Hyperoxemia During Cardiac Surgery Is Associated With Postoperative Pulmonary Complications.

The use of hyperoxemia during cardiac surgery remains controversial. We hypothesized that intraoperative hyperoxemia during cardiac surgery is associated with an increased risk of postoperative pulmonary complications. DESIGN: Retrospective cohort study. SETTING: We analyzed intraoperative data from five hospitals within the Multicenter Perioperative Outcomes Group between January 1, 2014, and December 31, 2019. We assessed intraoperative oxygenation of adult patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Hyperoxemia pre and post CPB was quantified as the area under the curve (AUC) of Fio2 above 0.21 in minutes when the corresponding peripheral oxygen saturation was greater than 92% measured by pulse oximetry. We quantified hyperoxemia during CPB as the AUC of Pao2 greater than 200 mm Hg measured by arterial blood gas. We analyzed the association of hyperoxemia during all phases of cardiac surgery with the frequency of postoperative pulmonary complications within 30 days, including acute respiratory insufficiency or failure, acute respiratory distress syndrome, need for reintubation, and pneumonia. PATIENTS: Twenty-one thousand six hundred thirty-two cardiac surgical patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During 21,632 distinct cardiac surgery cases, 96.4% of patients spent at least 1 minute in hyperoxemia (99.1% pre-CPB, 98.5% intra-CPB, and 96.4% post-CPB). Increasing exposure to hyperoxemia was associated with an increased risk of postoperative pulmonary complications throughout three distinct surgical periods. During CPB, increasing exposure to hyperoxemia was associated with an increased odds of developing postoperative pulmonary complications (p < 0.001) in a linear manner. Hyperoxemia before CPB (p < 0.001) and after CPB (p = 0.02) were associated with increased odds of developing postoperative pulmonary complications in a U-shaped relationship. CONCLUSIONS: Hyperoxemia occurs almost universally during cardiac surgery. Exposure to hyperoxemia assessed continuously as an AUC during the intraoperative period, but particularly during CPB, was associated with an increased incidence of postoperative pulmonary complications.

Complicaciones respiratorias en el posoperatorio inmediato en pacientes sometidos a cirugías de hemiabdomen superior

Las complicaciones respiratorias durante el posoperatorio inmediato justifica el interés del anestesiólogo por el conocimiento actualizado con el fin de disminuir la morbimortalidad. Con el objetivo de caracterizar las complicaciones respiratorias más frecuentes que se presentan en el posoperatorio inmediato de cirugía de hemiabdomen superior se realizó estudioobservacional, descriptivo de serie de casos, en 146 pacientes sometidos a cirugía de hemiabdomen superior atendidos en la unidad de cuidados posanestésicos del Hospital Provincial Clínico Quirúrgico Docente "Saturnino Lora", de Santiago de Cuba, duranteenero a diciembre de 2020; los datos se obtuvieron a partir de la historia clínica hospitalaria y examen clínico general realizado, los que fueron plasmados en una planilla confeccionada para el efecto. Fueron utilizados el test del Xi-cuadrado (X2), y la prueba de diferencias de proporciones, con un valor de p = 0,05durante el procesamiento estadístico. Los pacientes con edades mayores de 60 años, del sexo masculino y que presentaban como hábitos tóxicos el tabaquismo, la hipertensión arterial seguida de las neuropatías son las más frecuentes; mientras que los diagnósticos operatorios fueron la colecistitis aguda convencional y el trauma hepático. La intervención quirúrgica urgente, los pacientes ASA II, y los procedimientos que duraron más de 2 horas fueron los más frecuentes. Las complicaciones respiratorias más frecuentes encontradas fue la hipoxia; seguida de la ventilación mecánica prolongada y la atelectasia. Las complicaciones respiratorias encontradas en el posoperatorio inmediato de cirugía de hemiabdomen superior se asociaron desde el punto de vista estadístico con la clasificación ASA.

Respiratory complications during the immediate postoperative period justify the anesthesiologist's interest in updated knowledge in order to reduce morbidity and mortality. In order to characterize the most frequent respiratory complications that occur in the immediate postoperative period of upper hemiabdomen surgery, an observational, descriptive case series study was conducted in 146 patients undergoing upper hemiabdomen surgery attended at the post-anesthetic care unit of the "Saturnino Lora" Teaching Clinical Surgical Provincial Hospital in Santiago de Cuba. during January to December 2020; The data were obtained from the hospital clinical history and general clinical examination performed, which were reflected in a form prepared for this purpose. The Xi-square test (X2) and the proportions differences test were used, with a p value = 0.05 during statistical processing. Patients over 60 years of age, male and who presented smoking as toxic habits, hypertension followed by neuropathies are the most frequent; while the operative diagnoses were conventional acute cholecystitis and liver trauma. Urgent surgery, ASA II patients, and procedures lasting more than 2 hours were the most frequent. The most frequent respiratory complications found were hypoxia; followed by prolonged mechanical ventilation and atelectasis. The respiratory complications found in the immediate postoperative period of upper hemiabdomen surgery were statistically associated with the ASA classification.

As complicações respiratórias no pós-operatório imediato justificam o interesse do anestesiologista em atualizar o conhecimento para reduzir a morbimortalidade. Com o objetivo de caracterizar as complicações respiratórias mais frequentes que ocorrem no pós-operatório imediato de cirurgia de hemiabdome alto, foi realizado um estudo observacional descritivo de série de casos em 146 pacientes submetidos à cirurgia de hemiabdome superior atendidos na unidade de recuperação pós-anestésica do Hospital Provincial Clínico Cirúrgico Universitário "Saturnino Lora" em Santiago de Cuba de janeiro a dezembro de 2020; Os dados foram obtidos da história clínica hospitalar e do exame clínico geral realizados, os quais foram refletidos em um formulário elaborado para esse fim.Utilizou-se o teste do xi-quadrado (X2) e o teste de diferenças de proporções, com valor de p = 0,05 durante o processamento estatístico. Pacientes acima de 60 anos, do sexo masculino e que apresentavam o tabagismo como hábitos tóxicos, sendo a hipertensão arterial seguida de neuropatias os mais frequentes; enquanto os diagnósticos operatórios foram colecistite aguda convencional e trauma hepático. Cirurgias de urgência, pacientes ASA II e procedimentos com duração superior a 2 horas foram os mais frequentes. As complicações respiratórias mais frequentes encontradas foram hipóxia; seguido de ventilação mecânica prolongada e atelectasia. As complicações respiratórias encontradas no pós-operatório imediato de cirurgia de hemiabdome alto foram estatisticamente associadas à classificação ASA.

