Intraoperative Factors and the Risk of Respiratory Complications After Pneumonectomy

doi:10.1016/j.athoracsur.2011.06.022

The Annals of Thoracic Surgery

Volume 92, Issue 4, October 2011, Pages 1188-1194

https://doi.org/10.1016/j.athoracsur.2011.06.022 Get rights and content

Background

The potential effect of intraoperative factors on respiratory complications after pneumonectomy is still unclear.

Methods

We conducted a retrospective cohort study; charts of 129 patients who underwent elective pneumonectomy at the University of Virginia were reviewed. Logistic regression was used to estimate the effect of anesthetic factors on the odds of at least one respiratory complication. Linear regression models were fit to assess the impact of these outcomes on length of stay (LOS).

Results

The incidence of respiratory complications in this cohort was 21%. In univariate analysis total nonblood fluids (p = 0.001), and the blood products packed red blood cells (p < 0.001), plasma (p < 0.001), and platelets (p = 0.044) were significantly associated with respiratory complications. In a multivariable logistic regression analysis, single unit transfusion of any blood product (packed red blood cells, plasma, or platelets) was identified as a major risk factor for respiratory complications after controlling for covariates (odds ratio = 1.47, 95% confidence interval 1.06 to 2.05). Respiratory failure and complications were closely related to LOS, increasing the LOS by a factor of 4.7 (95% confidence interval 3.51 to 6.18) and 3.5 (95% confidence interval 2.69 to 4.41), respectively.

Conclusions

Blood product transfusion affects respiratory function and is an independent risk factor for respiratory complications after pneumonectomy.

Section snippets

Patients and Methods

This retrospective cohort study was approved by the Institutional Review Board of the University of Virginia. The requirement for written informed consent was waived by the Institutional Review Board.

Charts were reviewed for all 129 patients meeting the inclusion criteria, who underwent pneumonectomy at the University of Virginia Health System from January 1997 through May 2008. Inclusion criteria were age greater than or equal to 18 years and elective pneumonectomy. Data of interest were

Results

Twenty-one percent (27 of 129) of patients undergoing pneumonectomy experienced at least one respiratory complication postoperatively (Table 1). The incidence of respiratory failure in this cohort was 13% (17 of 129); the combined incidence of ALI and ARDS was 7% (9 of 129). Cardiac etiologies for respiratory failure accounted for three cases; two cases of cardiac arrest of unknown etiology and one case of atrial fibrillation associated with a failure to wean from the ventilator. In-hospital

Comment

The role of parenteral fluid administration in adverse outcomes after pulmonary resection surgery has been implied by some [1, 3, 6, 7, 8] but not all [9] retrospective and observational studies of pulmonary resection surgery. Comparisons among studies have been difficult because of differing endpoints, surgery type, periods of inclusion, and the degree to which potential confounding variables have been controlled. In a study of pneumonectomy patients, Møller and colleagues [8] demonstrated an

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Cited by (25)

