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Cited by 660Cardiac, Anesthesia and Surgical OutcomesRespiratory Support and MechanismsIntensive Care Unit Cognitive Disorders

Postoperative Pulmonary Complications, Early Mortality, and Hospital Stay Following Noncardiothoracic Surgery: A Multicenter Study by the Perioperative Research Network Investigators

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Fernandez-Bustamante, Ana, Frendl, Gyorgy, Sprung, Juraj, Kor, Daryl J., Subramaniam, Bala, Martinez Ruiz, Ricardo, Lee, Jae-Woo, Henderson, William G. +7 more·2017·JAMA Surgery
DOI 10.1001/jamasurg.2016.4065PMC PMC5334462
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Abstract

Importance: Postoperative pulmonary complications (PPCs), a leading cause of poor surgical outcomes, are heterogeneous in their pathophysiology, severity, and reporting accuracy. Objective: To prospectively study clinical and radiological PPCs and respiratory insufficiency therapies in a high-risk surgical population. Design, Setting, and Participants: We performed a multicenter prospective observational study in 7 US academic institutions. American Society of Anesthesiologists physical status 3 patients who presented for noncardiothoracic surgery requiring 2 hours or more of general anesthesia with mechanical ventilation from May to November 2014 were included in the study. We hypothesized that PPCs, even mild, would be associated with early postoperative mortality and use of hospital resources. We analyzed their association with modifiable perioperative variables. Exposure: Noncardiothoracic surgery. Main Outcomes and Measures: Predefined PPCs occurring within the first 7 postoperative days were prospectively identified. We used bivariable and logistic regression analyses to study the association of PPCs with ventilatory and other perioperative variables. Results: This study included 1202 patients who underwent predominantly abdominal, orthopedic, and neurological procedures. The mean (SD) age of patients was 62.1 (13.8) years, and 636 (52.9%) were men. At least 1 PPC occurred in 401 patients (33.4%), mainly the need for prolonged oxygen therapy by nasal cannula (n = 235; 19.6%) and atelectasis (n = 206; 17.1%). Patients with 1 or more PPCs, even mild, had significantly increased early postoperative mortality, intensive care unit (ICU) admission, and ICU/hospital length of stay. Significant PPC risk factors included nonmodifiable (emergency [yes vs no]: odds ratio [OR], 4.47, 95% CI, 1.59-12.56; surgical site [abdominal/pelvic vs nonabdominal/pelvic]: OR, 2.54, 95% CI, 1.67-3.89; and age [in years]: OR, 1.03, 95% CI, 1.02-1.05) and potentially modifiable (colloid administration [yes vs no]: OR, 1.75, 95% CI, 1.03-2.97; preoperative oxygenation: OR, 0.86, 95% CI, 0.80-0.93; blood loss [in milliliters]: OR, 1.17, 95% CI, 1.05-1.30; anesthesia duration [in minutes]: OR, 1.14, 95% CI, 1.05-1.24; and tidal volume [in milliliters per kilogram of predicted body weight]: OR, 1.12, 95% CI, 1.01-1.24) factors. Conclusions and Relevance: Postoperative pulmonary complications are common in patients with American Society of Anesthesiologists physical status 3, despite current protective ventilation practices. Even mild PPCs are associated with increased early postoperative mortality, ICU admission, and length of stay (ICU and hospital). Mild frequent PPCs (eg, atelectasis and prolonged oxygen therapy need) deserve increased attention and intervention for improving perioperative outcomes.

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Crossref · 10.1001/jamasurg.2016.4065

Cites

33 of 33 references verified0 citation errors · 0 not checkable

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Claims the paper makes

0 of 55 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    The most frequent PPC was prolonged need for oxygen supplementation by nasal cannula for more than 1 day (n=235; 19.6%).

    “mainly the need for prolonged oxygen therapy by nasal cannula (n = 235; 19.6%)”
    • Also stated in: § Results · plain
      “The most frequent PPC was the prolonged (>1 day) need for oxygen supplementation by NC, followed by atelectasis and pleural effusion (Table 2).”
    Quote in the paperNot a substantial claim
  • Findingown data

    Estimated blood loss was independently associated with PPC development (OR 1.17, 95% CI 1.05-1.30).

