Association between inspired oxygen fraction and development of postoperative pulmonary complications in thoracic surgery: a multicentre retrospective cohort study.

BACKGROUND: Limited data exist to guide oxygen administration during one-lung ventilation for thoracic surgery. We hypothesised that high intraoperative inspired oxygen fraction during lung resection surgery requiring one-lung ventilation is independently associated with postoperative pulmonary complications (PPCs). METHODS: We performed this retrospective multicentre study using two integrated perioperative databases (Multicenter Perioperative Outcomes Group and Society of Thoracic Surgeons General Thoracic Surgery Database) to study adult thoracic surgical procedures using one-lung ventilation. The primary outcome was a composite of PPCs (atelectasis, acute respiratory distress syndrome, pneumonia, respiratory failure, reintubation, and prolonged ventilation >48 h). The exposure of interest was high inspired oxygen fraction (FiO2), defined by area under the curve of a FiO2 threshold > 80%. Univariate analysis and logistic regression modelling assessed the association between intraoperative FiO2 and PPCs. RESULTS: Across four US medical centres, 141/2733 (5.2%) procedures conducted in 2716 patients (55% female; mean age 66 yr) resulted in PPCs. FiO2 was univariately associated with PPCs (adjusted OR [aOR]: 1.17, 95% confidence interval [CI]: 1.04-1.33, P=0.012). Logistic regression modelling showed that duration of one-lung ventilation (aOR: 1.20, 95% CI: 1.03-1.41, P=0.022), but not the time-weighted average FiO2 (aOR: 1.01, 95% CI: 1.00-1.02, P=0.165), was associated with PPCs. CONCLUSIONS: Our results do not support limiting the inspired oxygen fraction for the purpose of reducing postoperative pulmonary complications in thoracic surgery involving one-lung ventilation.

Neuraxial Anesthesia and Analgesia During Cardiothoracic Surgery: A Narrative Review.

PURPOSE OF REVIEW: The purpose of this review is to synthesize and examine the literature on the use of neuraxial anesthesia and analgesia during cardiothoracic surgery. As cardiothoracic procedures often require systemic anticoagulation, neuraxial techniques are quite often underutilized due to the theoretical risk of epidural hematoma. In this review, we seek to examine the literature to review the indications and contraindications and to explore if neuraxial anesthesia and analgesia has a role in cardiothoracic surgery. RECENT FINDINGS: Neuraxial techniques have multiple advantages during cardiothoracic surgery including coronary vasodilation, decreased sympathetic surge, and a decreased cortisol level leading to overall reduction in stress response. Multiple studies have shown an improvement in pain scores, reduction in pulmonary complications, faster extubation times, with minimal complications when neuraxial techniques are utilized in cardiothoracic surgeries. Given the numerous advantages and minimal complications of neuraxial techniques in cardiothoracic surgeries, we hope its utilization continues to increase. Moving forward, we hope additional studies continue to reaffirm the benefits of neuraxial anesthesia and analgesia for cardiothoracic surgeries to improve its utilization.

Prediction models for postoperative pulmonary complications in intensive care unit patients after noncardiac thoracic surgery.

BACKGROUND: Postoperative pulmonary complication (PPC) is a leading cause of mortality and poor outcomes in postoperative patients. No studies have enrolled intensive care unit (ICU) patients after noncardiac thoracic surgery, and effective prediction models for PPC have not been developed. This study aimed to explore the incidence and risk factors and construct prediction models for PPC in these patients. METHODS: This study retrospectively recruited patients admitted to the ICU after noncardiac thoracic surgery at West China Hospital, Sichuan University, from July 2019 to December 2022. The patients were randomly divided into a development cohort and a validation cohort at a 70% versus 30% ratio. The preoperative, intraoperative and postoperative variables during the ICU stay were compared. Univariate and multivariate logistic regression analyses were applied to identify candidate predictors, establish prediction models, and compare the accuracy of the models with that of reported risk models. RESULTS: A total of 475 ICU patients were enrolled after noncardiac thoracic surgery (median age, 58; 72% male). At least one PPC occurred in 171 patients (36.0%), and the most common PPC was pneumonia (153/475, 32.21%). PPC significantly increased the duration of mechanical ventilation (p < 0.001), length of ICU stay (p < 0.001), length of hospital stay (LOS) (p < 0.001), and rate of reintubation (p = 0.047) in ICU patients. Seven risk factors were identified, and then the prediction nomograms for PPC were constructed. At ICU admission, the area under the curve (AUC) was 0.766, with a sensitivity of 0.71 and specificity of 0.60; after extubation, the AUC was 0.841, with a sensitivity of 0.75 and specificity of 0.83. The models showed robust discrimination in both the development cohort and the validation cohort, and they were well calibrated and more accurate than reported risk models. CONCLUSIONS: ICU patients who underwent noncardiac thoracic surgery were at high risk of developing PPCs. Prediction nomograms were constructed and they were more accurate than reported risk models, with excellent sensitivity and specificity. Moreover, these findings could help assess individual PPC risk and enhance postoperative management of patients.

