and hospital length of stay, and the duration of ventilator support were similar between smokers and nonsmokers. There were no differences in the incidence of sepsis, pneumonia, adult respiratory distress syndrome, or multiple organ dysfunction syndrome. Mortality was low (1.2% in smokers; 0.6% in nonsmokers) and did not differ significantly between the groups. CONCLUSIONS The smoking status plays a minimal role in the outcome of healthy trauma patients. This suggests that the acute nicotine withdrawal that usually occurs in critically ill patients has no clinically significant implications after injury.
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Duggan M, Kavanagh BP. Perioperative modifications of respiratory function. Best Pract Res Clin Anaesthesiol 2010; 24:145-55. [DOI: 10.1016/j.bpa.2009.12.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Perioperative management of patients who have pulmonary disease. Oral Maxillofac Surg Clin North Am 2009; 18:81-94, vi. [PMID: 18088813 DOI: 10.1016/j.coms.2005.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The identification of risk factors and optimization of respiratory status are crucial to the successful management of patients who have pulmonary disease and are undergoing a surgical procedure. This article explores the approach to pulmonary patients, from the preoperative assessment to the intraoperative and postoperative periods. The management of specific pulmonary disorders in the perioperative period is discussed.
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Abstract
Preoperative pulmonary evaluation and optimization improves postoperative patient outcomes. Clinicians frequently evaluate patients with pulmonary disease before surgery who are at increased risk for pulmonary and nonpulmonary perioperative complications. Postoperative pulmonary complications are as common and costly as cardiac complications. In this article, the evaluation of patients with the most common conditions encountered in the preoperative setting, including unexplained dyspnea, asthma, chronic obstructive pulmonary disease, obstructive sleep apnea, and cigarette use, are discussed. Risk stratification for postoperative pulmonary complications and strategies to reduce them for high-risk patients are also discussed. From the available literature, high-risk patients and those patients for whom a multidisciplinary collaboration will be most helpful can be accurately identified.
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Abstract
Preoperative pulmonary evaluation and optimization improves postoperative patient outcomes. Clinicians frequently evaluate patients with pulmonary disease before surgery who are at increased risk for pulmonary and nonpulmonary perioperative complications. Postoperative pulmonary complications are as common and costly as cardiac complications. In this article, the evaluation of patients with the most common conditions encountered in the preoperative setting, including unexplained dyspnea, asthma, chronic obstructive pulmonary disease, obstructive sleep apnea, and cigarette use, are discussed. Risk stratification for postoperative pulmonary complications and strategies to reduce them for high-risk patients are also discussed. From the available literature, high-risk patients and those patients for whom a multidisciplinary collaboration will be most helpful can be accurately identified.
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Affiliation(s)
- Bobbie Jean Sweitzer
- Department of Anesthesia and Critical Care, University of Chicago, MC 4028, Chicago, IL 60637, USA.
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Mason DP, Subramanian S, Nowicki ER, Grab JD, Murthy SC, Rice TW, Blackstone EH. Impact of smoking cessation before resection of lung cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database study. Ann Thorac Surg 2009; 88:362-70; discussion 370-1. [PMID: 19632374 DOI: 10.1016/j.athoracsur.2009.04.035] [Citation(s) in RCA: 167] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2009] [Revised: 03/30/2009] [Accepted: 04/01/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Smoking cessation is presumed to be beneficial before resection of lung cancer. The effect of smoking cessation on outcome was investigated. METHODS From January 1999 to July 2007, in-hospital outcomes for 7990 primary resections for lung cancer in adults were reported to the Society of Thoracic Surgeons General Thoracic Surgery Database. Risk of hospital death and respiratory complications was assessed according to timing of smoking cessation, adjusted for clinical confounders. RESULTS Hospital mortality was 1.4% (n = 109), but 1.5% in patients who had smoked (105 of 6965) vs 0.39% in those who had not (4 of 1025). Compared with the latter, risk-adjusted odds ratios were 3.5 (p = 0.03), 4.6 (p = 0.03), 2.6 (p = 0.7), and 2.5 (p = 0.11) for those whose timing of smoking cessation was categorized as current smoker, quit from 14 days to 1 month, 1 to 12 months, or more than 12 months preoperatively, respectively. Prevalence of major pulmonary complications was 5.7% (456 of 7965) overall, but 6.2% in patients who had smoked (429 of 6941) vs 2.5%% in those who had not (27 of 1024). Compared with the latter, risk-adjusted odds ratios were 1.80 (p = 0.03), 1.62 (p = 0.14), 1.51 (p = 0.20), and 1.29 (p = 0.3) for those whose timing of smoking cessation was categorized as above. CONCLUSIONS Risks of hospital death and pulmonary complications after lung cancer resection were increased by smoking and mitigated slowly by preoperative cessation. No optimal interval of smoking cessation was identifiable. Patients should be counseled to stop smoking irrespective of surgical timing.
