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Intraoperative hypotension is associated with shortened overall survival after lung cancer surgery.

ABSTRACT: BACKGROUND:Intraoperative hypotension is associated with increased morbidity and mortality after surgery. We hypothesized that intraoperative hypotension might also be associated with worse long-term survival after cancer surgery. Herein, we analyzed the correlation between intraoperative hyper-/hypotension and overall survival after lung cancer surgery. METHODS:In this retrospective cohort study, 676 patients who received lung cancer surgery between January 1, 2006 and December 31, 2009 were reviewed. Intraoperative hyper- and hypotension were defined according to their correlation with long-term survival. The primary endpoint was overall survival. The association between episodes of intraoperative hyper-/hypotension and overall survival was analyzed with multivariable Cox proportional hazard models. RESULTS:Long-term follow-ups were completed in 515 patients with a median duration of 5.2?years. The estimated 5-year survival rates were 66.5, 61.3, 56.5, and 41.2% in patients with only hypertension (systolic blood pressure?>?140?mmHg for ?5?min), with both hyper- and hypotension (systolic blood pressure?

SUBMITTER: Huang WW

PROVIDER: S-EPMC7322881 | biostudies-literature | 2020 Jun

REPOSITORIES: biostudies-literature

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Intraoperative hypotension is associated with shortened overall survival after lung cancer surgery.

Huang Wen-Wen WW Zhu Wen-Zhi WZ Mu Dong-Liang DL Ji Xin-Qiang XQ Li Xue-Ying XY Ma Daqing D Wang Dong-Xin DX

BMC anesthesiology 20200629 1

<h4>Background</h4>Intraoperative hypotension is associated with increased morbidity and mortality after surgery. We hypothesized that intraoperative hypotension might also be associated with worse long-term survival after cancer surgery. Herein, we analyzed the correlation between intraoperative hyper-/hypotension and overall survival after lung cancer surgery.<h4>Methods</h4>In this retrospective cohort study, 676 patients who received lung cancer surgery between January 1, 2006 and December 3 ...[more]

PMID: 32600326

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Project description:BackgroundIntraoperative hypotension (IOH) occurs frequently during surgery and may be associated with organ ischemia; however, few multicenter studies report data regarding its associations with adverse postoperative outcomes across varying hemodynamic thresholds. Additionally, no study has evaluated the association between IOH exposure and adverse outcomes among patients by various age groups.MethodsA multicenter retrospective cohort study was conducted between 2008 and 2017 using intraoperative blood pressure data from the US electronic health records database to examine postoperative outcomes. IOH was assessed in 368,222 noncardiac surgical procedures using 5 methods: (a) absolute maximum decrease in mean arterial pressure (MAP) during surgery, (b) time under each absolute threshold, (c) total area under each threshold, (d) time-weighted average MAP under each threshold, and (e) cumulative time under the prespecified relative MAP thresholds. MAP thresholds were defined by absolute limits (≤75, ≤65, ≤55 mm Hg) and by relative limits (20% and 40% lower than baseline). The primary outcome was major adverse cardiac or cerebrovascular events; secondary outcomes were all-cause 30- and 90-day mortality, 30-day acute myocardial injury, and 30-day acute ischemic stroke. Residual confounding was minimized by controlling for observable patient and surgical factors. In addition, we stratified patients into age subgroups (18-40, 41-50, 51-60, 61-70, 71-80, >80) to investigate how the association between hypotension and the likelihood of major adverse cardiac or cerebrovascular events and acute kidney injury differs in these age subgroups.ResultsIOH was common with at least 1 reading of MAP ≤75 mm Hg occurring in 39.5% (145,743) of cases; ≤65 mm Hg in 19.3% (70,938) of cases, and ≤55 mm Hg in 7.5% (27,473) of cases. IOH was significantly associated with the primary outcome for all age groups. For an absolute maximum decrease, the estimated odds of a major adverse cardiac or cerebrovascular events in the 30-day postsurgery was increased by 12% (95% confidence interval [CI], 11-14) for ≤75 mm Hg; 17.0% (95% CI, 15-19) for ≤65 mm Hg; and by 26.0% (95% CI, 22-29) for ≤55 mm Hg.ConclusionsIOH during noncardiac surgery is common and associated with increased 30-day major adverse cardiac or cerebrovascular events. This observation is magnified with increasing hypotension severity. The potentially avoidable nature of the hazard, and the extent of the exposed population, makes hypotension in the operating room a serious public health issue that should not be ignored for any age group.