External validation of the CARDOT score for predicting respiratory complications after thoracic surgery.

BACKGROUND: The CARDOT scores have been developed for prediction of respiratory complications after thoracic surgery. This study aimed to externally validate the CARDOT score and assess the predictive value of preoperative neutrophil-to-lymphocyte ratio (NLR) for postoperative respiratory complication. METHODS: A retrospective cohort study of consecutive thoracic surgical patients at a single tertiary hospital in northern Thailand was conducted. The development and validation datasets were collected between 2006 and 2012 and from 2015 to 2021, respectively. Six prespecified predictive factors were identified, and formed a predictive score, the CARDOT score (chronic obstructive pulmonary disease, American Society of Anesthesiologists physical status, right-sided operation, duration of surgery, preoperative oxygen saturation on room air, thoracotomy), was calculated. The performance of the CARDOT score was evaluated in terms of discrimination by using the area under the receiver operating characteristic (AuROC) curve and calibration. RESULTS: There were 1086 and 1645 patients included in the development and validation datasets. The incidence of respiratory complications was 15.7% (171 of 1086) and 22.5% (370 of 1645) in the development and validation datasets, respectively. The CARDOT score had good discriminative ability for both the development and validation datasets (AuROC 0.789 (95% CI 0.753-0.827) and 0.758 (95% CI 0.730-0.787), respectively). The CARDOT score showed good calibration in both datasets. A high NLR (≥ 4.5) significantly increased the risk of respiratory complications after thoracic surgery (P < 0.001). The AuROC curve of the validation cohort increased to 0.775 (95% CI 0.750-0.800) when the score was combined with a high NLR. The AuROC of the CARDOT score with the NLR showed significantly greater discrimination power than that of the CARDOT score alone (P = 0.008). CONCLUSIONS: The CARDOT score showed a good discriminative performance in the external validation dataset. An addition of a high NLR significantly increases the predictive performance of CARDOT score. The utility of this score is valuable in settings with limited access to preoperative pulmonary function testing.

The effectiveness of music in improving the recovery of cardiothoracic surgery: a systematic review with meta-analysis and trial sequential analysis.

AIM: This study aimed to compile data on the effectiveness of music therapy for patients undergoing cardiothoracic surgery. BACKGROUND: After cardiac and thoracic surgery, patients often experience physiological and psychological complications, such as anxiety, pain, stress, depression and changes in vital signs, which have a great impact on prognosis. METHODS: A systematic search of six databases was performed to identify randomized controlled trials investigating music therapy and cardiothoracic surgery. The data were extracted from the qualified research, the data without heterogeneity were analysed by random-effects model (REM) meta-analysis, and the data with heterogeneity were analysed by fixed-effects model (FEM) meta-analysis. We evaluated anxiety, pain, duration of mechanical ventilation, hospital length of stay, stress hormones, opioid consumption, and vital signs, including heart rate (HR), respiratory rate (RR), oxygen saturation (SpO2), diastolic blood pressure (DBP), and systolic blood pressure (SBP) after cardiothoracic surgery. The meta-analysis and sensitivity analysis were performed with RevMan 5.4 and Stata 14 software, and trial sequential analysis was conducted using TSA 0.9.5.10 Beta software. This study was conducted in accordance with the PRISMA guidelines and was registered with PROSPERO. RESULTS: The study included 24 randomized controlled trials with a total of 1576 patients. Our analysis showed that music therapy can significantly reduce the anxiety scores (SMD= -0.74, 95% CI [-0.96, -0.53], p < 0.01) and pain scores (SMD= -1.21, 95% CI [-1.78, -0.65], p < 0.01) of patients after cardiothoracic surgery. Compared with the control group, music therapy dramatically raised postoperative SpO2 (SMD = 0.75, 95% CI [0.11, 1.39], p = 0.02). In addition, the experimental group had significant statistical significance in reducing HR, SBP and opioid consumption. However, there was no significant difference in respiratory rate, stress hormones, diastolic blood pressure, length of hospital stay, or the duration of mechanical ventilation between the two groups. CONCLUSIONS: Music therapy can significantly reduce anxiety, pain, HR, SBP, and postoperative opioid use and even improve SpO2 in patients who undergo cardiothoracic surgery. Music therapy has a positive effect on patients after cardiothoracic surgery with few side effects, so it is promising for use in clinics. TRIAL REGISTRATION: RROSPERO (registration number: CRD42023424602).