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Affiliation(s)
- David P Mason
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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Impact of preoperative smoking status on postoperative complication rates and pulmonary function test results 1-year following pulmonary resection for non-small cell lung cancer. Lung Cancer 2009; 64:352-7. [DOI: 10.1016/j.lungcan.2008.09.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2008] [Revised: 09/15/2008] [Accepted: 09/29/2008] [Indexed: 11/20/2022]
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Kirschbaum A, Kyriss T, Dippon J, Friedel G. Morbidity and mortality after pneumonectomy in smokers with NSCLC. THORACIC SURGICAL SCIENCE 2008; 5:Doc01. [PMID: 21289906 PMCID: PMC3011295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Perioperative morbidity and mortality in patients receiving pneumonectomy because of non-small cell lung cancer (NSCLC) remains quite high. The aim of this study is to identify risk factors to minimize perioperative mortality and morbidity. PATIENTS AND METHOD The results of 156 Patients who received pneumonectomy between 1995 and 2004 were reviewed retrospectively. All patients had stage I or II NSCLC. In 81 cases a right sided and in 75 a left sided pneumonectomy was performed. Cardiopulmonary function tests were sufficient for pneumonectomy. RESULTS Overall perioperative 30-day mortality was 7.1% (n=11), in hospital mortality 8.3% (n=13). The cause was sepsis in 6 cases, cardiac failure in 4 cases, and respiratory insufficiency in 3 cases. In univariable and multivariable regression analysis considering mortality, none of the prognostic factors reached significance. The odds ratio for postoperative death was 1.6 fold for smokers in comparison to non smokers. Complications after pneumonectomy were seen in 34.6%, with arrhythmia in 16.0%, sepsis in 1.9% and bronchopleural fistula (BPF) occurring in 6.4%. Smoking and intraoperative blood loss >500 ml were highly significant perioperative risk factors. CONCLUSION Smoking until operation and intraoperative blood loss were independent postoperative risk factors leading to complications after pneumonectomy for NSCLC. The risk for complications was 2.8-fold higher for smokers.
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Affiliation(s)
- Andreas Kirschbaum
- Department of Thoracic Surgery, Center for Pneumology and Thoracic Surgery, Schillerhöhe Hospital and Robert Bosch Hospital, Gerlingen, Deutschland
| | - Thomas Kyriss
- Department of Thoracic Surgery, Center for Pneumology and Thoracic Surgery, Schillerhöhe Hospital and Robert Bosch Hospital, Gerlingen, Deutschland
| | - Jürgen Dippon
- Department of Mathematics, University Stuttgart, Stuttgart, Germany
| | - Godehard Friedel
- Department of Thoracic Surgery, Center for Pneumology and Thoracic Surgery, Schillerhöhe Hospital and Robert Bosch Hospital, Gerlingen, Deutschland,*To whom correspondence should be addressed: Godehard Friedel, Klinik Schillerhöhe, Thoraxchirurgie, Solitudestr. 18, 70839, Gerlingen, Deutschland, E-mail:
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Abstract
Smoking is a well-known risk factor for perioperative complications. Smokers experience an increased incidence of respiratory complications during anaesthesia and an increased risk of postoperative cardiopulmonary complications, infections and impaired wound healing. Smokers have a greater risk of postoperative intensive care admission. Even passive smoking is associated with increased risk at operation. Preoperative smoking intervention 6-8 weeks before surgery can reduce the complications risk significantly. Four weeks of abstinence from smoking seems to improve wound healing. An intensive, individual approach to smoking intervention results in a significantly better postoperative outcome. Future research should focus upon the effect of a shorter period of preoperative smoking cessation. All smokers admitted for surgery should be informed of the increased risk, recommended preoperative smoking cessation, and offered a smoking intervention programme whenever possible.
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Affiliation(s)
- Ann Møller
- Department of Anaesthesiology, Herlev University Hospital, Herlev Ringvej, 2730 Herlev, Denmark.
