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• W3203141591 abstract "Central MessageEarlier identification of postoperative pulmonary complications after cardiac surgery may allow for earlier intervention.See Article page 2134. Earlier identification of postoperative pulmonary complications after cardiac surgery may allow for earlier intervention. See Article page 2134. In 2016, Edwards and colleagues1Edwards F.H. Ferraris V.A. Kurlansky P.A. Lobdell K.W. He X. O'Brien S.M. et al.Failure to rescue rates after coronary artery bypass grafting: an analysis from the Society of Thoracic Surgeons adult cardiac surgery database.Ann Thorac Surg. 2016; 102: 458-464Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar published an illuminating report on failure to rescue in more than 600,000 patients in the Society of Thoracic Surgeons National Database who had undergone coronary artery bypass grafting. Analyzing major complications (ie, stroke, reoperation, renal failure, and prolonged ventilation), the authors found that any 1 of those complications was reasonably tolerated, with a 5% mortality rate; however, having 2 complications increased mortality to 20% to 30%. Moreover, differences in postcomplication mortality were not explained by any complication's frequency; rather, higher rates of failure to rescue at higher-mortality surgical centers were more explanatory. This suggests that prompt recognition and timely management were responsible for much of the mortality differences. A Cardiothoracic Surgery Network analysis of 5158 adult cardiac surgery patients found a 2.4% incidence of pneumonia that was associated with a 9-fold increase in mortality; major risk factors included mechanical ventilation longer than 48 hours, nasogastric tubes, and transfusions.2Ailawadi G. Chang H.L. O'Gara P.T. O'Sullivan K. Woo Y.J. DeRose Jr., J.J. et al.Pneumonia after cardiac surgery: experience of the National Institutes of Health/Canadian Institutes of Health research cardiothoracic surgical trials network.J Thorac Cardiovasc Surg. 2017; 153: 1384-1391.e3Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar Prophylactic second-generation cephalosporins and platelet transfusion were protective. These complications have a major influence on costs, adding approximately $38,000 per case. In a systematic review and meta-analysis of 11 studies and 10,078 patients, He and colleagues3He S. Chen B. Li W. Yan J. Chen L. Wang X. et al.Ventilator-associated pneumonia after cardiac surgery: a meta-analysis and systematic review.J Thorac Cardiovasc Surg. 2014; 148: 3148-3155.e5Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar found that 35% of patients mechanically ventilated longer than 48 hours developed pneumonia. The significance of postoperative pulmonary complications after cardiac surgery is readily apparent. Khanna and colleagues4Khanna A.K. Kelava M. Ahuja S. Makarova N. Liang C. Tanner D. et al.A nomogram to predict postoperative pulmonary complications after cardiothoracic surgery.J Thorac Cardiovasc Surg. 2023; 165: 2134-2146Abstract Full Text Full Text PDF Scopus (3) Google Scholar from the Cleveland Clinic report results from a high-quality, statistically sound study with a robust dataset (a derivation cohort of 17,433 patients and a validation cohort of 12,843 patients), and they have provided a nomogram to predict the development of postoperative pulmonary complications (PPCs) (ie, pneumonia, reintubation, or the need for mechanical ventilation beyond 48 hours). Overall, almost 10% of patients developed 1 or more PPC (7.8% experienced 1 PPC, 1.6% experienced 2, and 0.2% had all 3); mortality in this group was 11.4%. The mortality rate was 16.2% for patients with pneumonia, 11.5% in reintubated patients, and 11.4% in patients requiring >48 hours of mechanical ventilation. In contrast, the mortality rate for patients who did not develop PPCs was only 0.4%. Targeted efforts to identify patients at higher risk for developing complications may help to reduce the incidence of PPCs. Khanna and colleagues'4Khanna A.K. Kelava M. Ahuja S. Makarova N. Liang C. Tanner D. et al.A nomogram to predict postoperative pulmonary complications after cardiothoracic surgery.J Thorac Cardiovasc Surg. 2023; 165: 2134-2146Abstract Full Text Full Text PDF Scopus (3) Google Scholar model for predicting PPCs includes 25 independent variables: 13 preoperative, 10 intraoperative, and 2 immediately postoperative. This model showed very good discrimination (C statistic, 0.87) and