Prevalence and Risk Factors for Chronic Postsurgical Pain After Thoracic Surgery: A Prospective Cohort Study.

OBJECTIVE: Thoracic surgery is associated with one of the highest rates of chronic postsurgical pain (CPSP) among all surgical subtypes. Chronic postsurgical pain carries significant medical, psychological, and economic consequences, and further interventions are needed to prevent its development. This study aimed to determine the prevalence, characteristics, and risk factors associated with CPSP after thoracic surgery. DESIGN: A prospective cohort study. SETTING: Single-center tertiary care hospital. PARTICIPANTS: This study included 285 adult patients who underwent thoracic surgery at Toronto General Hospital in Toronto, Canada, between 2012 and 2020. MEASUREMENTS AND MAIN RESULTS: Demographic, psychological, and clinical data were collected perioperatively, and follow-up evaluations were administered at 3, 6, and 12 months after surgery to assess CPSP. Chronic postsurgical pain was reported in 32.4%, 25.4%, and 18.2% of patients at 3, 6, and 12 months postoperatively, respectively. Average CPSP pain intensity was rated to be 3.37 (SD 1.82) at 3 months. Features of neuropathic pain were present in 48.7% of patients with CPSP at 3 months and 71% at 1 year. Multivariate logistic regression models indicated that independent predictors for CPSP at 3 months were scores on the Hospital Anxiety and Depression Scale (adjusted odds ratio [aOR] of 1.07, 95% CI of 1.02 to 1.14, p = 0.012) and acute postoperative pain (aOR of 2.75, 95% CI of 1.19 to 6.36, p = 0.018). INTERVENTIONS: None. CONCLUSIONS: Approximately 1 in 3 patients will continue to have pain at 3 months after surgery, with a large proportion reporting neuropathic features. Risk factors for pain at 3 months may include preoperative anxiety and depression and acute postoperative pain.

Development and validation of a nomogram for predicting pulmonary complications in elderly patients undergoing thoracic surgery.

BACKGROUND: Postoperative pulmonary complications (PPCs) remain a prevalent concern among elderly patients undergoing surgery, with a notably higher incidence observed in elderly patients undergoing thoracic surgery. This study aimed to develop a nomogram to predict the risk of PPCs in this population. METHODS: A total of 2963 elderly patients who underwent thoracic surgery were enrolled and randomly divided into a training cohort (80%, n = 2369) or a validation cohort (20%, n = 593). Univariate and multivariate logistic regression analyses were conducted to identify risk factors for PPCs, and a nomogram was developed based on the findings from the training cohort. The validation cohort was used to validate the model. The predictive accuracy of the model was evaluated by receiver operating characteristic (ROC) curve, area under ROC (AUC), calibration curve, and decision curve analysis (DCA). RESULTS: A total of 918 (31.0%) patients reported PPCs. Nine independent risk factors for PPCs were identified: preoperative presence of chronic obstructive pulmonary disease (COPD), elevated leukocyte count, higher partial pressure of arterial carbon dioxide (PaCO2) level, surgical site, thoracotomy, intraoperative hypotension, blood loss > 100 mL, surgery duration > 180 min, and malignant tumor. The AUC value for the training cohort was 0.739 (95% CI: 0.719-0.762), and it was 0.703 for the validation cohort (95% CI: 0.657-0.749). The P-values for the Hosmer-Lemeshow test were 0.633 and 0.144 for the training and validation cohorts, respectively, indicating a notable calibration curve fit. The DCA curve indicated that the nomogram could be applied clinically if the risk threshold was between 12% and 84%, which was found to be between 8% and 82% in the validation cohort. CONCLUSION: This study highlighted the pressing need for early detection of PPCs in elderly patients undergoing thoracic surgery. The nomogram exhibited promising predictive efficacy for PPCs in elderly patients undergoing thoracic surgery, enabling the identification of high-risk patients and consequently aiding in the implementation of preventive interventions.