Project description:Background: Choice of the fraction of inspiratory oxygen (FiO2) is controversial. The objective of this analysis was to evaluate whether intraoperative FiO2 was associated with recurrence-free survival after elective cancer surgery. Methods and Analysis: In this single-center, retrospective study, we analyzed 1,084 patients undergoing elective resection of pancreatic (n = 652), colorectal (n = 405), or hepatic cancer (n = 27) at Heidelberg University Hospital between 2009 and 2016. Intraoperative mean FiO2 values were calculated. For unstratified analyses, the study cohort was equally divided into a low- and a high-FiO2 group. For cancer-stratified analyses, this division was done within cancer-strata. The primary outcome measure was recurrence-free survival until the last known follow-up. Groups were compared using Kaplan-Meier analysis. A stratified log rank test was used to control for different FiO2 levels and survival times between the cancer strata. Cox-regression analyses were used to control for covariates. Sepsis, reoperations, surgical-site infections, and cardiovascular events during hospital stay and overall survival were secondary outcomes. Results: Median FiO2 was 40.9% (Q1-Q3, 38.3-42.9) in the low vs. 50.4% (Q1-Q3, 47.4-54.7) in the high-FiO2 group. Median follow-up was 3.28 (Q1-Q3, 1.68-4.97) years. Recurrence-free survival was considerable higher in the high-FiO2 group (p < 0.001). This effect was also confirmed when stratified for the different tumor entities (p = 0.007). In colorectal cancer surgery, increased FiO2 was independently associated with increased recurrence-free survival. The hazard for the primary outcome decreased by 3.5% with every 1% increase in FiO2. The effect was not seen in pancreatic cancer surgery and we did not find differences in any of the secondary endpoints. Conclusions: Until definite evidence from large-scale trials is available and in the absence of relevant clinical conditions warranting specific FiO2 values, perioperative care givers should aim for an intraoperative FiO2 of 50% in abdominal cancer surgery as this might benefit oncological outcomes.

Project description:IntroductionIn lung cancer surgery, large tidal volume and elevated inspiratory pressure are known risk factors of acute lung (ALI). Mechanical ventilation with low tidal volume has been shown to attenuate lung injuries in critically ill patients. In the current study, we assessed the impact of a protective lung ventilation (PLV) protocol in patients undergoing lung cancer resection.MethodsWe performed a secondary analysis of an observational cohort. Demographic, surgical, clinical and outcome data were prospectively collected over a 10-year period. The PLV protocol consisted of small tidal volume, limiting maximal pressure ventilation and adding end-expiratory positive pressure along with recruitment maneuvers. Multivariate analysis with logistic regression was performed and data were compared before and after implementation of the PLV protocol: from 1998 to 2003 (historical group, n = 533) and from 2003 to 2008 (protocol group, n = 558).ResultsBaseline patient characteristics were similar in the two cohorts, except for a higher cardiovascular risk profile in the intervention group. During one-lung ventilation, protocol-managed patients had lower tidal volume (5.3 +/- 1.1 vs. 7.1 +/- 1.2 ml/kg in historical controls, P = 0.013) and higher dynamic compliance (45 +/- 8 vs. 32 +/- 7 ml/cmH2O, P = 0.011). After implementing PLV, there was a decreased incidence of acute lung injury (from 3.7% to 0.9%, P < 0.01) and atelectasis (from 8.8 to 5.0, P = 0.018), fewer admissions to the intensive care unit (from 9.4% vs. 2.5%, P < 0.001) and shorter hospital stay (from 14.5 +/- 3.3 vs. 11.8 +/- 4.1, P < 0.01). When adjusted for baseline characteristics, implementation of the open-lung protocol was associated with a reduced risk of acute lung injury (adjusted odds ratio of 0.34 with 95% confidence interval of 0.23 to 0.75; P = 0.002).ConclusionsImplementing an intraoperative PLV protocol in patients undergoing lung cancer resection was associated with improved postoperative respiratory outcomes as evidence by significantly reduced incidences of acute lung injury and atelectasis along with reduced utilization of intensive care unit resources.

Project description:BackgroundDramatic hemodynamic fluctuation occurs frequently during surgery for pheochromocytoma or paraganglioma. However, the criteria of intraoperative hemodynamic instability vary widely, and most of them were defined arbitrarily but not according to patients' prognosis. The objective was to analyze the relationship between different thresholds and durations of intraoperative hyper-/hypotension and the risk of postoperative complications in patients undergoing surgery for pheochromocytoma or paraganglioma.MethodsThis was a retrospective single-center cohort study performed in a tertiary care hospital from January 1, 2005 to December 31, 2017. Three hundred twenty-seven patients who underwent surgery for pheochromocytoma or paraganglioma, of which the diagnoses were confirmed by postoperative pathologic examination, were enrolled. Those who were less than 18?years, underwent surgery involving non-tumor organs, or had incomplete data were excluded. The primary endpoint was a composite of the occurrence of AKI or other complications during hospital stay after surgery. Multivariate Logistic regression models were used to analyze the association between different thresholds and durations of intraoperative hyper-/hypotension and the development of postoperative complications.ResultsForty three (13.1%) patients developed complications during hospital stay after surgery. After adjusting for confounding factors, intraoperative hypotension, defined as systolic blood pressure (SBP) of ?95?mmHg for ?20?min (OR 3.211; 99% CI 1.081-9.536; P =?0.006), SBP of ?90?mmHg for ?20?min (OR 3.680; 98.8% CI 1.107-12.240; P =?0.006), SBP of ?85?mmHg for ?10?min (OR 3.975; 98.3% CI 1.321-11.961; P =?0.003), and SBP of ?80?mmHg for ?1?min (OR 3.465; 95% CI 1.484-8.093; P =?0.004), were associated with an increased risk of postoperative complications. On the other hand, intraoperative hypertension was not significantly associated with the development of postoperative complications.ConclusionsFor patients undergoing surgery for pheochromocytoma or paraganglioma, intraoperative hypotension is associated with increased postoperative complications; and the harmful effects are level- and duration-dependent. The effects of intraoperative hypertension need to be studied further.

