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The LAS VEGAS risk score for prediction of postoperative pulmonary complications: An observational study.

ABSTRACT: BACKGROUND:Currently used pre-operative prediction scores for postoperative pulmonary complications (PPCs) use patient data and expected surgery characteristics exclusively. However, intra-operative events are also associated with the development of PPCs. OBJECTIVE:We aimed to develop a new prediction score for PPCs that uses both pre-operative and intra-operative data. DESIGN:This is a secondary analysis of the LAS VEGAS study, a large international, multicentre, prospective study. SETTINGS:A total of 146 hospitals across 29 countries. PATIENTS:Adult patients requiring intra-operative ventilation during general anaesthesia for surgery. INTERVENTIONS:The cohort was randomly divided into a development subsample to construct a predictive model, and a subsample for validation. MAIN OUTCOME MEASURES:Prediction performance of developed models for PPCs. RESULTS:Of the 6063 patients analysed, 10.9% developed at least one PPC. Regression modelling identified 13 independent risk factors for PPCs: six patient characteristics [higher age, higher American Society of Anesthesiology (ASA) physical score, pre-operative anaemia, pre-operative lower SpO2 and a history of active cancer or obstructive sleep apnoea], two procedure-related features (urgent or emergency surgery and surgery lasting ? 1?h), and five intra-operative events [use of an airway other than a supraglottic device, the use of intravenous anaesthetic agents along with volatile agents (balanced anaesthesia), intra-operative desaturation, higher levels of positive end-expiratory pressures > 3?cmH2O and use of vasopressors]. The area under the receiver operating characteristic curve of the LAS VEGAS risk score for prediction of PPCs was 0.78 [95% confidence interval (95% CI), 0.76 to 0.80] for the development subsample and 0.72 (95% CI, 0.69 to 0.76) for the validation subsample. CONCLUSION:The LAS VEGAS risk score including 13 peri-operative characteristics has a moderate discriminative ability for prediction of PPCs. External validation is needed before use in clinical practice. TRIAL REGISTRATION:The study was registered at Clinicaltrials.gov, number NCT01601223.

SUBMITTER: Neto AS

PROVIDER: S-EPMC7450515 | biostudies-literature | 2018 Sep

REPOSITORIES: biostudies-literature

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The LAS VEGAS risk score for prediction of postoperative pulmonary complications: An observational study.

Neto Ary Serpa AS da Costa Luiz Guilherme V LGV Hemmes Sabrine N T SNT Canet Jaume J Hedenstierna Göran G Jaber Samir S Hiesmayr Michael M Hollmann Markus W MW Mills Gary H GH Vidal Melo Marcos F MF Pearse Rupert R Putensen Christian C Schmid Werner W Severgnini Paolo P Wrigge Hermann H Gama de Abreu Marcelo M Pelosi Paolo P Schultz Marcus J MJ

European journal of anaesthesiology 20180901 9

<h4>Background</h4>Currently used pre-operative prediction scores for postoperative pulmonary complications (PPCs) use patient data and expected surgery characteristics exclusively. However, intra-operative events are also associated with the development of PPCs.<h4>Objective</h4>We aimed to develop a new prediction score for PPCs that uses both pre-operative and intra-operative data.<h4>Design</h4>This is a secondary analysis of the LAS VEGAS study, a large international, multicentre, prospecti ...[more]

PMID: 29916860

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Project description:BACKGROUND:Limited information exists about the epidemiology and outcome of surgical patients at increased risk of postoperative pulmonary complications (PPCs), and how intraoperative ventilation was managed in these patients. OBJECTIVES:To determine the incidence of surgical patients at increased risk of PPCs, and to compare the intraoperative ventilation management and postoperative outcomes with patients at low risk of PPCs. DESIGN:This was a prospective international 1-week observational study using the 'Assess Respiratory Risk in Surgical Patients in Catalonia risk score' (ARISCAT score) for PPC for risk stratification. PATIENTS AND SETTING:Adult patients requiring intraoperative ventilation during general anaesthesia for surgery in 146 hospitals across 29 countries. MAIN OUTCOME MEASURES:The primary outcome was the incidence of patients at increased risk of PPCs based on the ARISCAT score. Secondary outcomes included intraoperative ventilatory management and clinical outcomes. RESULTS:A total of 9864 patients fulfilled the inclusion criteria. The incidence of patients at increased risk was 28.4%. The most frequently chosen tidal volume (VT) size was 500 ml, or 7 to 9?ml?kg predicted body weight, slightly lower in patients at increased risk of PPCs. Levels of positive end-expiratory pressure (PEEP) were slightly higher in patients at increased risk of PPCs, with 14.3% receiving more than 5?cmH2O PEEP compared with 7.6% in patients at low risk of PPCs (P?<?0.001). Patients with a predicted preoperative increased risk of PPCs developed PPCs more frequently: 19 versus 7%, relative risk (RR) 3.16 (95% confidence interval 2.76 to 3.61), P?<?0.001) and had longer hospital stays. The only ventilatory factor associated with the occurrence of PPCs was the peak pressure. CONCLUSION:The incidence of patients with a predicted increased risk of PPCs is high. A large proportion of patients receive high VT and low PEEP levels. PPCs occur frequently in patients at increased risk, with worse clinical outcome. TRIAL REGISTRATION:The study was registered at Clinicaltrials.gov, number NCT01601223.

