Intraoperative protective mechanical ventilation and risk of postoperative respiratory complications: hospital based registry study

Karim Ladha, Marcos F Vidal Melo, Duncan J McLean, Jonathan P Wanderer, Stephanie D Grabitz, Tobias Kurth, Matthias Eikermann, Karim Ladha, Marcos F Vidal Melo, Duncan J McLean, Jonathan P Wanderer, Stephanie D Grabitz, Tobias Kurth, Matthias Eikermann

Abstract

Objective: To evaluate the effects of intraoperative protective ventilation on major postoperative respiratory complications and to define safe intraoperative mechanical ventilator settings that do not translate into an increased risk of postoperative respiratory complications.

Design: Hospital based registry study.

Setting: Academic tertiary care hospital and two affiliated community hospitals in Massachusetts, United States.

Participants: 69,265 consecutively enrolled patients over the age of 18 who underwent a non-cardiac surgical procedure between January 2007 and August 2014 and required general anesthesia with endotracheal intubation.

Interventions: Protective ventilation, defined as a median positive end expiratory pressure (PEEP) of 5 cmH2O or more, a median tidal volume of less than 10 mL/kg of predicted body weight, and a median plateau pressure of less than 30 cmH2O.

Main outcome measure: Composite outcome of major respiratory complications, including pulmonary edema, respiratory failure, pneumonia, and re-intubation.

Results: Of the 69,265 enrolled patients 34,800 (50.2%) received protective ventilation and 34,465 (49.8%) received non-protective ventilation intraoperatively. Protective ventilation was associated with a decreased risk of postoperative respiratory complications in multivariable regression (adjusted odds ratio 0.90, 95% confidence interval 0.82 to 0.98, P=0.013). The results were similar in the propensity score matched cohort (odds ratio 0.89, 95% confidence interval 0.83 to 0.97, P=0.004). A PEEP of 5 cmH2O and median plateau pressures of 16 cmH2O or less were associated with the lowest risk of postoperative respiratory complications.

Conclusions: Intraoperative protective ventilation was associated with a decreased risk of postoperative respiratory complications. A PEEP of 5 cmH2O and a plateau pressure of 16 cmH2O or less were identified as protective mechanical ventilator settings. These findings suggest that protective thresholds differ for intraoperative ventilation in patients with normal lungs compared with those used for patients with acute lung injury.

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; MFVM has within the last two years received funding from the US National Institutes of Health (grant 1R01HL121228-01) and investigator initiated funding from Merck. TK has within the past two years received investigator initiated research funding from the French National Research Agency and the US National Institutes of Health. Further, he has received honorariums from the BMJ and Cephalalgia for editorial services. JPW is supported by a mentored research training grant in health services research from the Foundation for Anesthesia Education and Research and the Anesthesia Quality Institute. ME has within the past two years received investigator initiated research funding from Masimo, Merck, the ResMed Foundation, and the Buzen’s Foundation. Further, he has received honorariums from Anesthesiology for editorial services. There are no other relationships or activities that could appear to have influenced the submitted work.

© Ladha et al 2015.

Figures

https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4794079/bin/ladk020184.f1_default.jpg
Fig 1 Flow of patients through study
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4794079/bin/ladk020184.f2_default.jpg
Fig 2 Distributions of median positive end expiratory pressure (PEEP), tidal volume, and plateau pressure in full unmatched cohort
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4794079/bin/ladk020184.f3_default.jpg
Fig 3 Multivariable logistic regression analysis examining the impact of plateau pressure, positive end expiratory pressure (PEEP), and tidal volume on postoperative pulmonary complications in entire unmatched cohort. Each graph represents a separate regression model adjusting for body mass index, age, sex, American Society of Anesthesiologists classification, score for prediction of postoperative respiratory complications, Charlson comorbidity index, work relative value units, pre-existing chronic pulmonary disease, surgery type, duration of ventilation, epidural placement, units of packed red blood cells, fresh frozen plasma and platelets transfused, ambulatory surgery, urgent/emergent surgery, estimated blood loss, and total fluids administered