Project description:BackgroundAcute kidney injury (AKI) is a common surgical complication and is associated with intraoperative hypotension. However, the total duration and magnitude of intraoperative hypotension associated with AKI remains unknown. In this study, the causal relationship between the intraoperative arterial pressure and postoperative AKI was investigated among chronic hypertension patients undergoing non-cardiac surgery.MethodsA retrospective cohort study of 6552 hypertension patients undergoing non-cardiac surgery (2011 to 2019) was conducted. The primary outcome was AKI as diagnosed with the Kidney Disease-Improving Global Outcomes criteria and the primary exposure was intraoperative hypotension. Patients' baseline demographics, pre- and post-operative data were harvested and then analyzed with multivariable logistic regression to assess the exposure-outcome relationship.ResultsAmong 6552 hypertension patients, 579 (8.84%) had postoperative AKI after non-cardiac surgery. The proportions of patients admitted to ICU (3.97 vs. 1.24%, p < 0.001) and experiencing all-cause death (2.76 vs. 0.80%, p < 0.001) were higher in the patients with postoperative AKI. Moreover, the patients with postoperative AKI had longer hospital stays (13.50 vs. 12.00 days, p < 0.001). Intraoperative mean arterial pressure (MAP) < 60 mmHg for >20 min was an independent risk factor of postoperative AKI. Furthermore, MAP <60 mmHg for >10 min was also an independent risk factor of postoperative AKI in patients whose MAP was measured invasively in the subgroup analysis.ConclusionsOur work suggested that MAP < 60 mmHg for >10 min measured invasively or 20 min measured non-invasively during non-cardiac surgery may be the threshold of postoperative AKI development in hypertension patients. This work may serve as a perioperative management guide for chronic hypertension patients.Trial registrationclinical trial number: ChiCTR2100050209 (8/22/2021). http://www.chictr.org.cn/showproj.aspx?proj=132277.

Project description:ImportanceSeveral real-world oncology studies have produced findings that contradict those from randomized clinical trials. Such disparities may be associated with methodological shortcomings.ObjectiveTo examine the association between a shortened duration of adjuvant chemotherapy among individuals with stage III colon cancer using real-world data.Design, setting, and participantsThis comparative effectiveness study included individuals diagnosed with stage III colon cancer between January 2004 and December 2015 who initiated adjuvant chemotherapy at oncology clinics within the province of Alberta, Canada. Patients were identified through record linkage of various administrative databases and were followed up until September 2017. Eligibility criteria were modeled after those used in the International Duration Evaluation of Adjuvant (IDEA) trial. A target trial emulation and naive observational analysis were conducted. Results from both cohorts were benchmarked against findings from the IDEA trial. Data analysis was conducted from March to December 2020.ExposureA shortened duration of adjuvant 5-fluorouracil/leucovorin plus oxaliplatin (FOLFOX) or capecitabine plus oxaliplatin (CAPOX) chemotherapy, defined as 3 to 5 months of treatment vs 6 months.Main outcomes and measuresOverall survival assessed via vital statistics. The per-protocol hazard ratio (HR) was estimated using a weighted pooled logistic regression model. Subgroup analyses were conducted by treatment regimen (ie, FOLFOX vs CAPOX) and cancer stage (ie, T1-3 and N1 vs T4 or N2).ResultsFrom an initial cohort of 3086 patients, 485 (16%) were eligible for inclusion in the target trial analysis. The median age was 59 years (range, 19-81 years), and 230 (47%) were women. The maximum follow-up was 11.6 years. Median overall survival was not reached. A total of 90 patients (19%) died. The 5-year Kaplan Meier overall survival estimate was 0.79 (95% CI, 0.75-0.84). Estimates from the trial emulation were similar to those from the IDEA trial. For example, a shortened duration of adjuvant chemotherapy was not associated with overall survival among patients prescribed CAPOX in the IDEA trial (HR, 0.96; 95% CI, 0.85-1.08) or in the trial emulation (HR, 0.96; 95% CI, 0.43-2.14). In contrast, the naive observational analysis suggested that a shortened duration of CAPOX was significantly associated with worse survival (HR, 3.33; 95% CI, 1.04-10.65).Conclusions and relevanceIn this study, the explicit emulation of a target trial better approximated results from an analogous well-conducted randomized clinical trial.

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Intraoperative hypotension is associated with shortened overall survival after lung cancer surgery.

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Intraoperative hypotension is associated with shortened overall survival after lung cancer surgery.

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