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• W2103753613 abstract "Editor—In a retrospective single-centre study including 29 343 adult patients undergoing general non-cardiac surgeries under general anaesthesia, Levin and colleagues1Levin MA McCormick PJ Lin HM Hosseinian L Fischer GW Low intraoperative tidal volume ventilation with minimal PEEP is associated with increased mortality.Br J Anaesth. 2014; 113: 97-108Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar showed that intraoperative mechanical ventilation using low tidal volumes with minimal PEEP was associated with worse 30 day mortality and an increased hospital length of stay. The strengths of this study include a large sample of patients and use of multivariable Cox regression and propensity score-matched analyses to adjust for, and reduce, the influences of confounding variables on study end-points. However, their results are significantly different from the conclusions of two recent comprehensive analyses by Coppola and colleagues2Coppola S Froio S Chiumello D Protective lung ventilation during general anesthesia: is there any evidence?.Critical Care. 2014; 18: 210Crossref PubMed Scopus (26) Google Scholar and Futier and colleagues3Futier E Constantin J Jaber S Protective lung ventilation in operating room: systematic review.Minerva Anestesiol. 2014; 80: 726-735PubMed Google Scholar of the current randomized controlled clinical trials comparing protective with conventional lung ventilation strategy during general anaesthesia in surgical patients. These two systematic reviews provide evidence that protective lung ventilation strategy (low tidal volumes with PEEP and/or recruitment manoeuvres) is beneficial in abdominal surgery (lower inflammatory response and better outcome). During thoracic and cardiac surgery, protective lung ventilation strategy has also been associated with a reduced inflammatory response. After carefully reading the retrospective study and previously published randomized controlled clinical trials, we agree with Levin and colleagues1Levin MA McCormick PJ Lin HM Hosseinian L Fischer GW Low intraoperative tidal volume ventilation with minimal PEEP is associated with increased mortality.Br J Anaesth. 2014; 113: 97-108Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar that use of a low level of PEEP (median=4 cm H2O) without recruitment manoeuvres is one of the possible causes for their worse postoperative outcomes. Moreover, this study is a retrospective analysis using an observational design, which potentially introduces a number of confounding variables that in a non-randomized study may not have been removed completely. In our view, several important issues in this study are not well addressed. First, health status, types of surgery and comorbidities are important determinants for postoperative morbidity and mortality.4Modesti PA Simonetti I Olivo G Perioperative myocardial infarction in non-cardiac surgery. Pathophysiology and clinical implications.Intern Emerg Med. 2006; 1: 177-186Crossref PubMed Scopus (14) Google Scholar In the study by Levin and colleagues1Levin MA McCormick PJ Lin HM Hosseinian L Fischer GW Low intraoperative tidal volume ventilation with minimal PEEP is associated with increased mortality.Br J Anaesth. 2014; 113: 97-108Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar, patients′ age, ASA physical status, all patient refined-diagnosis related group (APR-DRG) severity of illness (SOI) and risk of mortality (ROM) scores, and types of surgery are significantly different among patients with various ventilation strategies. In our opinion, no matter how refined the adjustment is for differences in health status, surgery burden, and relevant comorbidities, it is never possible to ensure a complete adjustment for differences among patients with different ventilation strategies, even when propensity score matching is used. Most importantly, some of the independent risk factors related to postoperative morbidity and mortality are not included in data analysis. For example, preoperative anaemia is common among non-cardiac surgery patients, and low preoperative and postoperative haemoglobin levels are associated independently with increased perioperative mortality, increased postoperative pneumonia, and increased hospital length of stay.5Musallam KM Tamim HM Richards T et al.Preoperative anaemia and postoperative outcomes in non- cardiac surgery: a retrospective cohort study.Lancet. 2011; 378: 1396-1407Abstract Full Text Full Text PDF PubMed Scopus (758) Google Scholar, 6Dunne JR Malone D Tracy JK Gannon C Napolitano LM Perioperative anemia: an independent risk factor for infection, mortality, and resource utilization in surgery.J Surg Res. 2002; 102: 237-244Abstract Full Text PDF PubMed Scopus (305) Google Scholar Moreover, preoperative use of cardiac medicines such as angiotensin-converting enzyme inhibitors, β-blockers, and statins can also significantly affect hospital and long-term mortality in patients undergoing non-cardiac surgery.7Feringa HH Bax JJ Karagiannis SE et al.Elderly patients undergoing major vascular surgery: risk factors and medication associated with risk reduction.Arch Gerontol Geriatr. 2009; 48: 116-120Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Second, in the study by Levin and colleagues1Levin MA McCormick PJ Lin HM Hosseinian L Fischer GW Low intraoperative tidal volume ventilation with minimal PEEP is associated with increased mortality.Br J Anaesth. 2014; 113: 97-108Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar, anaesthetic agent, ventilation mode (volume control or pressure control), ventilator settings, and fraction of inspired oxygen were chosen at the discretion of the attending anaesthetist. Consequently, we cannot exclude the possibility that anaesthetists would have selected anaesthetic and ventilation strategies based on baseline characteristics and pre-existing comorbidities of patients. Furthermore, we are not provided with details of the anaesthetic and intraoperative management. Intraoperative hypoxaemia, blood loss, transfusion, hypotension, tachycardia, and hypertension are associated independently with postoperative morbidity and mortality of non-cardiac surgery patients.8Kheterpal S O'Reilly M Englesbe MJ et al.Preoperative and intraoperative predictors of cardiac adverse events after general, vascular, and urological surgery.Anesthesiology. 2009; 110: 58-66Crossref PubMed Scopus (191) Google Scholar, 9Bijker JB van Klei WA Vergouwe Y et al.Intraoperative hypotension and 1-year mortality after noncardiac surgery.Anesthesiology. 2009; 111: 1217-1226Crossref PubMed Scopus (223) Google Scholar We believe that a more persuasive result would have been presented if these data were included in the study design. Finally, we emphasize that postoperative morbidity and mortality are the results of many perioperative factors and their interaction.4Modesti PA Simonetti I Olivo G Perioperative myocardial infarction in non-cardiac surgery. Pathophysiology and clinical implications.Intern Emerg Med. 2006; 1: 177-186Crossref PubMed Scopus (14) Google Scholar To differentiate the effect of one factor on the postoperative adverse outcomes, all of the other factors have to be standardized and controlled in the study design. It is impossible for an observational study to achieve this target. Thus, we agree with the authors that an association between postoperative outcomes and low tidal volume ventilation with minimal PEEP in this study does not prove causality. Moreover, we argue that when making decisions about use of a treatment such as low tidal volume ventilation with PEEP to decrease postoperative morbidity and mortality of surgical patients, we should rely on the large body of robust evidence of efficacy and safety. This high-level evidence comes from a very large number of randomized controlled clinical trials and their meta-analysis, rather than any study using an observational design. None declared." @default.
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• W2103753613 title "Low intraoperative tidal volume ventilation with minimal PEEP and postoperative morbidity and mortality" @default.
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