    “estimated blood loss (OR, 1.17; 95% CI, 1.05–1.30)”
    Quote in the paperSubstantial claim
  • Findingown data

    Abdominal/pelvic surgery was independently associated with PPC development (OR 2.54, 95% CI 1.67-3.89).

    “abdominal/pelvic surgery (OR, 2.54; 95% CI, 1.67–3.89)”
    Quote in the paperSubstantial claim
  • Findingown data

    Anesthesia duration was independently associated with PPC development (OR 1.14, 95% CI 1.05-1.24).

    “anesthesia duration (OR, 1.14; 95% CI, 1.05–1.24)”
    Quote in the paperSubstantial claim
  • Findingown data

    Emergency surgery was independently associated with PPC development (OR 4.47, 95% CI 1.59-12.56).

    “emergency (OR, 4.47; 95% CI, 1.59–12.56)”
    Quote in the paperSubstantial claim
  • May combine two claims. 23
  • Classified as probably not a substantial claim. 18

  • May combine two claims.

    Findingown data

    Early mortality was significantly associated with pneumonia, pleural effusion, and atelectasis, with observed rates of 9.1%, 7.0%, and 4.4% and relative risks of 15.3, 75.3, and undefined.

    “but it was also significantly associated with pneumonia, pleural effusion, and atelectasis (observed rates of 9.1%, 7.0%, and 4.4%, respectively, and RRs of 15.3 [95% CI, 3.4–69.4], 75.3 [95% CI, 9.5–597.0], and undefined, respectively)”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Early mortality was highest in patients with ARDS (50%) and reintubation with POMV (14.3%), with relative risks of 74.8 and 28.0.

    “Early mortality rate was the highest in patients with ARDS and reintubation with POMV (50% and 14.3%, respectively, corresponding to relative risks [RR] of 74.8 [95% CI, 15.9–351.6] and 28.0 [95% CI, 7.5–104.6], respectively)”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Patients with at least 1 PPC had significantly increased ICU and hospital length of stay.

    “Patients with 1 or more PPCs, even mild, had significantly increased early postoperative mortality, intensive care unit (ICU) admission, and ICU/hospital length of stay.”
    • Also stated in: § Results · plain
      “Median hospital LOS increased as the number of PPCs per patient increased.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Pneumothorax, bronchospasm, and prolonged oxygen use by nasal cannula or face mask were not associated with early mortality.

    “Pneumothorax, bronchospasm, and requirement of prolonged use of oxygen by NC/FM were not associated with early mortality.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Nine patients (0.8%) died within the first 7 postoperative days, and all had more than 1 pulmonary complication.

    “Nine patients (0.8%) died within the first 7 PODs (early postoperative mortality), all with more than 1 pulmonary complication (Table 3).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Atelectasis or pleural effusion also increased mortality risk (relative risk undefined high or 75.3) and ICU/hospital length of stay.

    “Importantly, less severe but considerably more frequent PPCs, such as atelectasis or pleural effusion, also increased the risk for mortality (RR calculated as undefined high owing to denominator equal to 0 or 75.3, respectively) and ICU/ hospital LOS (see RRs in Table 4).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    ARDS and reintubation with POMV significantly increased early mortality risk (relative risks 74.8 and 28.0) and ICU length of stay but were rare.

    “The most severe PPCs— ARDS and reintubation with POMV—significantly increased the risk for early mortality risk (RRs, 74.8 and 28.0, respectively) and the ICU LOS but they were rare in ours and previous studies (Table 4).10,11”
    Quote in the paperSubstantial claim0 of 2 sources checked
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  • May combine two claims.

    Findingown data

    Pneumothorax, bronchospasm, and oxygen requirement by nasal cannula or face mask were significantly associated with longer hospital length of stay despite no association with mortality.

    “For example, the presence of pneumothorax, bronchospasm, and oxygen requirement by NC/FM were significantly associated with longer hospital LOS despite no association with mortality.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Pneumonia increased mortality risk (relative risk 15.3) and ICU/hospital length of stay.

    “Pneumonia could be considered a moderate PPC in both frequency and severity, increasing the risk for mortality (RR, 15.3) and the ICU/hospital LOS (Table 4).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    The study was a multicenter prospective observational study in 7 US academic institutions.

    “We performed a multicenter prospective observational study in 7 US academic institutions.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductcitation

    The estimated sample size of 1000 patients provided 80% power to detect an OR of at least 1.2 for each ventilatory variable with the composite PPC outcome, assuming multiple correlation of 0.25 or less, or 90% power for an OR of at least 1.3 assuming correlation of 0.50 or less.