The effects of video double-lumen tubes on intubation complications in patients undergoing thoracic surgery: A randomised controlled study.

BACKGROUND: Tracheal injuries, vocal cord injuries, sore throat and hoarseness are common complications of double-lumen tube (DLT) intubation. OBJECTIVE: This study aimed to evaluate the effects of 'video double-lumen tubes' (VDLTs) on intubation complications in patients undergoing thoracic surgery. DESIGN: A randomised controlled study. SETTINGT: Xuzhou Cancer Hospital, Xuzhou, China, from January 2023 to June 2023. PATIENTS: One hundred eighty-two patients undergoing elective thoracic surgery with one-lung ventilation were randomised into two groups: 90 in the DLT group and 92 in the VDLT group. INTERVENTION: VDLT was selected for intubation in the VDLT group, and DLT was selected for intubation in the DLT group. A fibreoptic bronchoscope (FOB) was used to record tracheal and vocal cord injuries. MAIN OUTCOME MEASURES: The primary outcomes were the incidence of moderate-to-severe tracheal injury and the incidence of vocal cord injury. The secondary outcomes included the incidence and severity of postoperative 24 and 48 h sore throat and hoarseness. RESULTS: The incidence of moderate-to-severe tracheal injury was 32/90 (35.6%) in the DLT group, and 45/92 (48.9%) in the VDLT group ( P  = 0.077; relative risk 1.38, 95% CI, 0.97 to 1.95). The incidence of vocal cord injury was 31/90 (34.4%) and 34/92 (37%) in the DLT and VDLT groups, respectively ( P  = 0.449). The incidence of postoperative 24 h sore throat and hoarseness was significantly higher in the VDLT group than in the DLT group (for sore throat: P  = 0.032, relative risk 1.63, 95% CI, 1.03 to 2.57; for hoarseness: P  = 0.018, relative risk 1.48, 95% CI, 1.06 to 2.06). CONCLUSION: There was no statistically significant difference in the incidence of moderate-to-severe tracheal injury and vocal cord injury between DLTs and VDLTs. While improving the first-attempt success rate, intubation with VDLT increased the incidence of postoperative 24 h sore throat and hoarseness. TRIAL REGISTRATION: Chinese Clinical Trial Registry identifier: ChiCTR2300067348.

Diaphragmatic dysfunction is associated with postoperative pulmonary complications and phrenic nerve paresis in patients undergoing thoracic surgery.

