Emerging risk factors and prevention of perioperative pulmonary complications.
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ABSTRACT:
SUBMITTER: Bhateja P
PROVIDER: S-EPMC3918871 | biostudies-other | 2014
REPOSITORIES: biostudies-other
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Project description:OBJECTIVE:To identify, appraise, and synthesise the best available evidence on the efficacy of perioperative interventions to reduce postoperative pulmonary complications (PPCs) in adult patients undergoing non-cardiac surgery. DESIGN:Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES:Medline, Embase, CINHAL, and CENTRAL from January 1990 to December 2017. ELIGIBILITY CRITERIA:Randomised controlled trials investigating short term, protocolised medical interventions conducted before, during, or after non-cardiac surgery were included. Trials with clinical diagnostic criteria for PPC outcomes were included. Studies of surgical technique or physiological or biochemical outcomes were excluded. DATA EXTRACTION AND SYNTHESIS:Reviewers independently identified studies, extracted data, and assessed the quality of evidence. Meta-analyses were conducted to calculate risk ratios with 95% confidence intervals. Quality of evidence was summarised in accordance with GRADE methods. The primary outcome was the incidence of PPCs. Secondary outcomes were respiratory infection, atelectasis, length of hospital stay, and mortality. Trial sequential analysis was used to investigate the reliability and conclusiveness of available evidence. Adverse effects of interventions were not measured or compared. RESULTS:117 trials enrolled 21?940 participants, investigating 11 categories of intervention. 95 randomised controlled trials enrolling 18?062 participants were included in meta-analysis; 22 trials were excluded from meta-analysis because the interventions were not sufficiently similar to be pooled. No high quality evidence was found for interventions to reduce the primary outcome (incidence of PPCs). Seven interventions had low or moderate quality evidence with confidence intervals indicating a probable reduction in PPCs: enhanced recovery pathways (risk ratio 0.35, 95% confidence interval 0.21 to 0.58), prophylactic mucolytics (0.40, 0.23 to 0.67), postoperative continuous positive airway pressure ventilation (0.49, 0.24 to 0.99), lung protective intraoperative ventilation (0.52, 0.30 to 0.88), prophylactic respiratory physiotherapy (0.55, 0.32 to 0.93), epidural analgesia (0.77, 0.65 to 0.92), and goal directed haemodynamic therapy (0.87, 0.77 to 0.98). Moderate quality evidence showed no benefit for incentive spirometry in preventing PPCs. Trial sequential analysis adjustment confidently supported a relative risk reduction of 25% in PPCs for prophylactic respiratory physiotherapy, epidural analgesia, enhanced recovery pathways, and goal directed haemodynamic therapies. Insufficient data were available to support or refute equivalent relative risk reductions for other interventions. CONCLUSIONS:Predominantly low quality evidence favours multiple perioperative PPC reduction strategies. Clinicians may choose to reassess their perioperative care pathways, but the results indicate that new trials with a low risk of bias are needed to obtain conclusive evidence of efficacy for many of these interventions. STUDY REGISTRATION:Prospero CRD42016035662.
| S-EPMC7190038 | biostudies-literature
Project description: Registry study with prospectively collected data Objective: To determine risk factors for pulmonary complications in spine surgery. The Spine End RESULTS Registry 2003-2004 is an exhaustive database of 1,592 patients who underwent spine surgery at the University of Washington Medical Center or Harborview Medical Center. Detailed information regarding patient demographic, medical comorbidity, and comorbidities, surgical invasiveness and adverse outcomes were prospectively recorded. The primary outcome measure was the occurrence of a pulmonary complication following surgery. Univariate relative risks and 95% confidence intervals for each of the risk factors were determined. Multivariate log binomial regression analysis was performed to investigate the association between each risk factor and a pulmonary complication, while controlling for other important risk factors. Altogether, there were 199 pulmonary complications after spine surgery. The cumulative incidence of a respiratory complication after spine surgery was 9% (144 patients). Multivariate analysis suggested gender, chronic obstructive pulmonary disease, congestive heart failure, diabetes, age, diagnosis, surgical invasiveness and surgery in the thoracic spine are significant risk factors for pulmonary complications after spinal surgery. The results of the present study suggest numerous statistically significant risk factors for pulmonary complications after spine surgery. These results may aid the clinician with preoperative risk stratification and patient counseling. [Table: see text] The definiton of the different classes of evidence is available on page 73.