    “The estimated sample size of 1000 patients provided 80% power to detect an odds ratio (OR) of 1.2 or greater as statistically significant for each ventilatory variable of interest and its association with the composite outcome of any of the PPCs”
    Quote in the paperNot a substantial claim0 of 1 sources checked
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  • Classified as probably not a substantial claim.

    Study design and conductown data

    The final model used multivariable hierarchical logistic regression to model relationships between PPC development and ventilatory settings.

    “For the final model, multivariable hierarchical logistic regression was used to model the relationships between the development of PPC and ventilatory settings.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Interventions to reduce PPCs include intraoperative ICU-like mechanical ventilation strategies, adopted by US academic centers over the past decade.

    “Interventions to reduce PPCs include intraoperative intensive care unit (ICU)–like mechanical ventilation strategies,5,10,12,13 which have been adopted over the past decade by US academic centers.14,15”
    Quote in the paperNot a substantial claim0 of 6 sources checked
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  • May combine two claims.

    Premisecitation

    Previous PPC studies were mostly retrospective, administrative-data based, or included patients at different risk levels.

    “Previous studies on PPCs1,2,6,10,11 have been mostly retrospective10,11 or based on administrative data,1,6 or they included patients at very different risk levels for PPCs.2,11”
    Quote in the paperSubstantial claim0 of 5 sources checked
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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Missing and outlier data values were individually revised for completion or correction or left as missing.

    “Any missing and outlier data values were individually revised for completion or correction or left as missing data points in our study database.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    ASA physical status 3 patients undergoing prolonged noncardiothoracic surgery are particularly susceptible to PPCs and are an ideal target for future interventions.

    “This surgical population subset is particularly susceptible to PPCs2 and would be an ideal target for future interventions based on their volume and severe, but not life-threatening, disease burden.”
    Quote in the paperSubstantial claim0 of 1 sources checked
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  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductnone given

    Radiological PPC diagnoses were reported by attending radiologists independent of the study, with final PPC consideration by local study principal investigators.

    “Radiological diagnoses were reported by attending radiologists independent of the study, with the final consideration as PPC by local study principal investigators.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisenone given

    Contemporary incidence, clinical impact, and risk factors of individual PPCs after practice changes are unknown.

    “Yet, the contemporary incidence, clinical impact, and risk factors of individual PPCs after these practice changes are unknown.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    PPCs were predefined and prospectively identified within the first 7 postoperative days.

    “Predefined PPCs occurring within the first 7 postoperative days were prospectively identified.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    PPC composite bivariable associations were adjusted for clustering of patients within sites using hierarchical logistic regression with site as a random effect.

    “These PPC composite bivariable associations were then individually adjusted by clustering of patients within sites using simple hierarchical logistic regression with site as a random effect.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The study was developed with preagreement of terms and data to be collected.

    “This study was developed in a detailoriented manner with preagreement of terms and data to be collected.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The study addressed residual bias and confounding with adjusted analyses.

    “We addressed the residual bias and confounding effects with adjusted analyses.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Residual confounding does not explain the observed associations between PPCs and outcomes.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The need for oxygen therapy was determined by local practices and not by a common protocol.

    “The need for oxygen therapy was determined by local practices and not by the implementation of a common protocol.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Local, non-protocolized oxygen therapy practices did not materially bias the association between prolonged oxygen requirement and outcomes.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    The findings reflect statistical associations and do not imply cause-effect relationships.

    “Our findings reflect statistical associations and do not imply cause-effect relationships.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    Prospective enrollment, data collection, and validation add reliability to clinical outcomes.

    “The prospective enrollment, data collection, and validation add reliability to clinical outcomes that are often more challenging to measure than mortality.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductreasoning

    Radiological examinations were not obtained in all patients and may induce selection bias.

    “Radiological examinations were not obtained in all patients and therefore may induce a selection bias.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Radiological examinations not obtained in all patients did not materially bias the PPC-outcome associations.

  • Classified as probably not a substantial claim.

    Premisecitation

    Open and laparoscopic abdominal procedures were combined because the impact on PPCs after varied operations remains unclear.

    “Open and laparoscopic abdominal procedures were combined because the impact on PPCs after varied operations remains unclear.5,23,24”
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  • May combine two claims.