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Baig MK, Zmora O, Derdemezi J, Weiss EG, Nogueras JJ, Wexner SD. Use of the ON-Q pain management system is associated with decreased postoperative analgesic requirement: double blind randomized placebo pilot study. J Am Coll Surg 2006; 202:297-305. [PMID: 16427556 DOI: 10.1016/j.jamcollsurg.2005.10.022] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2005] [Revised: 10/17/2005] [Accepted: 10/26/2005] [Indexed: 12/22/2022]
Abstract
BACKGROUND Narcotics are routinely used to decrease postoperative pain after laparotomy. But they are associated with unwarranted side effects. The aim of this study was to assess the effectiveness of local perfusion of bupivacaine in decreasing narcotic consumption after midline laparotomy. STUDY DESIGN We performed a prospective, randomized, double blind study involving patients who underwent a midline laparotomy with subsequent wound closure. Patients were randomized to receive a 72-hour continuous wound perfusion through the ON-Q pain management system (I Flow Corporation) of the local anesthetic bupivacaine (0.5%, study group) or 0.9% NaCl (control group). In addition, all patients received standardized intraoperative analgesia and postoperative morphine patient-controlled analgesia. Total postoperative analgesic requirement, pain control, recovery of bowel function, and complications were recorded. RESULTS Seventy patients were recruited: 35 in the study group (mean age, 55.7 years) and 35 in the control group (mean age, 58.8 years). There was no difference in overall postoperative pain scores. Patients in the study group reported earlier ambulation as compared with the control group. Mean (+/-SD) daily narcotic requirements were significantly less in the study group versus the control group (33.7+/-32 mg versus 60.1+/-62 mg, respectively; p=0.03). Patients in the study group made 50% fewer attempts to receive patient-controlled analgesia (p=0.011). But there was no significant difference in length of hospitalization or time to first bowel movement. CONCLUSIONS This preliminary pilot study revealed that the ON-Q pain management system after midline laparotomy, as part of a multimodal approach, is an effective approach to postoperative pain control.
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Affiliation(s)
- Mirza K Baig
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA
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Abstract
Fig. 2 is an algorithm for the preoperative pulmonary evaluation of the lung resection candidate. Patients should undergo routine spirometry and diffusion capacity testing. If the FEV1 and DLCO are greater than 80% predicted, no further study is needed. When these parameters are less than 80%, some estimation of postoperative function is likely needed, taking into account the proposed resection. Patients with ppoFEV1 or ppoDLCO less than 40% are at increased risk of perioperative complications or death and should undergo formal exercise testing. A VO2max or ppoVO2max less than 10 mL/kg/min is associated with prohibitive risk for anatomic lung resection, and alternative treatment modalities should be considered.
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Affiliation(s)
- Aditya K Kaza
- Section of General Thoracic Surgery, Division of Cardiothoracic Surgery, University of Colorado Health Sciences Center, 4200 East 9th Avenue, C-310, Denver, CO 80262, USA
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Barrera R, Shi W, Amar D, Thaler HT, Gabovich N, Bains MS, White DA. Smoking and timing of cessation: impact on pulmonary complications after thoracotomy. Chest 2005; 127:1977-83. [PMID: 15947310 DOI: 10.1378/chest.127.6.1977] [Citation(s) in RCA: 150] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
STUDY OBJECTIVE The benefit of smoking cessation just prior to surgery in preventing postoperative pulmonary complications has not been proven. Some studies actually show a paradoxical increase in complications in those quitting smoking only a few weeks or days prior to surgery. We studied the effect of smoking and the timing of smoking cessation on postoperative pulmonary complications in patients undergoing thoracotomy. DESIGN AND SETTING Prospective study conducted in a tertiary care cancer center in 300 consecutive patients with primary lung cancer or metastatic cancer to the lung who were undergoing anatomical lung resection. RESULTS The groups studied were nonsmokers (21%), past quitters of > 2 months duration (62%), recent quitters of < 2 months duration (13%), and ongoing smokers (4%). Overall pulmonary complications occurred in 8%, 19%, 23%, and 23% of these groups, respectively, with a significant difference between nonsmokers and all smokers (p = 0.03) but no difference among the subgroups of smokers (p = 0.76). The risk of pneumonia was significantly lower in nonsmokers (3%) compared to all smokers (average, 11%; p < 0.05), with no difference detected among subgroups of smokers (p = 0.17). Comparing recent quitters and ongoing smokers, no differences in pulmonary complications or pneumonia were found (p = 0.67). Independent risk factors for pulmonary complications were a lower diffusing capacity of the lung for carbon monoxide (Dlco) [odds ratio [ OR] per 10% decrement, 1.41; 95% confidence interval [ CI], 1.17 to 1.70; p = 0.01) and primary lung cancer rather than metastatic disease (OR, 3.94; 95% CI, 1.34 to 11.59; p = 0.003). Among smokers, a lower Dlco percent predicted (OR per 10% decrement, 1.42; 95% CI, 1.16 to 1.75; p = 0.008) and a smoking history of > 60 pack-years (OR, 2.54; 95% CI, 1.28 to 5.04; p = 0.0008) were independently associated with overall pulmonary complications. CONCLUSIONS In patients undergoing thoracotomy for primary or secondary lung tumors, there is no evidence of a paradoxical increase in pulmonary complications among those who quit smoking within 2 months of undergoing surgery. Smoking cessation can safely be encouraged prior to surgery.
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Affiliation(s)
- Rafael Barrera
- Department of Anesthesiology and Critical Care Medicine, Pulmonary Section, Weill Graduate School of Medical Sciences, Memorial Sloan-Kettering Hospital, 1275 York Ave, New York, NY 10021, USA
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Jiang SP, Li ZY, Huang LW, Zhang W, Lu ZQ, Zheng ZY. Multivariate analysis of the risk for pulmonary complication after gastrointestinal surgery. World J Gastroenterol 2005; 11:3735-41. [PMID: 15968730 PMCID: PMC4316026 DOI: 10.3748/wjg.v11.i24.3735] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To identify the risk factors for postoperative pulmonary complications (PPC) after gastrointestinal surgery.