Intraoperative positive end-expiratory pressure and postoperative pulmonary complications: a patient-level meta-analysis of three randomised clinical trials.

BACKGROUND: High intraoperative PEEP with recruitment manoeuvres may improve perioperative outcomes. We re-examined this question by conducting a patient-level meta-analysis of three clinical trials in adult patients at increased risk for postoperative pulmonary complications who underwent non-cardiothoracic and non-neurological surgery. METHODS: The three trials enrolled patients at 128 hospitals in 24 countries from February 2011 to February 2018. All patients received volume-controlled ventilation with low tidal volume. Analyses were performed using one-stage, two-level, mixed modelling (site as a random effect; trial as a fixed effect). The primary outcome was a composite of postoperative pulmonary complications within the first week, analysed using mixed-effect logistic regression. Pre-specified subgroup analyses of nine patient characteristics and seven procedure and care-delivery characteristics were also performed. RESULTS: Complete datasets were available for 1913 participants ventilated with high PEEP and recruitment manoeuvres, compared with 1924 participants who received low PEEP. The primary outcome occurred in 562/1913 (29.4%) participants randomised to high PEEP, compared with 620/1924 (32.2%) participants randomised to low PEEP (unadjusted odds ratio [OR]=0.87; 95% confidence interval [95% CI], 0.75-1.01; P=0.06). Higher PEEP resulted in 87/1913 (4.5%) participants requiring interventions for desaturation, compared with 216/1924 (11.2%) participants randomised to low PEEP (OR=0.34; 95% CI, 0.26-0.45). Intraoperative hypotension was associated more frequently (784/1913 [41.0%]) with high PEEP, compared with low PEEP (579/1924 [30.1%]; OR=1.87; 95% CI, 1.60-2.17). CONCLUSIONS: High PEEP combined with recruitment manoeuvres during low tidal volume ventilation in patients undergoing major surgery did not reduce postoperative pulmonary complications. CLINICAL TRIAL REGISTRATION: NCT03937375 (Clinicaltrials.gov).

Impact of drains positioning on pulmonary function after coronary artery bypass grafting: an observational study.

INTRODUCTION: Coronary artery bypass grafting (CABG) is a procedure associated with a decline in pulmonary function. Among the main causes is the presence of the drain that is usually positioned in the intercostal or subxiphoid region. OBJECTIVE: To measure the interference of drains positioning on pulmonary function in patients undergoing CABG. METHODS: Observational study that assessed preoperative pulmonary function through vital capacity (VC), maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), and peak expiratory flow (PEF). These variables were evaluated in three different moments: in the presence of two drains, when removing one, and after removing all drains. RESULTS: We evaluated 45 patients with a mean age of 62 ± 7 years with male prevalence of 29 (64%) individuals. The insertion of drains caused a decline in pulmonary function after surgery by reducing MIP by 48%, MEP by 11%, VC by 39%, and PEF by 6%. CONCLUSION: This study has demonstrated that drains positioning after CABG surgery may produce weakness of the respiratory muscles, change ventilatory mechanics, and impair normal pulmonary function postoperatively.

Adding autogenic drainage to chest physiotherapy after upper abdominal surgery: effect on blood gases and pulmonary complications prevention. Randomized controlled trial

ABSTRACT BACKGROUND: Hypoxemia and pulmonary complications are common after upper abdominal surgery (UAS). OBJECTIVE: To examine whether inclusion of autogenic drainage (AD) in chest physiotherapy after UAS confers additional benefits in improving blood gases and reducing postoperative pulmonary complications (PPCs). DESIGN AND SETTING: Randomized controlled study conducted at Kasr Al-Ainy teaching hospital, Egypt. METHODS: A randomized controlled trial was conducted on 48 subjects undergoing elective UAS with high risk of developing PPCs. The study group received AD plus routine chest physiotherapy (deep diaphragmatic breathing, localized breathing and splinted coughing) and the control group received routine chest physiotherapy only. The outcomes included arterial blood gases measured at the first and seventh postoperative days, incidence of PPCs within the first seven days and length of hospital stay. RESULTS: Baseline characteristics were similar between groups. In the AD group, SaO2, PaO2, PaCO2 and HCO3 significantly improved (P < 0.05) while in the physiotherapy group, only SaO2 and PaO2 significantly improved (P < 0.05). Nonetheless, significant differences in post-treatment SaO2 and PaO2 between the groups were observed. The overall incidence of PPCs was 16.66% (12.5% in the AD group and 20.8% in the physiotherapy group) (absolute risk reduction -8.3%; 95% confidence interval, CI, -13.5 to 29.6%), with no significant difference between the groups. The AD group had a significantly shorter hospital stay (P = 0.0001). CONCLUSION: Adding AD to routine chest physiotherapy after UAS provided a favorable blood gas outcome and reduced the length of hospital stay. It tended to reduce the incidence of PPCs. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04446520.