References

    1. Nunn JF, Payne JP. Hypoxaemia after general anaesthesia. Lancet 1962;2:631-2.
    1. Bendixen HH, Hedley-Whyte J, Laver MB. Impaired oxygenation in surgical patients during general anesthesia with controlled ventilation. A concept of atelectasis. N Engl J Med 1963;269:991-6.
    1. Amato MB, Barbas CS, Medeiros DM, Magaldi RB, Schettino GP, Lorenzi-Filho G, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med 1998;338:347-54.
    1. Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000;342:1301-8.
    1. Dimick JB, Chen SL, Taheri PA, Henderson WG, Khuri SF, Campbell DA. Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. J Am Coll Surg 2004;199:531-7.
    1. Khuri SF, Henderson WG, DePalma RG, Mosca C, Healey NA, Kumbhani DJ, et al. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg 2005;242:323-6.
    1. Johnson RG, Arozullah AM, Neumayer L, Henderson WG, Hosokawa P, Khuri SF. Multivariable predictors of postoperative respiratory failure after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg 2007;204:1188-98.
    1. Arozullah AM, Daley J, Henderson WG, Khuri SF. Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. The National Veterans Administration Surgical Quality Improvement Program. Ann Surg 2000;232:242-53.
    1. Canver CC, Chanda J. Intraoperative and postoperative risk factors for respiratory failure after coronary bypass. Ann Thorac Surg 2003;75:853-8.
    1. Smetana GW. Postoperative pulmonary complications: an update on risk assessment and reduction. Cleve Clin J Med 2009;76(Suppl 4):S60-5.
    1. Nafiu OO, Ramachandran SK, Ackwerh R, Tremper KK, Campbell DA, Stanley JC. Factors associated with and consequences of unplanned post-operative intubation in elderly vascular and general surgery patients. Eur J Anaesthesiol 2011;28:220-4.
    1. Ramachandran SK, Nafiu OO, Ghaferi A, Tremper KK, Shanks A, Kheterpal S. Independent predictors and outcomes of unanticipated early postoperative tracheal intubation after nonemergent, noncardiac surgery. Anesthesiology 2011;115:44-53.
    1. Futier E, Constantin J-M, Paugam-Burtz C, Pascal J, Eurin M, Neuschwander A, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med 2013;369:428-37.
    1. Severgnini P, Selmo G, Lanza C, Chiesa A, Frigerio A, Bacuzzi A, et al. Protective mechanical ventilation during general anesthesia for open abdominal surgery improves postoperative pulmonary function. Anesthesiology 2013;118:1307-21.
    1. Treschan TA, Kaisers W, Schaefer MS, Bastin B, Schmalz U, Wania V, et al. Ventilation with low tidal volumes during upper abdominal surgery does not improve postoperative lung function. Br J Anaesth 2012;109:263-71.
    1. Shah B, Sucher K, Hollenbeck CB. Comparison of ideal body weight equations and published height-weight tables with body mass index tables for healthy adults in the United States. Nutr Clin Pract 2006;21:312-9.
    1. Lellouche F, Dionne S, Simard S, Bussières J, Dagenais F. High tidal volumes in mechanically ventilated patients increase organ dysfunction after cardiac surgery. Anesthesiology 2012;116:1072-82.
    1. Schultz MJ, Haitsma JJ, Slutsky AS, Gajic O. What tidal volumes should be used in patients without acute lung injury? Anesthesiology 2007;106:1226-31.
    1. Quan H, Sundararajan V, Halfon P, Fong A, Burnand B, Luthi J-C, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 2005;43:1130-9.
    1. Brueckmann B, Villa-Uribe JL, Bateman BT, Grosse-Sundrup M, Hess DR, Schlett CL, et al. Development and validation of a score for prediction of postoperative respiratory complications. Anesthesiology 2013;118:1276-85.
    1. Bensley RP, Schermerhorn ML, Hurks R, Sachs T, Boyd CA, O’Malley AJ, et al. Risk of late-onset adhesions and incisional hernia repairs after surgery. J Am Coll Surg 2013;216:1159-67, 1167.e1-12.
    1. Davenport DL, Henderson WG, Khuri SF, Mentzer RM. Preoperative risk factors and surgical complexity are more predictive of costs than postoperative complications: a case study using the National Surgical Quality Improvement Program (NSQIP) database. Ann Surg 2005;242:463-8; discussion 468-71.