METHODS: A total of 1002 patients undergoing gastrointestinal surgery in the Second Affiliated Hospital, Sun Yat-Sen University, during December 1999 and December 2003, were retrospectively studied.
RESULTS: The overall incidence of PPC was 22.8% (228/1002). Multivariate logistic analysis identified nine risk factors associated with PPC, including age odds ratio (OR = 1.040) history of respiratory diseases (OR = 2.976), serum albumin (OR = 0.954), chemotherapy 2 wk before operation (OR = 3.214), volume of preoperative erythrocyte transfusion (OR = 1.002), length of preoperative antibiotic therapy (OR = 1.072), intraoperative intratracheal intubation (OR = 1.002), nasogastric intubation (OR = 1.050) and postoperative mechanical ventilation (OR = 1.878). Logistic regression equation for predicting the risk of PPC was P(1) = 1/[1+e-(-3.488+ 0.039×Y+1.090×Rd+0.001×Rbc-0.047×Alb+0.002×Lii+ 0.049×Lni+0.630×Lmv+0.070×Dat+ 1.168×Ct)].
CONCLUSION: Old patients are easier to develop PPC.
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Affiliation(s)
- Shan-Ping Jiang
- Department of Respiratory Medicine, the Second Affiliated Hospital, Sun Yat-Sen University, Guangzhou 510120, Guangdong Province, China.
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Rossi LA, Bromberg SH. Estudo prospectivo do derrame pleural pós-cirurgia abdominal e dos fatores de risco associados: avalição por ultra-sonografia. Radiol Bras 2005. [DOI: 10.1590/s0100-39842005000200005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
MOTIVAÇÃO: Derrame pleural é alteração pulmonar comumente observada em exames de imagem após cirurgias abdominais eletivas, sem repercussão clínica na maioria dos enfermos, devendo ser individualizada das complicações pulmonares que requerem tratamento. Sua incidência, bem como os indicadores de risco, são desconhecidos em nosso meio. OBJETIVO: Determinar, pela ultra-sonografia, a incidência de derrame pleural pós-operatório (DPPO) em cirurgias abdominais eletivas e averiguar suas possíveis associações com fatores de risco relacionados aos doentes e procedimentos anestésico-cirúrgicos. MATERIAIS E MÉTODOS: Estudaram-se 21 (56,8%) mulheres e 16 (43,2%) homens, entre 29 e 76 anos, submetidos a cirurgias abdominais eletivas. Os exames ecográficos foram realizados no pré-operatório e 48 horas após a cirurgia. Foram estudados os fatores de risco associados ao paciente - idade maior de 60 anos, sexo, obesidade, tabagismo, etilismo e presença de doenças associadas -, e ao procedimento anestésico-cirúrgico - cirurgia para ressecção de câncer, classe ASA > 2, tempo anestésico-cirúrgico, incisão longitudinal e incisão > 15 cm. A litíase biliar (43,2%) e a presença de câncer gastrintestinal (43,2%) foram os principais responsáveis pela indicação cirúrgica. O DPPO foi graduado de pequeno, médio e grande. RESULTADOS: A incidência de DPPO foi de 70,3% (26/37). Dois (5,4%) desses doentes evoluíram com complicações pulmonares graves, um deles vindo a falecer. Idade maior de 60 anos, tabagismo, etilismo, obesidade e presença de doenças associadas não influenciaram o aparecimento de DPPO. Cirurgia para ressecção de câncer, classe ASA > 2, incisão longitudinal e incisão > 15 cm associaram-se de modo significante à presença de DPPO, que ocorreu mesmo na vigência de antibioticoprofilaxia. O tempo de permanência hospitalar foi 2,4 vezes maior nos doentes com DPPO. CONCLUSÃO: A ocorrência de derrame pleural em pós-operatório de cirurgia abdominal eletiva é muito freqüente. A maioria dos DPPO é autolimitada, evoluindo de modo assintomático. A ecografia na constatação do DPPO mostrou-se efetiva e sua utilização merece ser difundida.