Complicaciones pulmonares tempranas en pacientes operados de cirugía cardiaca / Early pulmonary complications in cardiac surgery patients / Complicações pulmonares precoce em pacientes pós-operados de cirurgia cardíaca

Resumen: Introducción: Las complicaciones pulmonares postoperatorias tempranas (CPPT) son la principal causa de complicaciones no relacionadas con el procedimiento quirúrgico en la población de cirugía cardiaca. Material y métodos: Se realizó un estudio retrospectivo, observacional y descriptivo del 01 de enero de 2006 al 31 de diciembre de 2018 en pacientes sometidos a cirugía cardiaca que ingresaron a la Unidad de Cuidados Postquirúrgicos. Resultados: Se incluyeron 323 pacientes, 107 (33.1%) presentaron CPPT, siendo las más frecuentes las atelectasias (n = 60, 18.6%), derrame pleural (n = 39, 12%), neumonía (n = 5, 1.5%) y SIRA (n = 3, 1%). Los pacientes que presentaron CPPT tuvieron un EURO SCORE II más alto (3.9 ± 4.7 vs. 2.7 ± 2.2, p = 0.001), mayor tiempo de derivación cardiopulmonar (119.6 ± 40.2 vs. 75.5 ± 36.6, p = 0.001) y tiempo de pinzamiento (84.9 ± 30.5 vs. 53.5 ± 29.7, p = 0.001). La supervivencia en UCI de los pacientes con CPPT fue menor (74.8 vs. 88.4%, p = 0.002, OR = 2.6). La supervivencia hospitalaria también fue menor en los pacientes con CPPT (72.8 vs. 84.2%, p = 0.015). Conclusiones: La incidencia de CPPT posterior a la cirugía cardiaca en nuestro centro hospitalaria fue alta. Es necesaria la implementación de medidas preventivas como el retiro temprano de la ventilación mecánica y rehabilitación cardiopulmonar.

Abstract: Introduction: Early postoperative pulmonary complications (EPPC) are the main cause of complications unrelated to the surgical procedure in the cardiac surgery population. Material and methods: A retrospective, observational and descriptive study was conducted from January 1, 2006 to December 31, 2018 in patients undergoing cardiac surgery admitted to the post-surgical care unit. Results: 323 patients were included, 107 (33.1%) presented EPPC, the most frequent being atelectasis (n = 60, 18.6%), pleural effusion (n = 39, 12%), pneumonia (n = 5, 1.5%) and ARDS (n = 3, 1%). Patients who presented EPPC had a higher EURO SCORE II (3.9 ± 4.7 vs. 2.7 ± 2.2, p = 0.001), longer cardiopulmonary bypass time (119.6 ± 40.2 vs. 75.5 ± 36.6, p = 0.001) and clamping time (84.9 ± 30.5 vs. 53.5 ± 29.7, p = 0.001). The ICU survival of patients with EPPC was lower (74.8 vs. 88.4%, p = 0.002, OR = 2.6). Hospital survival was also lower in patients with EPPC (72.8 vs. 84.2%, p = 0.015). Conclusions: The incidence of EPPC after cardiac surgery in our hospital was high. The implementation of preventive measures such as early removal of mechanical ventilation and cardiopulmonary rehabilitation is necessary.

Resumo: Introdução: As complicações pulmonares pós-operatórias precoces (CPPP) são a principal causa de complicações não relacionadas ao procedimento cirúrgico na população de cirurgia cardíaca. Material e métodos: Estudo retrospectivo, observacional e descritivo realizado no período de 1o de janeiro de 2006 a 31 de dezembro de 2018 em pacientes submetidos à cirurgia cardíaca internados na unidade de recuperação pós-cirúrgica. Resultados: Foram incluídos 323 pacientes, 107 (33.1%) apresentavam TPPP, sendo os mais frequentes atelectasia (n = 60, 18.6%), derrame pleural (n = 39, 12%), pneumonia (n = 5, 1.5%) e SIRA (n = 3, 1%). Pacientes que apresentaram CPPP tiveram maior EURO SCORE II (3.9 ± 4.7 vs 2.7 ± 2.2, p = 0.001), maior tempo de circulação extracorpórea (119.6 ± 40.2 vs 75.5 ± 36.6, p = 0.001) e tempo de pinçamento (84.9 ± 30.5 vs 53.5 ± 29.7, p = 0.001). A sobrevida na UTI de pacientes com CPPP foi menor (74.8% vs 88.4%, p = 0.002, OR = 2.6). A sobrevivência hospitalar também foi menor em pacientes com CPPT (72.8% vs 84.2%, p = 0.015). Conclusões: A incidência de CPPP após cirurgia cardíaca em nosso centro hospitalar foi alta. É necessária a implementação de medidas preventivas como a retirada precoce da ventilação mecânica e a reabilitação cardiopulmonar.

Avaliação da função pulmonar em pacientes hospitalizados no pósoperatório de cirurgia cardíaca / Evaluation of pulmonary function in patients hospitalized in postoperative cardiac surgery