    1. Glance LG, Wissler R, Mukamel DB, Li Y, Diachun CAB, Salloum R, et al. Perioperative outcomes among patients with the modified metabolic syndrome who are undergoing noncardiac surgery. Anesthesiology 2010;113:859-72.
    1. Borzecki AM, Kaafarani HMA, Utter GH, Romano PS, Shin MH, Chen Q, et al. How valid is the AHRQ patient safety indicator “postoperative respiratory failure”? J Am Coll Surg 2011;212:935-45.
    1. Lawthers AG, McCarthy EP, Davis RB, Peterson LE, Palmer RH, Iezzoni LI. Identification of in-hospital complications from claims data. Is it valid? Med Care 2000;38:785-95.
    1. Utter GH, Cuny J, Sama P, Silver MR, Zrelak PA, Baron R, et al. Detection of postoperative respiratory failure: how predictive is the agency for healthcare research and quality’s patient safety indicator? J Am Coll Surg 2010;211:347-54.
    1. Heisler CA, Melton LJ, Weaver AL, Gebhart JB. Determining perioperative complications associated with vaginal hysterectomy: code classification versus chart review. J Am Coll Surg 2009;209:119-22.
    1. Grosse-Sundrup M, Henneman JP, Sandberg WS, Bateman BT, Uribe JV, Nguyen NT, et al. Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study. BMJ 2012;345:e6329.
    1. Hess DR, Kondili D, Burns E, Bittner EA, Schmidt UH. A 5-year observational study of lung-protective ventilation in the operating room: a single-center experience. J Crit Care 2013;28:533.e9-15.
    1. Jaber S, Coisel Y, Chanques G, Futier E, Constantin JM, Michelet P, et al. A multicentre observational study of intra-operative ventilatory management during general anaesthesia: tidal volumes and relation to body weight. Anaesthesia 2012;67:999-1008.
    1. Royston P, Ambler G, Sauerbrei W. The use of fractional polynomials to model continuous risk variables in epidemiology. Int J Epidemiol 1999;28:964-74.
    1. Sauerbrei W, Meier-Hirmer C, Benner A, Royston P. Multivariable regression model building by using fractional polynomials: description of SAS, STATA and R programs. Comput Stat Data Anal 2006;50:3464-85.
    1. Parsons LS. Reducing bias in a propensity score matched-pair sample using greedy matching techniques. In: Proceedings of the 26th Annual SAS Users. Paper. 2001;214-26.
    1. Kurth T, Walker AM, Glynn RJ, Chan KA, Gaziano JM, Berger K, et al. Results of multivariable logistic regression, propensity matching, propensity adjustment, and propensity-based weighting under conditions of nonuniform effect. Am J Epidemiol 2006;163:262-70.
    1. Van Buuren S. Multiple imputation of discrete and continuous data by fully conditional specification. Stat Methods Med Res 2007;16:219-42.
    1. Fernández-Pérez ER, Sprung J, Afessa B, Warner DO, Vachon CM, Schroeder DR, et al. Intraoperative ventilator settings and acute lung injury after elective surgery: a nested case control study. Thorax 2009;64:121-7.
    1. Serpa Neto A, Hemmes SN, Barbas CS, et al. Protective versus conventional ventilation for surgery: a systematic review and individual patient data meta-analysis. Anesthesiology 2015; published online 15 May.
    1. Amato MBP, Meade MO, Slutsky AS, Brochard L, Costa ELV, Schoenfeld DA, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med 2015;372:747-55.
    1. The PROVE Network Investigators. High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre randomised controlled trial. Lancet 2014;384:495-503.
    1. Eikermann M, Kurth T. Apply protective mechanical ventilation in the operating room in an individualized approach to perioperative respiratory care. Anesthesiology 2015; published online 15 May.
    1. Yilmaz M, Keegan MT, Iscimen R, Afessa B, Buck CF, Hubmayr RD, et al. Toward the prevention of acute lung injury: protocol-guided limitation of large tidal volume ventilation and inappropriate transfusion. Crit Care Med 2007;35:1660-6; quiz 1667.
    1. Schultz MJ, Haitsma JJ, Slutsky AS, Gajic O. What tidal volumes should be used in patients without acute lung injury? Anesthesiology 2007;106:1226-31.
    1. Wellman TJ, Winkler T, Costa EL, Musch G, Harris RS, Zheng H, et al. Effect of local tidal lung strain on inflammation in normal and lipopolysaccharide-exposed sheep*. Crit Care Med 2014;42:e491-500.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe