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1.
Minerva Anestesiol ; 82(3): 332-42, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25990430

RESUMO

Pulmonary complications are a source of greater postoperative morbidity and mortality and longer hospital stays. Although many factors have been implicated as predictors, few models have been developed with the rigorous methodology required for clinically useful tools. In this article we attempt to describe what to look for when developing or assessing a newly proposed predictive tool and to discuss what must be taken into consideration on incorporating a model into clinical practice. Above all, we stress that we still lack evidence for the clinical and cost effectiveness of many measures proposed for reducing risk or for managing complications perioperatively. For a good predictive model to truly prove its utility in clinical decision-making, such evidence is required.


Assuntos
Pneumopatias/diagnóstico , Pneumopatias/terapia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/terapia , Valor Preditivo dos Testes , Humanos , Pneumopatias/etiologia , Modelos Biológicos , Período Pós-Operatório , Fatores de Risco
3.
Eur J Anaesthesiol ; 32(7): 458-70, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-26020123

RESUMO

BACKGROUND: Postoperative respiratory failure (PRF) is the most frequent respiratory complication following surgery. OBJECTIVE: The objective of this study was to build a clinically useful predictive model for the development of PRF. DESIGN: A prospective observational study of a multicentre cohort. SETTING: Sixty-three hospitals across Europe. PATIENTS: Patients undergoing any surgical procedure under general or regional anaesthesia during 7-day recruitment periods. MAIN OUTCOME MEASURES: Development of PRF within 5 days of surgery. PRF was defined by a partial pressure of oxygen in arterial blood (PaO2) less than 8 kPa or new onset oxyhaemoglobin saturation measured by pulse oximetry (SpO2) less than 90% whilst breathing room air that required conventional oxygen therapy, noninvasive or invasive mechanical ventilation. RESULTS: PRF developed in 224 patients (4.2% of the 5384 patients studied). In-hospital mortality [95% confidence interval (95% CI)] was higher in patients who developed PRF [10.3% (6.3 to 14.3) vs. 0.4% (0.2 to 0.6)]. Regression modelling identified a predictive PRF score that includes seven independent risk factors: low preoperative SpO2; at least one preoperative respiratory symptom; preoperative chronic liver disease; history of congestive heart failure; open intrathoracic or upper abdominal surgery; surgical procedure lasting at least 2 h; and emergency surgery. The area under the receiver operating characteristic curve (c-statistic) was 0.82 (95% CI 0.79 to 0.85) and the Hosmer-Lemeshow goodness-of-fit statistic was 7.08 (P = 0.253). CONCLUSION: A risk score based on seven objective, easily assessed factors was able to predict which patients would develop PRF. The score could potentially facilitate preoperative risk assessment and management and provide a basis for testing interventions to improve outcomes.The study was registered at ClinicalTrials.gov (identifier NCT01346709).


Assuntos
Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/prevenção & controle , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/prevenção & controle , Adulto , Idoso , Anestesia por Condução , Anestesia Geral , Estudos de Coortes , Cuidados Críticos/estatística & dados numéricos , Europa (Continente) , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Oximetria , Oxigênio/sangue , Oxiemoglobinas/análise , Oxiemoglobinas/metabolismo , Complicações Pós-Operatórias/mortalidade , Estudos Prospectivos , Insuficiência Respiratória/mortalidade , Fatores de Risco , Resultado do Tratamento
5.
Anesthesiology ; 121(2): 219-31, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24901240

RESUMO

BACKGROUND: No externally validated risk score for postoperative pulmonary complications (PPCs) is currently available. The authors tested the generalizability of the Assess Respiratory Risk in Surgical Patients in Catalonia risk score for PPCs in a large European cohort (Prospective Evaluation of a RIsk Score for postoperative pulmonary COmPlications in Europe). METHODS: Sixty-three centers recruited 5,859 surgical patients receiving general, neuraxial, or plexus block anesthesia. The Assess Respiratory Risk in Surgical Patients in Catalonia factors (age, preoperative arterial oxygen saturation in air, acute respiratory infection during the previous month, preoperative anemia, upper abdominal or intrathoracic surgery, surgical duration, and emergency surgery) were recorded, along with PPC occurrence (respiratory infection or failure, bronchospasm, atelectasis, pleural effusion, pneumothorax, or aspiration pneumonitis). Discrimination, calibration, and diagnostic accuracy measures of the Assess Respiratory Risk in Surgical Patients in Catalonia score's performance were calculated for the Prospective Evaluation of a RIsk Score for postoperative pulmonary COmPlications in Europe cohort and three subsamples: Spain, Western Europe, and Eastern Europe. RESULTS: The full Prospective Evaluation of a RIsk Score for postoperative pulmonary COmPlications in Europe data set included 5,099 patients; 725 PPCs were recorded for 404 patients (7.9%). The score's discrimination was good: c-statistic (95% CI), 0.80 (0.78 to 0.82). Predicted versus observed PPC rates for low, intermediate, and high risk were 0.87 and 3.39% (score <26), 7.82 and 12.98% (≥ 26 and <45), and 38.13 and 38.01% (≥ 45), respectively; the positive likelihood ratio for a score of 45 or greater was 7.12 (5.93 to 8.56). The score performed best in the Western Europe subsample-c-statistic, 0.87 (0.83 to 0.90) and positive likelihood ratio, 11.56 (8.63 to 15.47)-and worst in the Eastern Europe subsample. The predicted (5.5%) and observed (5.7%) PPC rates were most similar in the Spain subsample. CONCLUSIONS: The Assess Respiratory Risk in Surgical Patients in Catalonia score predicts three levels of PPC risk in hospitals outside the development setting. Performance differs between geographic areas.