Introdução: a disfunção pulmonar no pós-operatório de cirurgia cardíaca continua sendo uma das mais importantes causas demorbidade, sendo que o comprometimento da função pulmonar, nessa circunstância, é frequente e contribui, significativamente, para o aumento do tempo de permanência hospitalar. O objetivo deste estudo foi avaliar o comportamento da função pulmonar em pacientes adultos hospitalizados, submetidos à cirurgia cardíaca por esternotomia mediana, no momento a alta da unidade tratamento intensivo, comparado ao quarto dia após a alta dessa unidade. Metodologia: o estudo foi realizado em uma unidade de pós-operatório de cirurgia cardiovascular, após aprovação do Comitê de Ética em Pesquisa. O Termo de Consentimento Livre Esclarecido foi obtido em todos os casos. Incluíram-se pacientes maiores de 18 anos, submetidos à cirurgia cardíaca eletiva. A função pulmonar foi realizada na alta da unidade de tratamento intensivo e, posteriormente, repetida no quarto dia. A função pulmonar foi mensurada pela capacidade vital forçada, pico de fluxo expiratório, além de variáveis do exame físico, como frequência respiratória e ausculta pulmonar. Resultados: 94 pacientes foram submetidos à cirurgia cardíaca eletiva via esternotomia mediana. A média (desvio padrão) de idade foi 50,64 (16,53) anos, com predomínio do sexo masculino (52,1%). A mediana (Q1-Q3) do tempo de permanência na unidade de tratamento intensivo foi de 2,00 dias (2,00-3,00), ao passo que a mediana (Q1-Q3) do tempo de permanência hospitalar foi de 6,00 dias (5,00-8,00). A mediana (Q1-Q3) da capacidade vital forçada e do fluxo respiratório, obtida pela espirometria no pós-operatório, no momento da alta, foi significativamente menor quando comparada ao quarto dia após alta da unidade de tratamento intensivo (p< 0,01). O tempo de permanência na unidade, assim como o tempo de permanência hospitalar não impactou na evolução das variáveis de função pulmonar. Conclusão: a função pulmonar é potencialmente reduzida no período inicial após a cirurgia cardíaca, com evolução gradual, e de recuperação lenta, no curso da recuperação cirúrgica. A manutenção desses valores reduzidos a níveis não críticos por um período prolongado no pós-operatório parece não afetar o desempenho dos pacientes, no que tange a capacidade de respirar profundamente e na efetividade de tosse.

Introduction: pulmonary dysfunction in the postoperative period of cardiac surgery continues to be one of the most important causes of morbidity, and the involvement of pulmonary function in this circumstance is frequent and contributes significantly to an increase in the length of hospital stay. Objective: the objective of this study was to evaluate the pulmonary function behavior in hospitalized adult patients submitted to cardiac surgery by median sternotomy at the time of discharge from the intensive care unit, compared to the fourth day after discharge from this unit. Metodology: the study was performed in a postoperative unit of cardiovascular surgery, after approval of the Research Ethics Committee. The Informed Consent Form was obtained in all cases. Patients older than 18 years who underwent elective cardiac surgery were included. Pulmonary function was performed on discharge from the intensive care unit and then repeated on the fourth day. Pulmonary function was measured by forced vital capacity, peak expiratory flow, besides variables of physical examination, such as respiratory rate and pulmonary auscultation. Results: a number of 94 patients underwent elective cardiac surgery via median sternotomy. Mean (standard deviation) of age was 50.64 (16.53) years, with a predominance of males (52.1%). Median (Q1-Q3) of the time spent in the intensive care unit was 2.00 days (2.00-3.00), while the median (Q1-Q3) of the length of hospital stay was 6.00 days (5.00-8.00). Median (Q1-Q3) of forced vital capacity and respiratory flow, obtained by spirometry in the postoperative period at discharge, was significantly lower when compared to the fourth day after discharge from the intensive care unit (p <0.01 ). The length of stay in the unit, as well as the length of hospital stay, did not affect the evolution of pulmonary function variables. Conclusion: pulmonary function is potentially reduced in the initial period after cardiac surgery, with gradual evolution, and slowness in the course of surgical recovery. Maintaining these reduced values at uncritical levels for a prolonged postoperative period does not appear to affect patients' performance with regard to their ability to breathe deeply and in cough effectiveness.

Preoperative expiratory and inspiratory muscle weakness to predict postoperative outcomes in patients undergoing elective cardiac surgery.

BACKGROUND: Few studies have evaluated preoperative respiratory muscle strength as a risk factor for postoperative morbidity and mortality. The objective of this study was to evaluate the association of preoperative inspiratory muscle weakness (IMW) and preoperative expiratory muscle weakness (EMW) with duration of mechanical ventilation, length of stay in the intensive care unit (ICU), incidence of postoperative pulmonary complications (PPCs), and mortality in patients undergoing elective cardiac surgery. MATERIALS AND METHODS: This was a prospective observational study. Patients admitted for elective cardiac surgery were recruited. Maximal inspiratory and expiratory pressure were measured before surgery. A multivariate regression model was used to adjust for possible confounding variables and test the association of IMW and EMW with the duration of mechanical ventilation, length of stay in the ICU, PPCs, and hospital mortality. RESULTS: Two hundred and fifty-five patients were included in this study. The presence of IMW was associated with an increase in the duration of mechanical ventilation (P = .012). The presence of EMW was associated with a reduction in the incidence of PPCs (P = .005). IMW had no significant association with length of stay in the ICU, PPCs, or hospital mortality. EMW had no significant association with the duration of mechanical ventilation, length of stay in the ICU, or hospital mortality. CONCLUSIONS: In patients undergoing elective cardiac surgery, preoperative IMW is associated with the duration of mechanical ventilation while preoperative EMW is associated with a decrease in PPCs.

International multicenter observational study on assessment of ventilatory management during general anaesthesia for robotic surgery and its effects on postoperative pulmonary complication (AVATaR): study protocol and statistical analysis plan.

INTRODUCTION: Robotic-assisted surgery (RAS) has emerged as an alternative minimally invasive surgical option. Despite its growing applicability, the frequent need for pneumoperitoneum and Trendelenburg position could significantly affect respiratory mechanics during RAS. AVATaR is an international multicenter observational study aiming to assess the incidence of postoperative pulmonary complications (PPC), to characterise current practices of mechanical ventilation (MV) and to evaluate a possible association between ventilatory parameters and PPC in patients undergoing RAS. METHODS AND ANALYSIS: AVATaR is an observational study of surgical patients undergoing MV for general anaesthesia for RAS. The primary outcome is the incidence of PPC during the first five postoperative days. Secondary outcomes include practice of MV, effect of surgical positioning on MV, effect of MV on clinical outcome and intraoperative complications. ETHICS AND DISSEMINATION: This study was approved by the Institutional Review Board of the Hospital Israelita Albert Einstein. The study results will be published in peer-reviewed journals and disseminated at international conferences. TRIAL REGISTRATION NUMBER: NCT02989415; Pre-results.

Pulmonary complications after non-cardiac surgeries: temporal patterns and risk factors.

BACKGROUND: Postoperative complications are the primary determinants of survival following major surgery. We aimed to characterize the early perioperative risk factors for postoperative pulmonary complications (POPCs) in patients undergoing major non-cardiac surgeries. METHODS: This study utilized a multicenter prospective observational cohort design. Adult patients undergoing non-cardiac surgeries and admitted to 21 Brazilian ICUs were screened for inclusion in the study. POPCs were defined as the presence of acute pulmonary oedema, nosocomial pneumonia, and extubation failure in the postoperative period. RESULTS: Of the 581 patients enrolled, 110 (19%) had at least one POPC, of whom 5% had acute pulmonary oedema, 10% extubation failure while 10% had pneumonia. Most cases of pulmonary oedema occurred in the first week after surgery, while pneumonia was more frequently a later occurrence. The mortality rate was significantly higher in the group with POPCs compared to the group of patients without POPCs (62% vs. 11%, RR: 5.1, 95% CI: 4.23-7.69; P < 0.001). A low functional capacity (RR: 4.6, 95% CI: 2.1-10.0), major surgery (RR: 3.6, 95% CI: 1.2-10.7), preoperative hemodynamic instability (RR: 3.4, 95% CI: 1.1-10.6), alcoholism (RR: 3.3, 95% CI: 1.0-10.7), unplanned surgery (RR: 2.3, 95% CI: 1.0-5.2), the SOFA score (RR: 1.1, 95% CI: 1.0-1.2), and increased central venous pressure (RR: 1.1, 95% CI: 1.0-1.1) were independent predictors of POPCs. CONCLUSIONS: Pulmonary complications are common in intensive care units after major non-cardiac surgeries. Awareness of the risk factors for POPCs may help multidisciplinary teams develop strategies to prevent these complications.

Performance in the 6-minute walk test and postoperative pulmonary complications in pulmonary surgery: an observational study

OBJECTIVES: To assess functional capacity in the preoperative phase of pulmonary surgery by comparing predicted and obtained values for the six-minute walk test (6MWT) in patients with and without postoperative pulmonary complication (PPC) METHOD: Twenty-one patients in the preoperative phase of open thoracotomy were evaluated using the 6MWT, followed by monitoring of the postoperative evolution of each participant who underwent the routine treatment. Participants were then divided into two groups: the group with PPC and the group without PPC. The results were also compared with the predicted values using reference equations for the 6MWT RESULTS: Over half (57.14%) of patients developed PPC. The 6MWT was associated with the odds for PPC (odds ratio=22, p=0.01); the group without PPC in the postoperative period walked 422.38 (SD=72.18) meters during the 6MWT, while the group with PPC walked an average of 340.89 (SD=100.93) meters (p=0.02). The distance traveled by the group without PPC was 80% of the predicted value, whereas the group with PPC averaged less than 70% (p=0.03), with more appropriate predicted values for the reference equations CONCLUSIONS: The 6MWT is an easy, safe, and feasible test for routine preoperative evaluation in pulmonary surgery and may indicate patients with a higher chance of developing PPC.

Complicaciones pulmonares posoperatorias en pacientes ingresados en Unidad de Cuidados Intensivos / Posoperative pulmonary complications in patients admitted to the intensive care service

Introducción: la cirugía y la anestesia provocan el aumento del riesgo de sufrir complicaciones pulmonares. Objetivo: evaluar el comportamiento delas complicaciones respiratorias en pacientes quirúrgicos. Métodos: estudio de cohorte, prospectivo, longitudinal, con 526 pacientes quirúrgicos que ingresaron en la Unidad de Cuidados Intensivos del Hospital Universitario Joaquín Albarrán Domínguez desde el 1ro. de enero de 2012 hasta el 31 de diciembre de 2014. La muestra quedó conformada por 127 pacientes operados que presentaron complicaciones de índole respiratoria. Resultados: 24,1 por ciento de los pacientes quirúrgicos presentaron complicaciones respiratorias. El mayor porcentaje de fallecidos estuvo dentro del grupo de 71 a 80 años (9,4 por ciento), seguidos por los de 61 a 70 (6,2 por ciento). Esto resultados fueron significativos (p≤ 0,05). El 18,8 por ciento de los fallecidos fue en operaciones de urgencia, y de ellos, con tiempo quirúrgico mayor de 2 horas 12,5 por ciento, con asociación significativa entre el tiempo quirúrgico y la mortalidad (p≤ 0,05). No hubo asociación entre el número de reintervenciones y la mortalidad (p= 3,721). El 35,4 por ciento, presentó bronconeumonía bacteriana nosocomial, seguido por la insuficiencia respiratoria aguda con 22,8 por ciento. El 50 por ciento falleció por fallo múltiple de órganos, seguido de 13,8 por ciento porinfarto pulmonar. Conclusiones: las principales complicaciones respiratorias en pacientes quirúrgicos fueron las infecciones de origen nosocomial, favorecidas por la edad avanzada, operaciones de urgencia y tiempo quirúrgico mayor de 2 horas con elevada frecuencia y letalidad. La bronconeumonía bacteriana nosocomial es la principal causa de muerte asociada al fallo multiorgánico(AU)