PURPOSE: We aimed to quantify perioperative changes in diaphragmatic function and phrenic nerve conduction in patients undergoing routine thoracic surgery. METHODS: A prospective observational study was performed in patients undergoing esophageal resection or pulmonary lobectomy. Examinations were carried out the day prior to surgery, 3 days and 10-14 days after surgery. Endpoints for diaphragmatic function included ultrasonographic measurements of diaphragmatic excursion and thickening fraction. Endpoints for phrenic nerve conduction included baseline-to-peak amplitude, peak-to-peak amplitude, and transmission delay. Measurements were assessed on both the surgical side and the non-surgical side of the thorax. RESULTS: Forty patients were included in the study. Significant reductions in diaphragmatic excursion were seen on the surgical side of the thorax for all excursion measures (posterior part of the right hemidiaphragm, p < 0.001; hemidiaphragmatic top point, p < 0.001; change in intrathoracic area, p < 0.001). Significant changes were seen for all phrenic nerve measures (baseline-to-peak amplitude, p < 0.001; peak-to-peak amplitude, p < 0.001; transmission delay, p = 0.041) on the surgical side. However, significant changes were also seen on the non-surgical side for all phrenic nerve measures (baseline-to-peak amplitude, p < 0.001; peak-to-peak amplitude, p < 0.001; transmission delay, p = 0.022). A postoperative reduction in posterior diaphragmatic excursion of more than 50% was significantly associated with postoperative pulmonary complications (coefficient: 2.69 (95% CI [1.38, 4.01], p < 0.001). CONCLUSION: Thoracic surgery caused a significant unilateral reduction in diaphragmatic excursion on the surgical side of the thorax, which was accompanied by significant changes in phrenic nerve conduction. However, phrenic nerve conduction was also significantly affected on the non-surgical side to a lesser extent, which was not mirrored in diaphragmatic excursion. Our findings suggest that phrenic nerve paresis plays a role in postoperative diaphragmatic dysfunction, which may be a contributing factor in the pathogenesis of postoperative pulmonary complications. CLINICAL TRIALS REGISTRATION NUMBER: NCT04507594.

Advances in the clinical use of patient-reported outcomes in thoracic surgery.

PURPOSE OF REVIEW: Patient-reported outcomes (PROs) are increasingly recognized as a clinical tool for measuring and improving patient-centric care. This review provides a summary on recent advances in the use of PROs in the field of thoracic surgery. RECENT FINDINGS: PROs have been used as primary endpoints in clinical trials and observational studies evaluating clinical care pathways and quantifying the benefits of minimally invasive surgical techniques for patients undergoing lung surgery. Qualitative and quantitative research has yielded fundamental insights into which PRO domains are meaningful and valued by patients after lung surgery. Patient experience and recovery after esophagectomy have been further characterized by using PROs. New disease-specific survey tools for patients have been developed to track long-term symptoms after esophageal reconstruction. Patient satisfaction has emerged as the key metric used to gauge the patient centeredness of hospital systems. SUMMARY: Advances have been made in the application of PROs in multiple areas of thoracic surgery, which include lung and esophageal surgery. The growing focus on the use of PROs in clinical pathways has led to a better understanding on how to optimize patient experience.

Risk factors associated with surgical site infections in patients undergoing cardiothoracic surgery: A systematic review and meta-analysis.

Surgical site infections (SSIs) following cardiothoracic surgery can pose significant challenges to patient recovery and outcome. This systematic review and meta-analysis aim to identify and quantify the risk factors associated with SSIs in patients undergoing cardiothoracic surgery. A comprehensive literature search adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and based on the PICO paradigm was conducted across four databases: PubMed, Embase, Web of Science and the Cochrane Library, without any temporal restrictions. The meta-analysis incorporated studies detailing the risk factors for post-operative sternal infections, especially those reporting odds ratios (OR) or relative risks with 95% confidence intervals (CI). Quality assessment of the studies was done using the Newcastle-Ottawa Scale. Statistical analysis was executed using the chi-square tests for inter-study heterogeneity, with further analyses depending on I2 values. Sensitivity analyses were performed, and potential publication bias was also assessed. An initial dataset of 2442 articles was refined to 21 articles after thorough evaluations based on inclusion and exclusion criteria. Patients with diabetes mellitus have an OR of 1.80 (95% CI: 1.40-2.20) for the incidence of SSIs, while obese patients demonstrate an OR of 1.63 (95% CI: 1.40-1.87). Individuals who undergo intraoperative blood transfusion present an OR of 1.13 (95% CI: 1.07-1.18), and smokers manifest an OR of 1.32 (95% CI: 1.03-1.60). These findings unequivocally indicate a pronounced association between these factors and an elevated risk of SSIs post-operatively. This meta-analysis confirms that diabetes, obesity, intraoperative transfusion and smoking heighten the risk of SSIs post-cardiac surgery. Clinicians should be alert to these factors to optimise patient outcomes.

Advancements in the Management of Postoperative Air Leak following Thoracic Surgery: From Traditional Practices to Innovative Therapies.

