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

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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 cmH ₂O 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 cmH ₂O.

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 cmH ₂O and median plateau pressures of 16 cmH ₂O 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 cmH ₂O and a plateau pressure of 16 cmH ₂O 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.

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Most cited references 29

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Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome.

M. B. P. Amato, C Barbas, D M Medeiros … (1998)

In patients with the acute respiratory distress syndrome, massive alveolar collapse and cyclic lung reopening and overdistention during mechanical ventilation may perpetuate alveolar injury. We determined whether a ventilatory strategy designed to minimize such lung injuries could reduce not only pulmonary complications but also mortality at 28 days in patients with the acute respiratory distress syndrome. We randomly assigned 53 patients with early acute respiratory distress syndrome (including 28 described previously), all of whom were receiving identical hemodynamic and general support, to conventional or protective mechanical ventilation. Conventional ventilation was based on the strategy of maintaining the lowest positive end-expiratory pressure (PEEP) for acceptable oxygenation, with a tidal volume of 12 ml per kilogram of body weight and normal arterial carbon dioxide levels (35 to 38 mm Hg). Protective ventilation involved end-expiratory pressures above the lower inflection point on the static pressure-volume curve, a tidal volume of less than 6 ml per kilogram, driving pressures of less than 20 cm of water above the PEEP value, permissive hypercapnia, and preferential use of pressure-limited ventilatory modes. After 28 days, 11 of 29 patients (38 percent) in the protective-ventilation group had died, as compared with 17 of 24 (71 percent) in the conventional-ventilation group (P<0.001). The rates of weaning from mechanical ventilation were 66 percent in the protective-ventilation group and 29 percent in the conventional-ventilation group (P=0.005): the rates of clinical barotrauma were 7 percent and 42 percent, respectively (P=0.02), despite the use of higher PEEP and mean airway pressures in the protective-ventilation group. The difference in survival to hospital discharge was not significant; 13 of 29 patients (45 percent) in the protective-ventilation group died in the hospital, as compared with 17 of 24 in the conventional-ventilation group (71 percent, P=0.37). As compared with conventional ventilation, the protective strategy was associated with improved survival at 28 days, a higher rate of weaning from mechanical ventilation, and a lower rate of barotrauma in patients with the acute respiratory distress syndrome. Protective ventilation was not associated with a higher rate of survival to hospital discharge.

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Results of multivariable logistic regression, propensity matching, propensity adjustment, and propensity-based weighting under conditions of nonuniform effect.

Tobias Kurth, Alexander Walker, Robert J Glynn … (2006)

Observational studies often provide the only available information about treatment effects. Control of confounding, however, remains challenging. The authors compared five methods for evaluating the effect of tissue plasminogen activator on death among 6,269 ischemic stroke patients registered in a German stroke registry: multivariable logistic regression, propensity score-matched analysis, regression adjustment with the propensity score, and two propensity score-based weighted methods-one estimating the treatment effect in the entire study population (inverse-probability-of-treatment weights), another in the treated population (standardized-mortality-ratio weights). Between 2000 and 2001, 212 patients received tissue plasminogen activator. The crude odds ratio between tissue plasminogen activator and death was 3.35 (95% confidence interval: 2.28, 4.91). The adjusted odds ratio depended strongly on the adjustment method, ranging from 1.11 (95% confidence interval: 0.67, 1.84) for the standardized-mortality-ratio weighted to 10.77 (95% confidence interval: 2.47, 47.04) for the inverse-probability-of-treatment-weighted analysis. For treated patients with a low propensity score, risks of dying were high. Exclusion of patients with a propensity score of <5% yielded comparable odds ratios of approximately 1 for all methods. High levels of nonuniform treatment effect render summary estimates very sensitive to the weighting system explicit or implicit in an adjustment technique. Researchers need to be clear about the population for which an overall treatment estimate is most suitable.

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Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program.

P Taheri, L. Chen, F Khuri … (2004)

The National Surgical Quality Improvement Project (NSQIP) has reduced morbidity rates in Veterans Affairs Hospitals. As the NSQIP methods move to private-sector hospitals, funding responsibilities will shift to the medical center. The objective of the current study was to calculate hospital costs associated with postoperative complications, because reducing morbidity may offset the costs of using the NSQIP. Patient data were obtained from a single private-sector center involved in the NSQIP from 2001 to 2002 (n=1,008). Cost data were derived from the hospital's internal cost-accounting database (TSI; Transitions Systems Inc). Total hospital costs associated with both minor complications and major complications were calculated. Multiple linear regression was used to determine the cost of each type of complication after adjusting for patient characteristics. Rates of minor complications (6.3%, 64 events) and major complications (6.6%, 67 events) were similar. Median hospital costs were lowest for patients without complications (4,487 dollars) compared with those with minor (14,094 dollars) and major complications (28,356 dollars) (p<0.001). After adjusting for differences in patient characteristics, major complications were associated with an increase of 11,626 dollars (95% CI, 9,419 dollars to 13,832 dollars; p<0.001). Minor complications were not associated with increased costs in the adjusted analysis. Given the substantial costs associated with major postoperative complications, reducing morbidity may provide sufficient cost savings to offset the resources needed to participate in the private-sector expansion of the NSQIP.

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Author and article information

Contributors

Karim Ladha: Role: research fellow

Marcos F Vidal Melo: Role: associate professor

Duncan J McLean: Role: research fellow

Jonathan P Wanderer: Role: assistant professor

Stephanie D Grabitz: Role: research assistant

Tobias Kurth: Role: research director

Matthias Eikermann: Role: associate professor of anesthesia and critical care medicine, clinical director

Journal

Journal ID (nlm-ta): BMJ

Journal ID (iso-abbrev): BMJ

Journal ID (publisher-id): bmj

Title: BMJ : British Medical Journal

Publisher: BMJ Publishing Group Ltd.

ISSN (Print): 0959-8138

ISSN (Electronic): 1756-1833

Publication date Collection: 2015

Publication date (Electronic): 14 July 2015

Volume: 351

Electronic Location Identifier: h3646

Affiliations

[1 ]Department of Anesthesia, Critical Care, Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA

[2 ]Department of Anesthesiology, Vanderbilt University, Nashville, TN, USA

[3 ]INSERM Research Center for Epidemiology and Biostatistics (U897)-Team Neuroepidemiology, Bordeaux, France

[4 ]College of Health Sciences, University of Bordeaux, Bordeaux, France

[5 ]Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

[6 ]Essen-Duisburg University, Essen, Germany

Author notes

Correspondence to: M Eikermann meikermann@ 123456partners.org

Article

Publisher ID: ladk020184

DOI: 10.1136/bmj.h3646

PMC ID: 4501577

PubMed ID: 26174419

SO-VID: 3468772a-0b43-4595-b5d9-6c5400be505e

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This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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

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Most cited references 29

Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome.

Results of multivariable logistic regression, propensity matching, propensity adjustment, and propensity-based weighting under conditions of nonuniform effect.

Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program.

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