| S-EPMC3623103 | biostudies-other
Project description:The current literature suggests that perioperative complications occur in 8%-10% of all inguinal hernia repairs. However, the clinical relevance of these complications is currently unknown. In our review, based on 571,445 hernia repairs reported in 39 publications, we identified the following potential risk factors: patient age, ASA score, diabetes, smoking, mode of admission (emergency vs. elective surgery), surgery in low resource settings, type of anesthesia, and (in men) bilateral and sliding hernias. The most commonly reported complications are bleeding (0.9%), wound infection (0.5%), and pulmonary and cardiovascular complications (0.2%). In 3.9% of the included publications, a reliable grading of the reported complications according to Clavien-Dindo classification was possible. Using this classification retrospectively, we could show that, in patients with complications, these are clinically relevant for about 22% of these patients (Clavien-Dindo grade ≥IIIa). About 78% of all patients suffered from complications needing only minor (meaning mostly medical) intervention (Clavien-Dindo grade <III). Especially with regard to the low incidence of complications in inguinal hernia repair, future studies should use the Clavien-Dindo classification to achieve better comparability between studies, thus enabling better correlation with potential risk factors.
| S-EPMC6754002 | biostudies-literature
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.
| S-EPMC6661098 | biostudies-literature
Project description:Posterior cervical decompression and fusion (PCF) is a common surgical technique used to treat various cervical spine pathologies. However, there are various complications associated with PCF that can negatively impact patient outcome. We performed a comprehensive literature review to identify the most common complications following PCF using PubMed, Cochrane Database of Systematic Reviews, and Google Scholar. The overall complication rates of PCF are estimated to range from about 15% to 25% in the current literature. The most common immediate complications include acute blood loss anemia, surgical site infection (SSI), C5 palsy, and incidental durotomy; the most common long-term complications include adjacent segment degeneration, junctional kyphosis, and pseudoarthrosis. Three principal mechanisms are thought to contribute to complications. First, higher number of fusion levels, obesity, and more complex pathologies can increase the invasiveness of the planned procedure, thus increase complications. Second, wound healing and arthrodesis may be impaired due to poor blood flow due to various patient factors such as smoking, diabetes, increased frailty, steroid use, and other medical comorbidities. Finally, increased biomechanical stress on the upper instrumented vertebra (UIV) and lowest instrumented vertebra (LIV) may predispose patient to chronic degeneration and result in adjacent level degeneration and/or junctional problems. Reducing the modifiable risk factors pre-operatively can decrease the overall complication rate. Neurologic deficits may be reduced with adequate intraoperative decompression of neural elements. SSI may be reduced with meticulous wound closure that minimizes dead space, drain placement, and the use of intra-wound antibiotics. Careful design of the fusion construct with consideration in spinal alignment and biomechanics can help to reduce the rate of junctional problems. Spine surgeons should be aware of these complications associated with PCF and the corresponding prevention strategies optimize patient outcomes.
| S-EPMC7154364 | biostudies-literature
Project description:Stroke is a major cause of long-term disability and death for women in the United States, with recent evidence suggesting a higher rate of stroke in midlife women than men, as well as higher lifetime risk of stroke for older women. Several recent studies highlight emerging areas of interest for research on risk factors for stroke in women. This article reviews data published in the last year, focusing on 3 potential risk factors that may partially explain these differences between men and women: central adiposity and related adipocytokines, endogenous sex hormones, and depression.
| S-EPMC2957189 | biostudies-literature
Project description:BackgroundPostoperative operative pulmonary complications (PPCs) after hepatic surgery are associated with increased length of hospital stays. Intraoperative blood transfusion, extensive resection and different comorbidities have been identified. Other parameters, like time of hepatic ischemia, have neither been clinically studied, though experimental studies show that hepatic ischemia can provide lung injury. The objective of this study was to determinate the risk factors of postoperative pulmonary complications (PPCs) after hepatic resection within 7 postoperative days.MethodNinety-four patients consecutively who underwent elective hepatectomy between January and December 2013. Demographic data, pathological variables, and preoperative, intraoperative, and postoperative variables had been prospectively collected in a data base. The dependant variables studied were the occurrence of PPCs, defined before analysis of the data.ResultsPPCs occurred in 32 (34%) patients. A multivariate analysis allowed identifying the risk factors for PPCs. On multivariate analysis, preoperative gamma-glutamyltransferase (GGT) elevation OR =5,12 [1,85-15,69] p = 0,002, liver ischemia duration OR = 1,03 [1,01-1,06] p = 0,01 and the intraoperative use of vasopressor OR = 4,40 [1,58-13,36] p = 0,006 were independently associated with PPCs. For every 10 min added in ischemia duration, the OR of the risk of PPCs was estimated to be 1.37 (CI95% = [1.08-1.81], p = 0.01).ConclusionThree risk factors for PPCs have been identified in a population undergoing liver resection: preoperative GGT elevation, ischemia duration and the intraoperative use of vasopressor. PPCs after liver surgery could be related to lung injury induced by liver ischemia reperfusion and not solely by direct infectious process. That could explain why factors influencing directly or indirectly liver ischemia were independently associated with PPCs.