Background: Postoperative air leak (PAL) is a frequent and potentially serious complication following thoracic surgery, characterized by the persistent escape of air from the lung into the pleural space. It is associated with extended hospitalizations, increased morbidity, and elevated healthcare costs. Understanding the mechanisms, risk factors, and effective management strategies for PAL is crucial in improving surgical outcomes. Aim: This review seeks to synthesize all known data concerning PAL, including its etiology, risk factors, diagnostic approaches, and the range of available treatments from conservative measures to surgical interventions, with a special focus on the use of autologous plasma. Materials and Methods: A comprehensive literature search of databases such as PubMed, Cochrane Library, and Google Scholar was conducted for studies and reviews published on PAL following thoracic surgery. The selection criteria aimed to include articles that provided insights into the incidence, mechanisms, risk assessment, diagnostic methods, and treatment options for PAL. Special attention was given to studies detailing the use of autologous plasma in managing this complication. Results: PAL is influenced by a variety of patient-related, surgical, and perioperative factors. Diagnosis primarily relies on clinical observation and imaging, with severity assessments guiding management decisions. Conservative treatments, including chest tube management and physiotherapy, serve as the initial approach, while persistent leaks may necessitate surgical intervention. Autologous plasma has emerged as a promising treatment, offering a novel mechanism for enhancing pleural healing and reducing air leak duration, although evidence is still evolving. Conclusions: Effective management of PAL requires a multifaceted approach tailored to the individual patient's needs and the specifics of their condition. Beyond the traditional treatment approaches, innovative treatment modalities offer the potential to improve outcomes for patients experiencing PAL after thoracic surgery. Further research is needed to optimize treatment protocols and integrate new therapies into clinical practice.

Acute Kidney Injury After General Thoracic Surgery: A Systematic Review and Meta-analysis.

INTRODUCTION: The clinical importance of postoperative acute kidney injury (AKI) in patients undergoing general thoracic surgery is unclear. We aimed to systematically review the incidence, risk factors, and prognostic implications of AKI as a complication after general thoracic surgery. METHODS: We searched PubMed, EMBASE, and the Cochrane Library from January 2004 to September 2021. Observational or interventional studies that enrolled ≥50 patients undergoing general thoracic surgery and reported postoperative AKI defined using contemporary consensus criteria were included for meta-analysis. RESULTS: Thirty-seven articles reporting 35 unique cohorts were eligible. In 29 studies that enrolled 58,140 consecutive patients, the pooled incidence of postoperative AKI was 8.0% (95% confidence interval [CI]: 6.2-10.0). The incidence was 3.8 (2.0-6.2) % after sublobar resection, 6.7 (4.1-9.9) % after lobectomy, 12.1 (8.1-16.6) % after bilobectomy/pneumonectomy, and 10.5 (5.6-16.7) % after esophagectomy. Considerable heterogeneity in reported incidences of AKI was observed across studies. Short-term mortality was higher (unadjusted risk ratio: 5.07, 95% CI: 2.99-8.60) and length of hospital stay was longer (weighted mean difference: 3.53, 95% CI: 2.56-4.49, d) in patients with postoperative AKI (11 studies, 28,480 patients). Several risk factors for AKI after thoracic surgery were identified. CONCLUSIONS: AKI occurs frequently after general thoracic surgery and is associated with increased short-term mortality and length of hospital stay. For patients undergoing general thoracic surgery, AKI may be an important postoperative complication that needs early risk evaluation and mitigation.

Perioperative cardiovascular pathophysiology in patients undergoing lung resection surgery: a narrative review.

Although thoracic surgery is understood to confer a high risk of postoperative respiratory complications, the substantial haemodynamic challenges posed are less well appreciated. This review highlights the influence of cardiovascular comorbidity on outcome, reviews the complex pathophysiological changes inherent in one-lung ventilation and lung resection, and examines their influence on cardiovascular complications and postoperative functional limitation. There is now good evidence for the presence of right ventricular dysfunction postoperatively, a finding that persists to at least 3 months. This dysfunction results from increased right ventricular afterload occurring both intraoperatively and persisting postoperatively. Although many patients adapt well, those with reduced right ventricular contractile reserve and reduced pulmonary vascular flow reserve might struggle. Postoperative right ventricular dysfunction has been implicated in the aetiology of postoperative atrial fibrillation and perioperative myocardial injury, both common cardiovascular complications which are increasingly being appreciated to have impact long into the postoperative period. In response to the physiological demands of critical illness or exercise, contractile reserve, flow reserve, or both can be overwhelmed resulting in acute decompensation or impaired long-term functional capacity. Aiding adaptation to the unique perioperative physiology seen in patients undergoing thoracic surgery could provide a novel therapeutic avenue to prevent cardiovascular complications and improve long-term functional capacity after surgery.