Introduction: surgery and anesthesia cause the increase of risk of suffering pulmonary complications. Objective: to evaluate the behavior of respiratory complications in surgical patients. Methods: prospective, longitudinal and cohort study of 526 surgical patients who were admitted to the intensive care service of Joaquin Albarrán Dominguez university hospital from January 1st 2012 to December 31st 2014. The sample was made up of 127 surgical patients who presented with respiratory complications. Results: in this group, 24.1 percent of patients suffered respiratory complications. The highest percentage of deaths occurred in the 71-80 year age group (9.4 percent) followed by the 61-70 y group (6.2 percent). These results were significant (p≤0.05). Of the number of deaths, 18.8 percent occurred in emergency surgeries, with over 2-hour surgical time in 12.5 percent of cases. There was significant association between the surgical time and mortality (p≤0.05). The number of reoperations and mortality were not related (p=3.721). In the sample, 35.4 percent had nosocomial bacterial bronchopneumonia followed by acute respiratory failure (22.8 percent). The main cause of death in 50 percent of patients was multiple organ failure followed by pulmonary infarction in 13.8 percent. Conclusions: the main respiratory complications in surgical patients were nosocomial infections prompted by the older age, emergency operations and surgical times over 2 hours with high frequency and lethality. Nosocomial bacterial bronchopneumonia is the main cause of death associated to multiple organ failure(AU)

Papel da estratégia protetora de ventilação mecânica na lesão pulmonar induzida pelo ventilador mecânico em pacientes sem síndrome do desconforto respiratório agudo: uma meta-análise de dados individuais de pacientes / Protective ventilation and ventilator-induced lung injury in patients without acute respiratory distress syndrome: an individual patient data meta-analysis

INTRODUÇÃO: Estudos recentes sugerem que o uso da estratégia protetora de ventilação mecânica no intra-operatório pode reduzir a incidência de complicações pulmonares pós-operatórias (CPP). O objetivo desta meta-análise de dados individuais de pacientes é avaliar o efeito independente do volume corrente e da pressão positiva ao final da expiração (PEEP) na ocorrência de CPP. MÉTODOS: Foram incluídos ensaios clínicos randomizados que compararam a estratégia protetora de ventilação mecânica com a estratégia convencional em pacientes submetidos à anestesia para cirurgia. O desfecho primário foi o desenvolvimento de CPP. Diversos fatores prognósticos pré-definidos foram testados por meio da regressão logística multivariada. RESULTADOS: Quatorze ensaios clínicos randomizados foram incluídos (2.095 pacientes). Houve 97 casos de CPP em 1.102 pacientes (8,8%) ventilados com a estratégia protetora e 148 casos em 993 pacientes (14,9%) ventilados com a estratégia convencional (risco ajustado relativo [RR], 0,64; 95% intervalo de confiança [IC], 0,46 - 0,88, p < 0,01). Houve 85 casos de CPP em 957 pacientes (8,9%) ventilados com volume corrente baixo e PEEP alto e 63 casos em 525 pacientes (12%) ventilados com volume corrente baixo e PEEP baixo (RR, 0,93; 95% CI, 0,64 - 1,37, p = 0,72). Foi encontrada uma relação de dose-resposta entre o aparecimento de CPP e o volume corrente (R2 por meio termo quadrático = 0,390), mas não entre o aparecimento de CPP e o nível de PEEP (R2 = 0,082). A manutenção de uma driving pressure inferior a 13 cmH2O durante a cirurgia está associado a menor incidência de síndrome do desconforto respiratório agudo (SDRA). CONCLUSÃO: Esta meta-análise de dados individuais suporta os efeitos benéficos da estratégia protetora de ventilação mecânica em pacientes submetidos à cirurgia e sugere que altos níveis de PEEP, na vigência de volume corrente baixo, não acrescentam benefícios...

INTRODUCTION: Recent studies show that intraoperative mechanical ventilation using low tidal volumes can prevent postoperative pulmonary complications (PPC). The aim of this individual patient data meta-analysis is to evaluate the individual associations between tidal volume size and PEEP level, and occurrence of PPC. METHODS: Randomized controlled trials comparing protective ventilation and conventional ventilation in patients undergoing general surgery were screened for inclusion. The primary outcome was development of PPC. Predefined prognostic factors were tested using multivariate logistic regression. RESULTS: Fourteen randomized controlled trials were included (2095 patients). There were 97 cases of PPC in 1102 patients (8.8%) assigned to protective ventilation and 148 cases in 993 patients (14.9%) assigned to conventional ventilation (adjusted relative risk [RR], 0.64; 95% confidence interval [CI], 0.46 - 0.88; p < 0.01). There were 85 cases of PPC in 957 patients (8.9%) assigned to ventilation with low tidal volume and high PEEP levels and 63 cases in 525 patients (12%) assigned to ventilation with low tidal volume and low PEEP levels (RR, 0.93; 95% CI, 0.64 - 1.37; p = 0.72). A dose-response relationship was found between the appearance of PPC and tidal volume size (R2 for mean quadratic term = 0.390), but not between the appearance of PPC and PEEP level (R2 = 0.082). The maintenance of a driving pressure below 13 cmH2O during surgery is associated with reduced incidence of acute respiratory distress syndrome. CONCLUSION: This individual data meta-analysis supports the beneficial effects of protective ventilation settings in patients undergoing surgery and suggests no benefit from high PEEP levels with use of low tidal volume...

Frecuencia de complicaciones respiratorias en cirugía electiva general. Experiencia en un hospital universitario / Frequency of respiratory complications in elective general surgery. Experience of a university hospital