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Oto T, Griffiths AP, Levvey B, Pilcher DV, Whitford H, Kotsimbos TC, Rabinov M, Esmore DS, Williams TJ, Snell GI. A donor history of smoking affects early but not late outcome in lung transplantation. Transplantation 2004; 78:599-606. [PMID: 15446321 DOI: 10.1097/01.tp.0000131975.98323.13] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Liberalization of tobacco exposure history as an exclusion to lung donation has recently occurred to increase donor organ availability. This study investigated the effect of donor smoking status and current and cumulative cigarette dose on early and late outcomes in lung transplantation. METHODS From 1995 to 2002, 173 heart-lung and bilateral single-lung transplant recipients were retrospectively reviewed. Seventy-seven (45%) of 173 donors were ever-smokers and 64 of those 77 were current smokers. These were divided into subgroups by current number of cigarettes smoked to investigate acute dose effects and by pack-year to investigate cumulative dose effects. Risks of smoking were assessed by univariate and multivariate hazard regression models. RESULTS Univariate analysis revealed that there were significant differences between current and cumulative dose subgroups in early postoperative variables, including Pao2/Fio2 ratio, ventilation time, and intensive care unit stay. Additionally, these variables were dose dependent. There was no significant difference in 3-year survival between never-smokers and ever-smokers (73% versus 64%, P = 0.27), and a rate of decline of survival was similar. There was a trend for the percentage of patients dying of bronchiolitis obliterans syndrome to be lower in the ever-smokers group compared with the never-smokers group (6% versus 11%, respectively). Multivariate analysis revealed current and cumulative smoking as a risk factor for early but not late outcomes. CONCLUSIONS Donor smoking history had a significant effect on early outcomes in lung transplantation in a current and cumulative dose-dependent fashion. However, no significant effect on late outcomes, including bronchiolitis obliterans syndrome, was seen.
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Affiliation(s)
- Takahiro Oto
- Heart and Lung Transplant Unit, Alfred Hospital, Monash University Medical School, Commercial Road, Melbourne, Victoria 3004, Australia
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Abstract
Sex determination and gametogenesis are key processes in human reproduction, and any defect can lead to infertility. We describe here the molecular mechanisms of male sex determination and testis formation; defects in sex determination lead to a female phenotype despite the presence of a Y chromosome, more rarely to a male phenotype with XX chromosomes, or to intersex phenotypes. Interestingly, these phenotypes are often associated with other developmental malformations. In testis, spermatozoa are produced from renewable stem cells in a complex differentiation process called spermatogenesis. Gene expression during spermatogenesis differs to a surprising degree from gene expression in somatic cells, and we discuss here mechanistic differences and their effect on the differentiation process and male fertility.
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Affiliation(s)
- L. Ronfani
- San Raffaele Scientific Institute and San Raffaele University, via Olgettina 58, 20132 Milan, Italy
| | - M. E. Bianchi
- San Raffaele Scientific Institute and San Raffaele University, via Olgettina 58, 20132 Milan, Italy
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Jules-Elysee K, Urban MK, Urquhart BL, Susman MH, Brown AC, Kelsey WT. Pulmonary complications in anterior-posterior thoracic lumbar fusions. Spine J 2004; 4:312-6. [PMID: 15125855 DOI: 10.1016/j.spinee.2003.11.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2003] [Accepted: 11/19/2003] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Surgery for adult spinal deformity may require both an anterior and posterior approach in order to stabilize the spine and achieve the desired correction. These procedures can be associated with significant pulmonary complications, including atelectasis, pneumonia and respiratory failure. The etiology of some of the respiratory complications is clear: poor inspiratory effort from incision pain and previous pulmonary disease. However, for many patients the direct cause of these complications is not obvious. PURPOSE To delineate the incidence, severity and risks associated with pulmonary complications in the setting of major spine surgery. STUDY DESIGN/SETTING Retrospective chart review study of adult patients undergoing combined anterior-posterior thoracic, lumbar and sacral fusion spine surgery. PATIENT SAMPLE A total of 60 charts were reviewed for this study. OUTCOME MEASURES Radiographic abnormalities correlated with clinical findings, postoperative need for ventilation and lengths of hospital stay were used as outcome measures. METHODS Perioperative pulmonary complications were assessed for 60 patients with spinal deformities who underwent combined anterior-posterior thoracic, lumbar and sacral fusion over a 2-year period. RESULTS One patient was eliminated from analysis because of multiple surgeries during his hospital course. Of the remaining 59 patients, 38 (64%) developed roentgenographic abnormalities. The most common radiographic finding was an effusion found in 66% of these patients, followed by atelectasis in 53%. Twenty-one percent (8 of 38) had infiltrates. Five (5 of 38) or 13% had evidence of partial or complete lobar collapse; in two bronchoscopy was required because of profound hypoxemia. Two patients had pneumonia requiring antibiotic treatment. All but two patients were extubated within 36 hours of surgery. They were kept intubated because of hemodynamic instability. There was no statistically significant difference in the group of patients with and without roentgenographic abnormalities with regard to age, weight, American Society of Anesthesiologists class, smoking history, pulmonary function test results, blood loss, perioperative blood and crystalloid requirement and length of surgery. Patients with radiographic abnormalities were more likely to have had invasion of their thoracic cavity (p=.02) and had a longer mean hospital stay of 13.5 versus 10.2 days (p=.009). CONCLUSION Radiographic abnormalities of the lungs are common after major spine surgery involving both an anterior and posterior approach, especially when the thoracic cavity is invaded. In view of the morbidity and longer hospital stay associated with such findings, close monitoring of pulmonary status with aggressive pulmonary toilet are indicated.