Driving pressure-guided ventilation and postoperative pulmonary complications in thoracic surgery: a multicentre randomised clinical trial.

BACKGROUND: Airway driving pressure, easily measured as plateau pressure minus PEEP, is a surrogate for alveolar stress and strain. However, the effect of its targeted reduction remains unclear. METHODS: In this multicentre trial, patients undergoing lung resection surgery were randomised to either a driving pressure group (n=650) receiving an alveolar recruitment/individualised PEEP to deliver the lowest driving pressure or to a conventional protective ventilation group (n=650) with fixed PEEP of 5 cm H2O. The primary outcome was a composite of pulmonary complications within 7 days postoperatively. RESULTS: The modified intention-to-treat analysis included 1170 patients (mean [standard deviation, sd]; age, 63 [10] yr; 47% female). The mean driving pressure was 7.1 cm H2O in the driving pressure group vs 9.2 cm H2O in the protective ventilation group (mean difference [95% confidence interval, CI]; -2.1 [-2.4 to -1.9] cm H2O; P<0.001). The incidence of pulmonary complications was not different between the two groups: driving pressure group (233/576, 40.5%) vs protective ventilation group (254/594, 42.8%) (risk difference -2.3%; 95% CI, -8.0% to 3.3%; P=0.42). Intraoperatively, lung compliance (mean [sd], 42.7 [12.4] vs 33.5 [11.1] ml cm H2O-1; P<0.001) and Pao2 (median [inter-quartile range], 21.5 [14.5 to 30.4] vs 19.5 [13.5 to 29.1] kPa; P=0.03) were higher and the need for rescue ventilation was less frequent (6.8% vs 10.8%; P=0.02) in the driving pressure group. CONCLUSIONS: In lung resection surgery, a driving pressure-guided ventilation improved pulmonary mechanics intraoperatively, but did not reduce the incidence of postoperative pulmonary complications compared with a conventional protective ventilation. CLINICAL TRIAL REGISTRATION: NCT04260451.

Do we have the 'power' to 'drive' down the incidence of pulmonary complications after thoracic surgery.

The concept, mechanisms, and physical and physiological determinants of ventilator-induced lung injury, as well as the influence of lung-protective ventilation strategies, are novel paradigms of modern intensive care and perioperative medicine. Driving pressure and mechanical power have emerged as meaningful and modifiable targets with specific relevance to thoracic anaesthesia and one-lung ventilation. The relationship between these factors and postoperative pulmonary complications remains complex because of the methodological design and outcome selection. Larger observational studies are required to better understand the characteristics of driving pressure and power in current practice of thoracic anaesthesia in order to design future trials in high-risk thoracic populations at risk of acute lung injury.

Prevalence and Characteristics of Persistent Postoperative Pain After Thoracic Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: A systematic review and meta-analysis was conducted to investigate the prevalence and characteristics of persistent (≥3 months) postoperative pain (PPP) after thoracic surgery. METHODS: For this purpose, Medline, Embase, and CINAHL databases were searched for the prevalence and characteristics of PPP after thoracic surgery from their inception to May 1, 2022. Random-effect meta-analysis was used to estimate pooled prevalence and characteristics. RESULTS: We included 90 studies with 19,001 patients. At a median follow-up of 12 months, the pooled overall prevalence of PPP after thoracic surgery was 38.1% (95% confidence interval [CI], 34.1-42.3). Among patients with PPP, 40.6% (95% CI, 34.4-47.2) and 10.1% (95% CI, 6.8-14.8) experienced moderate-to-severe (rating scale ≥4/10) and severe (rating scale ≥7/10) PPP, respectively. Overall, 56.5% (95% CI, 44.3-67.9) of patients with PPP required opioid analgesic use, and 33.0% (95% CI, 22.5-44.3) showed a neuropathic component. CONCLUSIONS: One in 3 thoracic surgery patients developed PPP. There is a need for adequate pain treatment and follow-up in patients undergoing thoracic surgery.