Las complicaciones respiratorias post quirúrgicas (CRPq) son causa importante de morbimortalidad asociada a la cirugía general. Objetivos: 1-Estimar la frecuencia de CRPq en cirugía electiva general. 2- Identificar factores asociados con el riesgo de CRPq, simples y accesibles desde la perspectiva del neumonólogo. Diseño: Estudio prospectivo, descriptivo y transversal. Pacientes y métodos: De una muestra de 233 evaluaciones prequirúrgicas respiratorias (EPR) consecutivas, en 156 pacientes operados en el Hospital de Clínicas ôJosé de San Martínö, la edad, localización de la cirugía, tabaquismo, un score de riesgo respiratorio, espirometría, clasificación de la Sociedad Americana de Anestesiólogos (ASA), los hallazgos clínicos, la prescripción de medicamentos y la preexistencia de enfermedad respiratoria (EPOC y SAOS) fueron evaluados para predecir riesgo de CRPq, con prueba de X² para los respectivos intervalos de confianza (CI). El análisis de regresión logística múltiple buscó identificar predictores independientes de riesgo. Resultados: Se presentaron 26 complicaciones respiratorias en 19 pacientes (12%). El examen respiratorio anormal, el patrón obstructivo, la clasificación de ASA, el score de riesgo respiratorio y la cirugía torácica o abdominal superior se asociaron a CRPq en el análisis individual. La localización de la cirugía, la obstrucción severa de la vía aérea y el score de riesgo respiratorio resultaron predictores independientes de complicaciones. Conclusiones: Se hallaron CRPq en 12% de las cirugías estudiadas. Los factores hallados como predictores independientes coinciden en general con la revisión bibliográfica realizada. En este trabajo, el patrón ventilatorio obstructivo severo resultó un predictor significativo de CRPq. (AU)

Postoperative Respiratory Complications (PRCs) are important causes of morbidity and mortality associated to general surgery. Objectives: 1-To estimate the frequency of PRCs in General Elective Surgery. 2- To identify risk factors associated to PRCs from the pulmonologistÆs perspective. Design: Prospective, descriptive and transversal study. Methods: In a sample of 233 consecutive preoperative respiratory evaluations, 156 patients were studied for PPCs risk before undergoing elective surgery at the Buenos Aires University Hospital. Age, surgery site, smoking habit, respiratory risk score, spirometry, American Society of Anesthesiology (ASA) classification, clinical respiratory findings, prescribed medication, and respiratory concomitant disease (COPD, Obstructive Sleep Apnea) were assessed to predict the risk of PRCs, through Chi Square analysis (X²) for the corresponding confidence intervals. Variables significantly associated to PPCs were evaluated with multivariate logistic regression analysis. Results: In 19 patients, 26 PPCs were observed (12% of surgical interventions). Abnormal clinical findings, obstructive and severe obstructive pattern in spirometry, ASA classification, respiratory risk score, thoracic and upper abdominal surgery were associated to PPCs in the monovariate analysis. Surgery site, severe airway obstruction, and respiratory risk score were significantly associated to PPCs, in the multivariate analysis. Conclusions: PPCs was found in 12 % of performed surgeries. Respiratory risk factors were similar to those reported in the literature. Additionally, the analysis indicated that severe airway obstruction was a significant predictor of PRCs in this study. (AU)

Frecuencia de complicaciones respiratorias en cirugía electiva general. Experiencia en un hospital universitario / Frequency of respiratory complications in elective general surgery. Experience of a university hospital

Las complicaciones respiratorias post quirúrgicas (CRPq) son causa importante de morbimortalidad asociada a la cirugía general. Objetivos: 1-Estimar la frecuencia de CRPq en cirugía electiva general. 2- Identificar factores asociados con el riesgo de CRPq, simples y accesibles desde la perspectiva del neumonólogo. Diseño: Estudio prospectivo, descriptivo y transversal. Pacientes y métodos: De una muestra de 233 evaluaciones prequirúrgicas respiratorias (EPR) consecutivas, en 156 pacientes operados en el Hospital de Clínicas “José de San Martín”, la edad, localización de la cirugía, tabaquismo, un score de riesgo respiratorio, espirometría, clasificación de la Sociedad Americana de Anestesiólogos (ASA), los hallazgos clínicos, la prescripción de medicamentos y la preexistencia de enfermedad respiratoria (EPOC y SAOS) fueron evaluados para predecir riesgo de CRPq, con prueba de X² para los respectivos intervalos de confianza (CI). El análisis de regresión logística múltiple buscó identificar predictores independientes de riesgo. Resultados: Se presentaron 26 complicaciones respiratorias en 19 pacientes (12%). El examen respiratorio anormal, el patrón obstructivo, la clasificación de ASA, el score de riesgo respiratorio y la cirugía torácica o abdominal superior se asociaron a CRPq en el análisis individual. La localización de la cirugía, la obstrucción severa de la vía aérea y el score de riesgo respiratorio resultaron predictores independientes de complicaciones. Conclusiones: Se hallaron CRPq en 12% de las cirugías estudiadas. Los factores hallados como predictores independientes coinciden en general con la revisión bibliográfica realizada. En este trabajo, el patrón ventilatorio obstructivo severo resultó un predictor significativo de CRPq.

Postoperative Respiratory Complications (PRCs) are important causes of morbidity and mortality associated to general surgery. Objectives: 1-To estimate the frequency of PRCs in General Elective Surgery. 2- To identify risk factors associated to PRCs from the pulmonologist’s perspective. Design: Prospective, descriptive and transversal study. Methods: In a sample of 233 consecutive preoperative respiratory evaluations, 156 patients were studied for PPCs risk before undergoing elective surgery at the Buenos Aires University Hospital. Age, surgery site, smoking habit, respiratory risk score, spirometry, American Society of Anesthesiology (ASA) classification, clinical respiratory findings, prescribed medication, and respiratory concomitant disease (COPD, Obstructive Sleep Apnea) were assessed to predict the risk of PRCs, through Chi Square analysis (X²) for the corresponding confidence intervals. Variables significantly associated to PPCs were evaluated with multivariate logistic regression analysis. Results: In 19 patients, 26 PPCs were observed (12% of surgical interventions). Abnormal clinical findings, obstructive and severe obstructive pattern in spirometry, ASA classification, respiratory risk score, thoracic and upper abdominal surgery were associated to PPCs in the monovariate analysis. Surgery site, severe airway obstruction, and respiratory risk score were significantly associated to PPCs, in the multivariate analysis. Conclusions: PPCs was found in 12 % of performed surgeries. Respiratory risk factors were similar to those reported in the literature. Additionally, the analysis indicated that severe airway obstruction was a significant predictor of PRCs in this study.