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Affiliation(s)
- Kethy Jules-Elysee
- Department of Anesthesiology, The Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY 10021, USA
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Basu S, Tamijmarane A, Bulters D, Wells JKG, John TG, Rees M. An alternative method of wound pain control following hepatic resection: a preliminary study. HPB (Oxford) 2004; 6:186-9. [PMID: 18333074 PMCID: PMC2020673 DOI: 10.1080/13651820410030844] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Epidural analgesia is considered one of the optimal methods for provision of postoperative pain relief in patients recovering from major upper abdominal operations. Concerns regarding the potential risk of neurological complications prompted an evaluation of an alternative strategy using a continuous intermuscular bupivacaine (CIB) infusion combined with patient-controlled analgesia (PCA). METHODS Two fine-bore catheters are inserted in the deep intermuscular intercostal neuronal plane during abdominal wound closure, and a continuous infusion of bupivacaine 0.25% is commenced for 72 h postoperatively. Simultaneously, patient-controlled analgesia provided intravenous morphine on demand. The study comprised 10 consecutive patients undergoing liver resection in whom CIB infusion and PCA were employed. The feasibility, safety and efficacy of the technique were investigated, analysing postoperative pain scores, morphine requirements, spirometry and oxygen saturation. RESULTS There were no postoperative deaths. Postoperative morbidity included one urinary tract infection, one minor chest infection and acute confusional episodes in two patients. Median pain scores and morphine requirements at 12, 24, 48 and 72 h postoperatively were satisfactory. Spirometry and oxygen saturation values also remained within the normal range. DISCUSSION Preliminary experience with CIB infusion/PCA in the aftermath of major liver resection has demonstrated its simplicity and safety as an alternative method of postoperative pain control. Further study is required to investigate the role of CIB infusion/PCA as a practical alternative to epidural analgesia or PCA alone.
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Affiliation(s)
- S Basu
- Hepato-biliary Unit, North Hampshire HospitalBasingstokeUK
| | - A Tamijmarane
- Hepato-biliary Unit, North Hampshire HospitalBasingstokeUK
| | - D Bulters
- Hepato-biliary Unit, North Hampshire HospitalBasingstokeUK
| | - JKG Wells
- Hepato-biliary Unit, North Hampshire HospitalBasingstokeUK
| | - TG John
- Hepato-biliary Unit, North Hampshire HospitalBasingstokeUK
| | - M Rees
- Hepato-biliary Unit, North Hampshire HospitalBasingstokeUK
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Affiliation(s)
- Katherine P Grichnik
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, Duke Heart Center, Duke University Health Care Systems, Durham, NC 27710, USA.
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Abstract
Postoperative pulmonary complications in the elderly are common and are a significant source of morbidity, mortality, and prolonged length of stay. Risk factors differ from the well-known risk factors for cardiac complications and can be divided into patient- and procedure-related factors. Patient-related factors include COPD, recent cigarette use, poor general health status as defined by Goldman or ASA class, dependent functional status, and laboratory parameters including abnormal chest radiograph, renal insufficiency, and low serum albumin. Age is a minor risk factor when adjusted for comorbidities and confers approximately a two-fold increase in risk. Elderly patients who are otherwise acceptable surgical candidates should not be denied surgery based solely on age and concern for postoperative pulmonary complications. The surgical site is the single most important predictor of pulmonary complications. High-risk surgeries include thoracic, upper abdominal, aortic, neurosurgery, and peripheral vascular. Other procedure-related risk factors include surgery lasting longer than 3 hours, the use of general anesthesia, pancuronium use, and emergency surgery. Clinicians should not recommend routine preoperative spirometry before high-risk surgery because it is no more accurate in predicting risk than clinical evaluation. Patients who might benefit from preoperative spirometry include those who have unexplained dyspnea or exercise intolerance and those who have COPD or asthma in whom uncertainty exists as to the status of airflow obstruction when compared with baseline. After identifying patients at risk for postoperative pulmonary complications, clinicians can recommend strategies to reduce risk throughout the operative period. In addition to minimizing or avoiding the above risk factors, optimization of COPD or asthma, deep breathing exercises, incentive spirometry, and epidural local anesthetics reduce the risk of postoperative pulmonary complications in elderly surgical patients.
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Affiliation(s)
- Gerald W Smetana
- Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Tammaro D, McGarry KA, Cyr MG. Perioperative care of the patient with hip fracture. COMPREHENSIVE THERAPY 2003; 29:233-43. [PMID: 14989045 DOI: 10.1007/s12019-003-0027-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Primary care physicians can intervene to reduce perioperative complications due to comorbid medical illness in patients hospitalized with hip fracture. We review the role of the primary care physician in the treatment and prevention of perioperative morbidity and mortality.