Practice Advisory for Preoperative and Intraoperative Pain Management of Thoracic Surgical Patients: Part 1.

Pain after thoracic surgery is of moderate-to-severe intensity and can cause increased postoperative distress and affect functional recovery. Opioids have been central agents in treating pain after thoracic surgery for decades. The use of multimodal analgesic strategies can promote effective postoperative pain control and help mitigate opioid exposure, thus preventing the risk of developing persistent postoperative pain. This practice advisory is part of a series developed by the Society of Cardiovascular Anesthesiologists (SCA) Quality, Safety, and Leadership (QSL) Committee's Opioid Working Group. It is a systematic review of existing literature for various interventions related to the preoperative and intraoperative pain management of thoracic surgical patients and provides recommendations for providers caring for patients undergoing thoracic surgery. This entails developing customized pain management strategies for patients, which include preoperative patient evaluation, pain management, and opioid use-focused education as well as perioperative use of multimodal analgesics and regional techniques for various thoracic surgical procedures. The literature related to this field is emerging and will hopefully provide more information on ways to improve clinically relevant patient outcomes and promote recovery in the future.

Predictors and impact of postoperative atrial fibrillation following thoracic surgery: a state-of-the-art review.

This review of 19 studies (39,783 patients) of atrial fibrillation after thoracic surgery addresses the pathophysiology, incidence, and consequences of atrial fibrillation in this population, as well as its prevention and management. Interestingly, atrial fibrillation was most often identified in patients not previously known to have the disease. Rhythm control with amiodarone was the most commonly used treatment and nearly all patients were discharged in sinus rhythm. Major predictors were age; male sex; history of atrial fibrillation; congestive heart failure; left atrial enlargement; elevated brain natriuretic peptide level; and the invasiveness of procedures. Overall, patients with atrial fibrillation stayed 3 days longer in hospital. We also discuss the importance of standardising research on this subject and provide recommendations that might mitigate the impact postoperative atrial fibrillation on hospital resources.

Hypotension prediction index guided versus conventional goal directed therapy to reduce intraoperative hypotension during thoracic surgery: a randomized trial.

PURPOSE: Intraoperative hypotension is linked to increased incidence of perioperative adverse events such as myocardial and cerebrovascular infarction and acute kidney injury. Hypotension prediction index (HPI) is a novel machine learning guided algorithm which can predict hypotensive events using high fidelity analysis of pulse-wave contour. Goal of this trial is to determine whether use of HPI can reduce the number and duration of hypotensive events in patients undergoing major thoracic procedures. METHODS: Thirty four patients undergoing esophageal or lung resection were randomized into 2 groups -"machine learning algorithm" (AcumenIQ) and "conventional pulse contour analysis" (Flotrac). Analyzed variables were occurrence, severity and duration of hypotensive events (defined as a period of at least one minute of MAP below 65 mmHg), hemodynamic parameters at 9 different timepoints interesting from a hemodynamics viewpoint and laboratory (serum lactate levels, arterial blood gas) and clinical outcomes (duration of mechanical ventilation, ICU and hospital stay, occurrence of adverse events and in-hospital and 28-day mortality). RESULTS: Patients in the AcumenIQ group had significantly lower area below the hypotensive threshold (AUT, 2 vs 16.7 mmHg x minutes) and time-weighted AUT (TWA, 0.01 vs 0.08 mmHg). Also, there were less patients with hypotensive events and cumulative duration of hypotension in the AcumenIQ group. No significant difference between groups was found in terms of laboratory and clinical outcomes. CONCLUSIONS: Hemodynamic optimization guided by machine learning algorithm leads to a significant decrease in number and duration of hypotensive events compared to traditional goal directed therapy using pulse-contour analysis hemodynamic monitoring in patients undergoing major thoracic procedures. Further, larger studies are needed to determine true clinical utility of HPI guided hemodynamic monitoring. TRIAL REGISTRATION: Date of first registration: 14/11/2022 Registration number: 04729481-3a96-4763-a9d5-23fc45fb722d.