Características de las complicaciones pulmonares asociadas a la ventilación mecánica en recién nacidos / Characteristics of pulmonary complications associated with mechanical ventilation in newborns

Objetivo: Analizar las complicaciones pulmonares de los recién nacidos que requirieron asistencia respiratoria mecánica (ARM) durante su internación en la Unidad de Cuidados Intensivos Neonatales (UCIN) en el Instituto de Previsión Social, Hospital Central (IPS-HC). Material y Método: Estudio descriptivo, retrospectivo, transversal, en la UCIN del HC- IPS, de Julio 2008 a Junio de 2009, con datos obtenidos de los Registros estadísticos de nacimientos de la Sala de RN y las Historias Clínicas de la Unidad de Terapia Intensiva Neonatal. Resultados: Ingresaron 156 prematuros, que representa el 3.46% del total de RN y 37 RN de termino que representa 0.82%. De estas cifras 135(86,5%) RN de pre termino y 33(89.1%) RN de término requirieron ARM. De los 193 RN ingresados en UCIN que corresponde al 4,2% del total de RN, 168(87%) pacientes recibieron procedimiento invasivo de ARM. De estos 73(43%) presentaron complicaciones pulmonares; el 22% correspondían a edades entre 25-28 semanas, 22% eran de 28,5-31 semanas, 21% fueron de 31,5-34 semanas, 21% de 34,5-36.5 semanas, 14% de 37,5-40 semanas. El sexo masculino predomino en un 67%. Se encontró que el 50% fueron RN con peso entre 1000-2000 gr, que junto con los de 2001 a 3000 gr fueron los que con mayor frecuencia presentaron complicaciones respiratorias, de ellos 76,3% fueron RN de pre término y 5,7% de termino en ambos grupos. Las complicaciones pulmonares fueron: neumotórax en un 26/73, atelectasia 26/73, neumonía asociada a respirador 33/73, displasia broncopulmonar 7/73, enfisema intersticial 7/73, hemorragia pulmonar 5/73, derrame pleural 3/73. La estancia hospitalaria fue en promedio de 11-20 días. Del total de RN que requirieron ventilación mecánica y presentaron complicaciones pulmonares se encontró que 75,3% de los RN egresaron vivos y 24,6% egresaron fallecidos. Las causales de muerte se presentaron en el siguiente orden: neumotórax, neumonía asociada a respirador y atelectasia...

Introduction: Mechanical ventilation is an invasive procedure with known risks that must be anticipated and when possible identified early in order to implement immediate treatment. Respiratory complications represent one of those risks. Objective: To analyze pulmonary complications in newborns (NB) that required mechanical ventilation (MAV) during hospitalization in the Neonatal Intensive Care Unit (NICU) at the central hospital of the Instituto de Previsión Social (IPS-HC).Method: A descriptive, retrospective, cross sectional study in the NICU of the HC-IPS from July 2008 to June 2009, with data obtained from delivery room statistical records and those of the Neonatal Intensive Care Unit. Results: 4500 births were recorded. Of the NB, 156 (3.46%) premature and 37 (0.82%) at-term infants were admitted. Of those admitted, 135 (86.5%) pre-term and 33 (89.1%) at-term NB required MAV. Of the 193 NB admitted to the NICU (4.2% of all newborns), 168 (87%) received invasive MAV procedures, with 73 (43%) of those showing pulmonary complications; 22% were aged 25 to 28 weeks, 22% were 28.5 to 31 weeks, 21% were 31.5 to 34 weeks, 21% were 34.5-36.5 weeks, and 14% were from 37.5 to 40 weeks of age. Males predominated, making up 67%.It was found that 50% of NB weighed between 1000g and 2000g, and these, together with those of 2001g-3000g, were those most commonly presenting respiratory complications. Of those, 76.3% were pre-term newborns and 5.7% at term in both groups. Pulmonary complications found were pneumothorax (26/73), atelectasis (26/73), ventilator-associated pneumonia (33/73), bronchopulmonary dysplasia (7/73) interstitial emphysema (7/73), pulmonary hemorrhage (5/73), and pleural effusion, (3/73).Average hospital stay was 11-20 days. Of the NB who required mechanical ventilation and in whom pulmonary complications were found, 75.3% were discharged alive and 24.6% died...

Pneumopatias em pacientes com imunodeficiência comum variável / Pulmonary diseases in common variable immunodeficiency

A imunodeficiência comum variável (ICV) é uma imunodeficiência primária predominantemente humoral que se caracteriza pela hipogamaglobulinemia, infecções piogênicas recorrentes e outros distúrbios imunológicos, como autoimunidade e câncer. As pneumopatias são freqüentes e estão associadas a altas taxas de morbidade e mortalidade. Cerca de 80% dos pacientes com ICV apresentam pelo menos um episódio de pneumonia prévio ao diagnóstico e cerca de 30% evoluem com doença pulmonar crônica, particularmente a bronquiectasia. A avaliação pulmonar através de espirometria e exames de imagem, predominantemente a tomografia computadorizada de tórax de alta resolução, deve ser realizada precocemente nestes pacientes. Este artigo traz uma revisão das principais pneumopatias encontradas nos pacientes com ICV.

Common variable immunodeficiency (CVID) is a primary immunodeficiency, a predominantly antibody deficiency, characterized by hypogammaglobulinemia, recurrent bacterial infections, and others immunologic disorders as autoimmunity and malignity. Pulmonary complications are common and are related with high morbidity and mortality. About 80% of CVID patients have experienced at least one episode of pneumonia before diagnosis, and about 30% have chronic lung disease, particularly the development of bronchiectasis. Screening examinations, such as pulmonary function testing and high-resolution computed tomography of the chest, must be used to evaluate pulmonary status. This is a review of the major pulmonary complications in CVID patients.