Project description:BackgroundPostoperative pulmonary complications (PPCs) are important contributors to mortality and morbidity after surgery. The available predicting models are useful in preoperative risk assessment, but there is a need for validated tools for the early postoperative period as well. Lung ultrasound is becoming popular in intensive and perioperative care and there is a growing interest to evaluate its role in the detection of postoperative pulmonary pathologies.ObjectivesWe aimed to identify characteristics with the potential of recognizing patients at risk by comparing the lung ultrasound scores (LUS) of patients with/without PPC in a 24-h postoperative timeframe.MethodsObservational study at a university clinic. We recruited ASA 2-3 patients undergoing elective major abdominal surgery under general anaesthesia. LUS was assessed preoperatively, and also 1 and 24 h after surgery. Baseline and operative characteristics were also collected. A one-week follow up identified PPC+ and PPC- patients. Significantly differing LUS values underwent ROC analysis. A multi-variate logistic regression analysis with forward stepwise model building was performed to find independent predictors of PPCs.ResultsOut of the 77 recruited patients, 67 were included in the study. We evaluated 18 patients in the PPC+ and 49 in the PPC- group. Mean ages were 68.4 ± 10.2 and 66.4 ± 9.6 years, respectively (p = 0.4829). Patients conforming to ASA 3 class were significantly more represented in the PPC+ group (66.7 and 26.5%; p = 0.0026). LUS at baseline and in the postoperative hour were similar in both populations. The median LUS at 0 h was 1.5 (IQR 1-2) and 1 (IQR 0-2; p = 0.4625) in the PPC+ and PPC- groups, respectively. In the first postoperative hour, both groups had a marked increase, resulting in scores of 6.5 (IQR 3-9) and 5 (IQR 3-7; p = 0.1925). However, in the 24th hour, median LUS were significantly higher in the PPC+ group (6; IQR 6-10 vs 3; IQR 2-4; p < 0.0001) and it was an independent risk factor (OR = 2.6448 CI95% 1.5555-4.4971; p = 0.0003). ROC analysis identified the optimal cut-off at 5 points with high sensitivity (0.9444) and good specificity (0.7755).ConclusionPostoperative LUS at 24 h can identify patients at risk of or in an early phase of PPCs.

Project description:BackgroundPostoperative pulmonary complications (PPCs) increase morbidity and mortality of surgical patients, duration of hospital stay and costs. Postoperative atelectasis of dorsal lung regions as a common PPC has been described before, but its clinical relevance is insufficiently examined. Pulmonary electrical impedance tomography (EIT) enables the bedside visualization of regional ventilation in real-time within a transversal section of the lung. Dorsal atelectasis or effusions might cause a ventral redistribution of ventilation. We hypothesized the existence of ventral redistribution in spontaneously breathing patients during their recovery from abdominal and peripheral surgery and that vital capacity is reduced if regional ventilation shifts to ventral lung regions.MethodsThis prospective observational study included 69 adult patients undergoing elective surgery with an expected intermediate or high risk for PPCs. Patients undergoing abdominal and peripheral surgery were recruited to obtain groups of equal size. Patients received general anesthesia with and without additional regional anesthesia. On the preoperative, the first and the third postoperative day, EIT was performed at rest and during spirometry (forced breathing). The center of ventilation in dorso-ventral direction (COVy) was calculated.ResultsBoth groups received intraoperative low tidal volume ventilation. Postoperative ventral redistribution of ventilation (forced breathing COVy; preoperative: 16.5 (16.0-17.3); first day: 17.8 (16.9-18.2), p < 0.004; third day: 17.4 (16.2-18.2), p = 0.020) and decreased forced vital capacity in percentage of predicted values (FVC%predicted) (median: 93, 58, 64%, respectively) persisted after abdominal surgery. In addition, dorsal to ventral shift was associated with a decrease of the FVC%predicted on the third postoperative day (r = - 0.66; p < 0.001). A redistribution of pulmonary ventilation was not observed after peripheral surgery. FVC%predicted was only decreased on the first postoperative day (median FVC%predicted on the preoperative, first and third day: 85, 81 and 88%, respectively). In ten patients occurred pulmonary complications after abdominal surgery also in two patients after peripheral surgery.ConclusionsAfter abdominal surgery ventral redistribution of ventilation persisted up to the third postoperative day and was associated with decreased vital capacity. The peripheral surgery group showed only minor changes in vital capacity, suggesting a role of the location of surgery for postoperative redistribution of pulmonary ventilation.Trial registrationThis prospective observational single centre study was submitted to registration prior to patient enrollment at ClinicalTrials.gov (NCT02419196, Date of registration: December 1, 2014). Registration was finalized at April 17, 2015.