calibration (Brier score, 0.07). In comparison, 1 model using artificial neural networks and preoperative variables produced an area under the curve of 0.62 to 0.72 for predicting reintubation and prolonged ventilation after cardiac surgery.5Mendes R.G. de Souza C.R. Machado M.N. Correa P.R. Di Thommazo-Luporini L. Arena R. et al.Predicting reintubation, prolonged mechanical ventilation and death in post-coronary artery bypass graft surgery: a comparison between artificial neural networks and logistic regression models.Arch Med Sci. 2015; 11: 756-763Crossref PubMed Scopus (10) Google Scholar Of note, a scoring system with a cumbersome number of variables might be easy to use with a retrospective database containing already-entered values but would have less clinical utility at the bedside. The challenge with risk-scoring systems is that 1 based only on preoperative variables will be less accurate; nonetheless, early analysis could provide an opportunity to intervene preoperatively or intraoperatively to reduce PPC incidence or, in prohibitively high-risk cases, to consider alternative, less-invasive procedures (or no surgery at all). On the other hand, introducing intraoperative variables improves the accuracy of the risk score but affords fewer opportunities for intervention before surgery. By including 2 variables that are determined on arrival to the intensive care unit (inhaled nitric oxide/prostaglandin E2 and higher plateau pressures), Khanna and colleagues'4Khanna A.K. Kelava M. Ahuja S. Makarova N. Liang C. Tanner D. et al.A nomogram to predict postoperative pulmonary complications after cardiothoracic surgery.J Thorac Cardiovasc Surg. 2023; 165: 2134-2146Abstract Full Text Full Text PDF Scopus (3) Google Scholar model further increases prediction accuracy, even while PPCs are actually occurring. In comparing Khanna and colleagues'4Khanna A.K. Kelava M. Ahuja S. Makarova N. Liang C. Tanner D. et al.A nomogram to predict postoperative pulmonary complications after cardiothoracic surgery.J Thorac Cardiovasc Surg. 2023; 165: 2134-2146Abstract Full Text Full Text PDF Scopus (3) Google Scholar model with other recent cardiac surgery models developed through multivariable analysis, we noted 3 common major risk factors: age, cardiopulmonary bypass time, and transfusions. Specifically, Kilic and colleagues6Kilic A. Ohkuma R. Grimm J.C. Magruder J.T. Sussman M. Schneider E.B. et al.A novel score to estimate the risk of pneumonia after cardiac surgery.J Thorac Cardiovasc Surg. 2016; 151: 1415-1420Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar analyzed 6222 patients undergoing cardiac surgery and found a 4.5% incidence of pneumonia. The authors developed a scoring system that included 6 risk factors (age, chronic lung disease, peripheral vascular disease, cardiopulmonary bypass time, intraoperative red blood cell transfusion, and preoperative/intraoperative intra-aortic balloon pump use) with modest predictive accuracy (C statistic, 0.76). Allou and colleagues7Allou N. Bronchard R. Guglielminotti J. Dilly M.P. Provenchere S. Lucet J.C. et al.Risk factors for postoperative pneumonia after cardiac surgery and development of a preoperative risk score.Crit Care Med. 2014; 42: 1150-1156Crossref PubMed Scopus (60) Google Scholar analyzed 5582 patients with a 3% overall pneumonia rate and developed a scoring system that included age, chronic obstructive pulmonary disease, left ventricular ejection fraction, red blood cell transfusion, and cardiopulmonary bypass time. Finally, Wang and colleagues8Wang D. Huang X. Wang H. Le S. Yang H. Wang F. et al.Risk factors for postoperative pneumonia after cardiac surgery: a prediction model.J Thorac Dis. 2021; 13: 2351-2362Crossref PubMed Scopus (14) Google Scholar analyzed 5323 patients with a 10% pneumonia incidence and developed a scoring system comprising 13 risk factors, including age, transfusion, and cardiopulmonary bypass duration, among other preoperative variables (C statistic, 0.80). What, then, is one to do with patients identified as having higher risk for developing pulmonary complications, to reduce that risk or minimize adverse consequences? What risk factors are modifiable? It is likely that, aside from a prohibitively high risk for respiratory failure from severe underlying lung disease, most patients will proceed with surgery. What specific interventions (if any) should be introduced, beyond standard lung protective ventilation and other fundamentals of ventilator management and postoperative