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Affiliation(s)
- Dominick Tammaro
- Rhode Island Hospital, Division of General Internal Medicine, Department of Medicine, Brown Medical School, Providence, RI, USA
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Sindjelić R, Vlajković G, Ristić M, Divac I, Marković D. The role of nitric oxide in treatment of acute lung injury after surgery with extracorporeal circulation. ACTA ACUST UNITED AC 2003; 50:49-54. [PMID: 14994569 DOI: 10.2298/aci0302049s] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Postoperative acute lung injury (ALI) compromises oxygen transfer across alveolar-capillary membrane with consecutive hypoxia, one of its indicators being reduction of oxygenation index PaO2/FiO2 below 40 kPa (300 mm Hg). Management of ALI includes different procedures like mechanical lung ventilation (MLV), drugs and others. One of the new possibilities for treatment of ALI is nitric oxide (NO) inhalation. The aim of this prospective study was to examine the role of NO inhalation in treatment of ALI. 14 patients with ALI developed immediately after operation with extracorporeal circulation (ECC) were included in the study. Group A (n = 8) inhaled NO and group B (n = 6) did not inhale NO during treatment of ALI. All other therapeutic measures were the same in both groups. The groups were similar in relation to demographic data, type of surgery and duration of ECC. PaO2/FiO2 was calculated before operation (T1), immediately after surgery (T2) and after lung recovery, when the need for MLV stopped (T3). The duration of MLV was also registered. PaO2/FiO2 (kPa) in referent times was in group A 54,9 ? 1,6, 33,8 ? 1,2 and 46,2 ? 0,8 and in group B 52,2 ? 1,1, 33,5 ? 1,5 and 47,3 ? 0,9, respectively. There was a statistically significant decrease of PaO2/FiO2 in T2 and T3 vs T1 in both groups (p < 0,05), while the difference between the groups was not statistically significant. The duration of MLV (h) in group B (28,5 ? 1,6) was statistically significantly shorter than in group A (63,1 ? 8,7) (p < 0,01). According to the results of this study we conclude that NO inhalation during ALI after surgery with ECC significantly reduces the duration of MVL and improves pulmonary recovery .
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Affiliation(s)
- R Sindjelić
- Institut za anesteziju i reanimaciju KCS, Beograd
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Fisher BW, Majumdar SR, McAlister FA. Predicting pulmonary complications after nonthoracic surgery: a systematic review of blinded studies. Am J Med 2002; 112:219-25. [PMID: 11893349 DOI: 10.1016/s0002-9343(01)01082-8] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To determine the performance of variables commonly used in the prediction of postoperative pulmonary complications in patients undergoing nonthoracic surgery. METHODS We conducted a systematic review of the literature in English, using MEDLINE (1966-2001), manual searches of identified articles, and contact with content experts. All studies reporting independent and blinded comparisons of preoperative or operative factors with postoperative pulmonary complications were included. Two reviewers independently abstracted inclusion and exclusion criteria, study designs, patient characteristics, predictors of interest, and the nature and occurrence of postoperative pulmonary complications. RESULTS Seven studies fulfilled the inclusion criteria. The definition of postoperative pulmonary complications differed among studies, and the incidence of postoperative pulmonary complications varied from 2% to 19%. Of the 28 preoperative or operative predictors that were evaluated in the 7 studies, 16 were associated significantly with postoperative pulmonary complications, although only 2 (duration of anesthesia and postoperative nasogastric tube placement) were significant in more than one study. The positive (2.2 to 5.1) and negative (0.2 to 0.8) likelihood ratios for these 16 variables suggest that they have only modest predictive value. Neither hypercarbia nor reduced spirometry values were independently associated with an increased risk of postoperative pulmonary complications. CONCLUSION Few studies have rigorously evaluated the performance of the preoperative or operative variables in the prediction of postoperative pulmonary complications. Prospective studies with independent and blinded comparisons of these variables with postoperative outcomes are needed.