| S-EPMC5477742 | biostudies-literature
Project description:BackgroundSwimming-induced pulmonary oedema (SIPE) can affect people with no underlying health problems, but may be life threatening and is poorly understood. The aim of this systematic review was to synthesise the evidence on SIPE incidence, prevalence, risk factors, short- and long-term outcomes, recurrence and effectiveness of interventions to prevent recurrences.MethodsWe carried out a literature search using bibliographic databases and reference lists. Risk of bias was assessed by adapting existing quality assessment tools including those developed by the National Heart Lung and Blood Institute.ResultsNine studies met the inclusion criteria. Quantitative synthesis was not possible because of study heterogeneity. Five studies, which differed from each other in case definition, swimming environment, population characteristics and denominators, reported an incidence of 0.01% of UK triathlons raced over 5 years in unspecified swimming environments (one study, not fully reported, of men and women of unspecified age); 0.5% of river races swum over 3 days in Sweden (one study, of men and women up to the age of 70); and 1.8-26.7% of time trials in the sea around Israel (three studies of male teenage military trainees). One study reported that 1.4% of triathletes in the USA had experienced SIPE. One study found that hypertension, female sex, fish oil use, long course distance and another lower initial lung volumes and flows were risk factors for SIPE. A third study reported that higher mean pulmonary artery pressures and pulmonary artery wedge pressures, and lower tidal volumes were associated with SIPE. Three studies suggested that SIPE symptoms usually resolve within 24 h, although a restrictive deficit in lung function persisted for a week in one small study. We found no studies that reported deaths from SIPE. The single small study of longer-term outcomes reported no difference between affected and unaffected swimmers. Two studies suggested that around 30% of people report recurrences of SIPE. Two very small uncontrolled studies of the effect of sildenafil for recurrence prevention were inconclusive.ConclusionsSIPE may be an important public health problem affecting the growing number of recreational open water swimmers. Further research should clarify the frequency of SIPE among recreational open water swimmers, confirm reported risk factors and explore others, explore long-term consequences and test interventions to prevent recurrences.
| S-EPMC6146959 | biostudies-literature
Project description:The incidence rates of adverse events secondary to any operation are a well-known problem in any surgical field. One outstanding example of such adverse events is postoperative pain. Thus, the incidence of acute postoperative pain following any surgical procedure and its treatment are central issues for every surgeon. In the times of Enhanced Recovery After Surgery (ERAS) programs, acute pain therapy became an increasingly well investigated and accepted aspect in almost all surgical subspecialties. However, if it comes to the reduction of postoperative complications, in the actual context of postoperative pain, surgeons tend to focus on the operative process rather than on the perioperative procedures. Undoubtedly, postoperative pain became an important factor with regard to the quality of surgical care: both, the extent and the quality of the surgical procedure and the extent and the quality of the analgesic technique are decisive issues for a successful pain management. There is growing evidence that supports the role of acute pain therapy in reducing postoperative morbidity, and it has been demonstrated that high pain scores postoperatively may contribute to a complicated postoperative course. This overview comprises the current knowledge on the role of acute pain therapy with regard to the occurrence of postoperative complications. Most of the knowledge is derived from studies that primarily focus on the type and quality of postoperative pain therapy in relation to specific surgical procedures and only secondary on complications. As far as existent, data that report on the recovery period after surgery, on the rehabilitation status, on perioperative morbidity, on the development of chronic pain after surgery, and on possible solutions of the latter problem with the institution of transitional pain services will be presented.
| S-EPMC8059349 | biostudies-literature
Project description:Wound complications, including surgical site infections (SSIs) and wound dehiscence, are among the most common complications following spine surgery often leading to readmission. The authors sought to identify preoperative characteristics predictive of wound complications after spine surgery.The American College of Surgeons National Surgical Quality Improvement Program database for years 2012-2014 was reviewed for patients undergoing spine surgery, defined by the Current Procedural Terminology codes. Forty-four preoperative and surgical characteristics were analyzed for associations with wound complications.Of the 99,152 patients included in this study, 2.2% experienced at least one wound complication (superficial SSI: 0.9%, deep SSI: 0.8%, organ space SSI: 0.4%, and dehiscence: 0.3%). Multivariate binary logistic regression testing found 10 preoperative characteristics associated with wound complications: body mass index ?30, smoker, female, chronic steroid use, hematocrit <38%, infected wound, inpatient status, emergency case, and operation time >3 hours. A risk score for each patient was created from the number of characteristics present. Receiver operating characteristic curves of the unweighted and weighted risk scores generated areas under the curve of 0.701 (95% CI: 0.690-0.713) and 0.715 (95% CI: 0.704-0.726), respectively. Patients with unweighted risk scores >7 were 25-fold more likely to develop a wound complication compared to patients with scores of 0. In addition, mortality rate, reoperation rate, and total length of stay each increased nearly 10-fold with increasing risk score.This study introduces a novel risk score for the development of wound dehiscence and SSIs in patients undergoing spine surgery, using new risk factors identified here.
| S-EPMC5682694 | biostudies-other