respiratory care? Could high-risk patients benefit from preoperative pulmonary rehabilitation,9Shakouri S.K. Salekzamani Y. Taghizadieh A. Sabbagh-Jadid H. Soleymani J. Sahebi L. et al.Effect of respiratory rehabilitation before open cardiac surgery on respiratory function: a randomized clinical trial.J Cardiovasc Thorac Res. 2015; 7: 13-17Crossref PubMed Google Scholar avoidance of after-hours extubation, increased duration of perioperative antibiotics, toilet bronchoscopy before extubation, and progression from extubation to noninvasive modes of ventilation or high-flow nasal oxygen in a protocolized manner?10Melton N. Lazar J.F. Childers W.K. Anderson D. Jaik N.P. Loran D.B. et al.Preventing respiratory failure after cardiac surgery using post-extubation bilevel positive airway pressure therapy.Cureus. 2019; 11: e4236PubMed Google Scholar,11Stéphan F. Barrucand B. Petit P. Rézaiguia-Delclaux S. Médard A. Delannoy B. et al.High-flow nasal oxygen vs noninvasive positive airway pressure in hypoxemic patients after cardiothoracic surgery: a randomized clinical trial.JAMA. 2015; 313: 2331-2339Crossref PubMed Scopus (388) Google Scholar Indeed, evidence-based strategies such as chlorhexidine oral care, head-of-bed elevation, pulmonary hygiene, and postoperative protocols encouraging pulmonary toilet and mobilization are necessary. Moreover, there may be opportunities to reduce the risk of PPCs from intraoperative strategies. Blood conservation efforts should be encouraged, because the transfusion of even 1 to 2 U packed red blood cells doubles the risk for pneumonia.12Likosky D.S. Paone G. Zhang M. Rogers M.A. Harrington S.D. Theurer P.F. et al.Red blood cell transfusions impact pneumonia rates after coronary artery bypass grafting.Ann Thorac Surg. 2015; 100: 794-800Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar Moreover, intraoperative ventilation management may reduce the likelihood of PPC development; 1 analysis of 4694 cardiac surgical procedures found that an intraoperative lung-protective ventilation bundle was independently associated with fewer pulmonary complications.13Mathis M.R. Duggal N.M. Likosky D.S. Haft J.W. Douville N.J. Vaughn M.T. et al.Intraoperative mechanical ventilation and postoperative pulmonary complications after cardiac surgery.Anesthesiology. 2019; 131: 1046-1062Crossref PubMed Scopus (52) Google Scholar Increasingly in the acute respiratory distress syndrome literature, the concept of driving pressure expressed as the ratio of tidal volume to static lung compliance (or at the bedside as plateau pressure minus positive end-expiratory pressure) has been identified as the central variable for mechanical ventilation optimization.14Amato M.B. Meade M.O. Slutsky A.S. Brochard L. Costa E.L. Schoenfeld D.A. et al.Driving pressure and survival in the acute respiratory distress syndrome.N Engl J Med. 2015; 372: 747-755Crossref PubMed Scopus (1460) Google Scholar By sensitivity analysis, a modified intraoperative driving pressure <16 cm H2O was most protective, compared with intraoperative vital volume <8 mL/kg of predicted body weight or positive end-expiratory pressure ≥5 cm H2O.13Mathis M.R. Duggal N.M. Likosky D.S. Haft J.W. Douville N.J. Vaughn M.T. et al.Intraoperative mechanical ventilation and postoperative pulmonary complications after cardiac surgery.Anesthesiology. 2019; 131: 1046-1062Crossref PubMed Scopus (52) Google Scholar This highlights a potential role for intraoperative ventilation optimization that can be systematically implemented. Reducing the incidence and severity of pulmonary complications after cardiac surgery requires preoperative, intraoperative, and postoperative strategies. Even a 1% absolute reduction in the incidence of pulmonary complications would measurably decrease mortality rates and cost savings. Achieving such a reduction will require multidisciplinary collaboration to identify higher-risk patients. A nomogram to predict postoperative pulmonary complications after cardiothoracic surgeryThe Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 6PreviewThe objective was to develop a novel scoring system that would be predictive of postoperative pulmonary complications in critically ill patients after cardiac and major vascular surgery. Full-Text PDF" @default.
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• W3203141591 title "Commentary: Earlier warning for pulmonary complications: It's never too soon to take action" @default.
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