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Affiliation(s)
- Bruce W Fisher
- Division of General Internal Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Montravers P, Veber B, Auboyer C, Dupont H, Gauzit R, Korinek AM, Malledant Y, Martin C, Moine P, Pourriat JL. Diagnostic and therapeutic management of nosocomial pneumonia in surgical patients: results of the Eole study. Crit Care Med 2002; 30:368-75. [PMID: 11889312 DOI: 10.1097/00003246-200202000-00017] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess clinical, microbiological, and therapeutic features of nosocomial pneumonias in surgical patients. DESIGN Prospective (October 1997 through May 1998), consecutive case series analysis of patients suspected of having pneumonia during the fortnight after a surgical procedure or trauma and receiving antibiotic therapy prescribed by the attending physician for this diagnosis. SETTING A total of 230 study centers in teaching (n = 66) and nonteaching hospitals (n = 164) (surgical wards and intensive care units). PATIENTS A total of 837 evaluable patients (mean age 61 +/- 18 yrs) including 629 intensive care unit patients. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS The diagnostic and therapeutic procedures followed were based on guidelines. Antibiotics and any changes of therapy and duration of treatment were decided by the attending physician. The charts were reviewed by a panel of experts that classified the cases according to clinical, radiologic, and microbiological criteria (when available). The efficacy of treatment was evaluated over a 30-day period following the index episode. The patients were classified into three groups: definite pneumonia (n = 261), possible pneumonia (n = 392), or low-probability pneumonia (n = 184). Ventilator-acquired pneumonia was reported in 303 patients. Early onset pneumonia was reported in 512 cases. Microbiological sampling was performed in 718 patients, by bronchoscopy in 367 cases, recovering 450 organisms in 328 patients, including 94 polymicrobial specimens. High proportions of Gram-negative bacteria and staphylococci were cultured, even in early onset pneumonias. Antibiotic therapy was administered for 13 +/- 4 days, using monotherapy in 254 cases. Changes in the initial antibiotic therapy (135 monotherapies) were decided in 517 patients (including clinical failure or persistent infection, n = 171; organisms resistant to initial therapy, n = 177; pulmonary superinfection, n = 68). Death occurred in 180 patients, related to pneumonia in 53 cases. CONCLUSIONS Nosocomial pneumonias in surgical patients are characterized by high frequency of early onset pneumonia, high proportion of nosocomial organisms even in these early onset pneumonias, and moderate mortality rate.
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Abstract
Pulmonary function testing (PFT) is used extensively by pulmonary specialists to address two common clinical questions: (1) What is the risk of a postoperative pulmonary complication in an individual with lung disease? and (2) Will the patient be able to tolerate lung resection surgery? Today, there are numerous tests available to measure pulmonary function; making judicious use of these tests essential. In this article, the authors describe significant postoperative pulmonary complications, and discuss the surgical and patient factors contributing to the risk of these complications. They provide an evidence-based approach using pulmonary function data to determine an individual patient's risk for pulmonary complications associated with three types of surgical procedures-upper abdominal, cardiac, and lung resection-and discuss recommendations for risk education.
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Affiliation(s)
- C A Powell
- Division of Pulmonary, Allergy and Critical Care Medicine Columbia Presbyterian Medical Center, New York, New York USA
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Overend TJ, Anderson CM, Lucy SD, Bhatia C, Jonsson BI, Timmermans C. The effect of incentive spirometry on postoperative pulmonary complications: a systematic review. Chest 2001; 120:971-8. [PMID: 11555536 DOI: 10.1378/chest.120.3.971] [Citation(s) in RCA: 138] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE To systematically review the evidence examining the use of incentive spirometry (IS) for the prevention of postoperative pulmonary complications (PPCs). METHODS We searched MEDLINE, CINAHL, HealthSTAR, and Current Contents databases from their inception until June 2000. Key terms included "incentive spirometry," "breathing exercises," "chest physical therapy," and "pulmonary complications." Articles were limited to human studies in English. A secondary search of the reference lists of all identified articles also was conducted. A critical appraisal form was developed to extract and assess information. Each study was reviewed independently by one of three pairs of group members. The pair then met to reach consensus before presenting the report to the entire review group for final agreement. RESULTS The search yielded 85 articles. Studies dealing with the use of IS for preventing PPCs (n = 46) were accepted for systematic review. In 35 of these studies, we were unable to accept the stated conclusions due to flaws in methodology. Critical appraisal of the 11 remaining studies indicated 10 studies in which there was no positive short-term effect or treatment effect of IS following cardiac or abdominal surgery. The only supportive study reported that IS, deep breathing, and intermittent positive-pressure breathing were equally more effective than no treatment in preventing PPCs following abdominal surgery. CONCLUSIONS Presently, the evidence does not support the use of IS for decreasing the incidence of PPCs following cardiac or upper abdominal surgery.
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Affiliation(s)
- T J Overend
- School of Physical Therapy, University of Western Ontario, London, Ontario, Canada.
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Abstract
Patients undergoing elective surgery first need to be screened for operative risks by reviewing factors that relate to the patient and factors that relate to the procedure they are undergoing. The identification of high-risk patients undergoing high-risk procedures may be aided by reviewing the following factors: the presence of symptomatic lung disease, smoking, obesity, abnormal blood gas values, spirometry, and presence of sleep apnea. The more risk factors a patient has, the more likely the patient will develop postoperative complications. Further risk stratification may be accomplished by means of exercise testing, either through formal cardiopulmonary exercise testing or through symptom-limited stair climbing. When high-risk patients are identified, preoperative therapy aimed at reducing overall postoperative morbidity and mortality may help decrease the risk to a minimum.
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Affiliation(s)
- E Trayner
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA.
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