Project description:The interest in perioperative lung protective ventilation has been increasing. However, optimal management during one-lung ventilation (OLV) remains undetermined, which not only includes tidal volume (VT) and positive end-expiratory pressure (PEEP) but also inspired oxygen fraction (FIO2). We aimed to investigate current practice of intraoperative ventilation during OLV, and analyze whether the intraoperative ventilator settings are associated with postoperative pulmonary complications (PPCs) after thoracic surgery.We performed a prospective observational two-center study in Japan. Patients scheduled for thoracic surgery with OLV from April to October 2014 were eligible. We recorded ventilator settings (FIO2, VT, driving pressure (?P), and PEEP) and calculated the time-weighted average (TWA) of ventilator settings for the first 2 h of OLV. PPCs occurring within 7 days of thoracotomy were investigated. Associations between ventilator settings and the incidence of PPCs were examined by multivariate logistic regression.We analyzed perioperative information, including preoperative characteristics, ventilator settings, and details of surgery and anesthesia in 197 patients. Pressure control ventilation was utilized in most cases (92%). As an initial setting for OLV, an FIO2 of 1.0 was selected for more than 60% of all patients. Throughout OLV, the median TWA FIO2 of 0.8 (0.65-0.94), VT of 6.1 (5.3-7.0) ml/kg, ?P of 17 (15-20) cm H2O, and PEEP of 4 (4-5) cm H2O was applied. Incidence rate of PPCs was 25.9%, and FIO2 was independently associated with the occurrence of PPCs in multivariate logistic regression. The adjusted odds ratio per FIO2 increase of 0.1 was 1.30 (95% confidence interval: 1.04-1.65, P =?0.0195).High FIO2 was applied to the majority of patients during OLV, whereas low VT and slight degree of PEEP were commonly used in our survey. Our findings suggested that a higher FIO2 during OLV could be associated with increased incidence of PPCs.

Project description:Background:Postoperative pulmonary complications (PPCs) contribute significantly to overall postoperative morbidity and mortality. In abdominal surgery, PPCs remain frequent. The study aimed to analyze the profile and outcomes of PPCs in patients submitted to abdominal surgery and admitted in a Portuguese polyvalent intensive care unit. Methods:From January to December 2017 in the polyvalent intensive care unit of Hospital Garcia de Orta, Almada, Portugal, we conducted a retrospective, observational study of inpatients submitted to urgent or elective abdominal surgery who had severe PPCs. We evaluated the perioperative risk factors and associated mortality. Logistic regression was performed to find which perioperative risk factors were most important in the occurrence of PPCs. Results:Sixty patients (75% male) with a median age of 64.5 [47-81] years who were submitted to urgent or elective abdominal surgery were included in the analysis. Thirty-six patients (60%) developed PPCs within 48?h and twenty-four developed PPCs after 48?h. Pneumonia was the most frequent PPC in this sample. In this cohort, 48 patients developed acute respiratory failure and needed mechanical ventilation. In the emergency setting, peritonitis had the highest rate of PPCs. Electively operated patients who developed PPCs were mostly carriers of digestive malignancies. Thirty-day mortality was 21.7%. The risk of PPCs development in the first 48?h was related to the need for neuromuscular blocking drugs several times during surgery and preoperative abnormal arterial blood gases. Median abdominal surgical incision, long surgery duration, and high body mass index were associated with PPCs that occurred more than 48?h after surgery. The American Society of Anesthesiologists physical status score 4 and COPD/Asthma determined less mechanical ventilation needs since they were preoperatively optimized. Malnutrition (low albumin) before surgery was associated with 30-day mortality. Conclusion:PPCs after abdominal surgery are still a major problem since they have profound effects on outcomes. Our results suggest that programs before surgery, involve preoperative lifestyle changes, such as nutritional supplementation, exercise, stress reduction, and smoking cessation, were an effective strategy in mitigating postoperative complications by decreasing mortality.

Dataset Information

The LAS VEGAS risk score for prediction of postoperative pulmonary complications: An observational study.

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The LAS VEGAS risk score for prediction of postoperative pulmonary complications: An observational study.

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