Fluid Management During Lung Resection
2021, Cohen's Comprehensive Thoracic Anesthesia
Managing fluid administration during lung resection by the anesthesiologist is very similar to a tightrope walker, trying to balance the risk of acute lung injury and of acute kidney injury. There is a narrow interval between fluid overload and hypovolemia, two conditions that may impair lung and renal function, respectively. This challenge is crucial to win because it has a profound impact on perioperative morbidity and mortality. The aim of this chapter is to discuss how much and which fluid to administer, trying to guide fluid management.
Intraoperative Lung Injury During One-Lung Ventilation: Causes and Prevention
2021, Cohen's Comprehensive Thoracic Anesthesia
Lung injury may occur during thoracic surgery and can, in predisposed patients undergoing prolonged and major thoracic surgery, induce intraoperative lung injury and lead to overt postoperative pulmonary complications (PPCs). PPC is a serious problem for thoracic anesthesia because it increases morbidity and mortality. Patient factors such as age, pulmonary comorbidity and lung function, preoperative care, extent of surgery, experience of the surgical and anesthesiologic teams, and quality of postoperative care may all play a role in the occurrence and severity of PPCs. Among intraoperative factors, ventilation strategy does have the potential of causing harm although clinical data are neither consistent nor conclusive on a specific strategy to prevent them. Consensus opinion at this stage suggests a protective open lung strategy with low tidal volumes, appropriate levels of positive end-expiratory pressure, and recruitment maneuvers to avoid or treat atelectasis. Driving pressure is a valuable tool to help diagnose problems, and help adapt ventilation to lung compliance. It is improbable that we will find a one-size-fits-all solution. Rather, we need to adapt the components of protective ventilation to the individual patients’ lung function.
Delving into the details of postpneumonectomy prognosis
2018, Journal of Thoracic and Cardiovascular Surgery
Extravascular Lung Water and Tissue Perfusion Biomarkers after Lung Resection Surgery under a Normovolemic Fluid Protocol
2015, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
In each case, AKI was short-lived, with full recovery of serum creatinine seen within 24 hours. Multiple risk factors have been associated with the development of ARDS after lung resection surgery, including major resections like pneumonectomy, large tidal volumes and high peak airway pressures during the one-lung ventilation period, and excessive perioperative fluid intake.4–6,16 The findings, that normovolemia does not result in increases in EVLWI, were consistent with the current understanding of ARDS after lung resection as primarily a disorder of capillary permeability rather than that of elevated hydrostatic pressure.
The optimal fluid management for lung resection surgery remains undefined. Concern related to postoperative pulmonary edema has led to the practice of fluid restriction. This practice risks hypovolemia and tissue hypoperfusion. The authors examined the extravascular lung water accumulation and tissue perfusion biomarkers under protective lung ventilation and normovolemia.
A prospective observational study.
A single-center study.
Forty patients aged 18 years or older undergoing lung resection surgery.
Patients were maintained on protective lung ventilation and a normovolemic fluid protocol. Hemodynamic variables, including global end-diastolic volume index, cardiac index, and extravascular lung water index, together with tissue perfusion biomarkers, including serum creatinine, lactic acid, central venous oxygen saturation, and brain natriuretic peptide, were measured perioperatively. Parametric or nonparametric techniques were used to assess changes of these parameters over 72 hours postoperatively.
The global end-diastolic volume index was maintained; cardiac index was increased, without a significant change in extravascular lung water index. Acute kidney injury based on AKIN criteria occurred in 3 patients (7.5%), and in 1 patient (2.5 %) based on RIFLE criteria. Lactic acid and central venous oxygen saturation remained within normal limits, and brain natriuretic peptide showed an insignificant increase.
In patients undergoing lesser lung resections, a fluid protocol targeting normovolemia together with protective lung ventilation did not increase extravascular lung water. These results suggest further study to identify the optimal fluid regimen to mitigate pulmonic and extrapulmonic complications after lung resection.
Imaging the Post-Thoracotomy Patient. Anatomic Changes and Postoperative Complications.
2014, Radiologic Clinics of North America
Citation Excerpt :
Changes in fluid dynamics are compounded by perioperative fluid administration that decreases serum osmotic pressure, transfusion of blood products that not only adds fluid volume but may also contribute to changes in capillary permeability, and cardiac arrhythmia.24 Multivariate analyses among pneumonectomy patients found that liberal fluid administration and transfusion of even a single unit of any blood product significantly increased the risk for cardiovascular or respiratory complications.19,25 In cases of mild pulmonary edema, subtle radiographic findings suggest the diagnosis, with fine peripheral Kerley lines, peribronchial cuffing, and increasingly indistinct central pulmonary vasculature with perihilar haziness.
Invited commentary
2011, Annals of Thoracic Surgery

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^*: Drs. Blank and Hucklenbruch contributed equally to this work.

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Original articleGeneral thoracicIntraoperative Factors and the Risk of Respiratory Complications After Pneumonectomy

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Comment

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

J Cardiothorac Vasc Anesth

J Clin Anesth

J Thorac Cardiovasc Surg

Ann Thorac Surg

Chest

Ann Thorac Surg

Recent results of postoperative mortality for surgical resections in lung cancer

Ann Thorac Surg

Predicting pulmonary complications after pneumonectomy for lung cancer

Eur J Cardiothorac Surg

The American-European Consensus Conference on ARDSDefinitions, mechanisms, relevant outcomes, and clinical trial coordination

Am J Respir Crit Care Med

Original article
General thoracic
Intraoperative Factors and the Risk of Respiratory Complications After Pneumonectomy