Assuntos
Pneumopatias/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Anemia/complicações , Calibragem , Estudos de Coortes , Coleta de Dados , Emergências , Feminino , Humanos , Tempo de Internação , Pneumopatias/etiologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Controle de Qualidade , Infecções Respiratórias/complicações , Medição de Risco , Fatores de Risco , Tamanho da Amostra
6.
Curr Opin Anaesthesiol ; 27(2): 201-9, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24419159

RESUMO

PURPOSE OF REVIEW: This review of progress toward reliable prediction of postoperative pulmonary complications (PPCs) discusses risk assessment against the background of patient management strategies, clinical outcomes, and cost of healthcare. RECENT FINDINGS: Among the variety of conditions grouped as PPCs are pneumonia, aspiration pneumonitis, respiratory failure, reintubation within 48 h, weaning failure, pleural effusion, atelectasis, bronchospasm, and pneumothorax. PPC incidence rates range from 2 to 40% depending on context. These events increase mortality, postoperative length of stay, ICU admissions, hospital readmissions, and costs. PPC-associated mortality varies, but can reach as high as 48% in some contexts. ICU admission rates are between 9.5 and 91% higher in patients with PPCs. The mean increase in PPC-related postoperative length of stay is approximately 8 days. The cost of surgery can be two-fold to 12-fold higher when PPCs develop. Strategies proposed to reduce the impact of modifiable risk factors include alcohol and smoking abstinence before surgery, shortening the duration of surgery, and physiotherapy and incentive spirometry techniques; however, little scientific evidence supports them at this time. SUMMARY: PPCs are associated with a higher incidence of life-threatening events and higher costs. Reliable PPC risk-stratification tools are essential for guiding clinical decision-making in the perioperative period. The care team can act on modifiable factors and optimize vigilance over nonmodifiable ones. It would be useful to focus resources on determining whether low-cost preemptive interventions improve outcomes satisfactorily or new strategies need to be developed.


Assuntos
Pneumopatias/etiologia , Complicações Pós-Operatórias/etiologia , Custos de Cuidados de Saúde , Humanos , Pneumopatias/mortalidade , Programas de Assistência Gerenciada , Respiração com Pressão Positiva , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/mortalidade , Fatores de Risco , Resultado do Tratamento
9.
Anesthesiology ; 113(6): 1338-50, 2010 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-21045639

RESUMO

BACKGROUND: Current knowledge of the risk for postoperative pulmonary complications (PPCs) rests on studies that narrowly selected patients and procedures. Hypothesizing that PPC occurrence could be predicted from a reduced set of perioperative variables, we aimed to develop a predictive index for a broad surgical population. METHODS: Patients undergoing surgical procedures given general, neuraxial, or regional anesthesia in 59 hospitals were randomly selected for this prospective, multicenter study. The main outcome was the development of at least one of the following: respiratory infection, respiratory failure, bronchospasm, atelectasis, pleural effusion, pneumothorax, or aspiration pneumonitis. The cohort was randomly divided into a development subsample to construct a logistic regression model and a validation subsample. A PPC predictive index was constructed. RESULTS: Of 2,464 patients studied, 252 events were observed in 123 (5%). Thirty-day mortality was higher in patients with a PPC (19.5%; 95% [CI], 12.5-26.5%) than in those without a PPC (0.5%; 95% CI, 0.2-0.8%). Regression modeling identified seven independent risk factors: low preoperative arterial oxygen saturation, acute respiratory infection during the previous month, age, preoperative anemia, upper abdominal or intrathoracic surgery, surgical duration of at least 2 h, and emergency surgery. The area under the receiver operating characteristic curve was 90% (95% CI, 85-94%) for the development subsample and 88% (95% CI, 84-93%) for the validation subsample. CONCLUSION: The risk index based on seven objective, easily assessed factors has excellent discriminative ability. The index can be used to assess individual risk of PPC and focus further research on measures to improve patient care.


Assuntos
Pneumopatias/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestesia , Estudos de Coortes , Coleta de Dados/normas , Feminino , Humanos , Tempo de Internação , Modelos Logísticos , Pneumopatias/epidemiologia , Pneumopatias/mortalidade , Masculino , Pessoa de Meia-Idade , População , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/mortalidade , Valor Preditivo dos Testes , Estudos Prospectivos , Respiração Artificial , Fatores de Risco , Tamanho da Amostra , Estações do Ano , Espanha/epidemiologia , Resultado do Tratamento
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