    Interpretationown data

    Not only severe but also mild PPCs are associated with significantly increased morbidity, mortality, and ICU and hospital length of stay.

    “Our findings underline that not only severe but also mild PPCs are associated with significantly increased morbidity, mortality, and ICU and hospital LOS.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    The observed PPC incidence of 33.4% was higher than previous reports, likely due to differences in patient characteristics, surgical procedures, and PPC definitions.

    “The observed incidence of at least 1 PPC in 33.4% of patients was higher than previous reports,2,6–9 likely due to a combination of different patient characteristics, surgical procedures, and PPC definitions.”
    Quote in the paperNot a substantial claim0 of 5 sources checked
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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    There is increased interest in perioperative protective mechanical ventilation and a trend to use lower intraoperative tidal volumes despite limited information on optimal settings.

    “There is an increased interest in perioperative protective mechanical ventilation and a trend to use lower intraoperative VTs despite limited information on the specific optimal settings for different surgical patients.5,10,29”
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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Surgical procedures were classified into abdominal/pelvic and nonabdominal/pelvic following previous PPC risk assessments reporting highest risk after thoracic, then abdominal, then peripheral procedures.

    “Surgical procedures were classified into abdominal/pelvic and nonabdominal/pelvic following previous PPC risk assessments2,22 reporting the highest risk for PPCs after thoracic procedures (excluded from this study) followed by abdominal surgical procedures, then peripheral procedures (lowest risk).”
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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Hypoxemia is a common, persistent, and often underdiagnosed postoperative complication.

    “Indeed, hypoxemia32 has been found to be a common, persistent, and often underdiagnosed postoperative complication.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Recent studies show increased PPC risk in surgical patients with hypoalbuminemia.

    “Interestingly, recent studies have shown an increased PPC risk in surgical patients with hypoalbuminemia.2,26”
    Quote in the paperNot a substantial claim0 of 2 sources checked
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    Interpretationreasoning

    The lack of a common oxygen protocol likely introduced heterogeneity, with both avoidable oxygen therapy and untreated hypoxemia present.

    “This has likely introduced heterogeneity with potential avoidable oxygen therapy but also untreated hypoxemia being present in our sample.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    The study presents limitations primarily related to its observational nature, preselection of specific PPC definitions, and possible multiple testing.

    “Our study presents several limitations primarily related to its observational nature, preselection of specific PPC definitions, and possible multiple testing.”
    Quote in the paperNot a substantial claim
35 of 35

  • The paper relies on this without support.

    Residual confounding does not explain the observed associations between PPCs and outcomes.

    “We addressed the residual bias and confounding effects with adjusted analyses.”

  • The paper relies on this without support.

    Local, non-protocolized oxygen therapy practices did not materially bias the association between prolonged oxygen requirement and outcomes.

    “The need for oxygen therapy was determined by local practices and not by the implementation of a common protocol.”

  • The paper relies on this without support.

    Radiological examinations not obtained in all patients did not materially bias the PPC-outcome associations.

    “Radiological examinations were not obtained in all patients and therefore may induce a selection bias.”
3 of 3

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Authors
Fernandez-Bustamante, A., Frendl, G., Sprung, J., Kor, D. J., Subramaniam, B., Martinez Ruiz, R., Lee, J.-W., Henderson, W. G., Moss, A., Mehdiratta, N., Colwell, M. M., Bartels, K., Kolodzie, K., Giquel, J., & Vidal Melo, M. F.
Affiliations
  • University of Colorado Anschutz (US)
  • Brigham and Women’s Hospital, Boston, Massachusetts
  • Mayo Clinic College of Medicine, Rochester, Minnesota
  • Mayo Clinic (US)
  • Beth Israel Deaconess Medical Center (US)
  • University of Miami, Palmetto Bay, Florida
  • University of California, San Francisco (US)
  • Brigham and Women's Hospital (US)
  • Massachusetts General Hospital (US)
  • University of Miami (US)
  • Massachusetts General Hospital, Boston
Corresponding author
Fernandez-Bustamante, Ana
ORCID
Venue
JAMA Surgery
Publisher
American Medical Association (AMA)
Published
2017-02-01
Volume
152
Issue
2
Pages
157
ISSN
2168-6254 (ISSN-L)
DOI
10.1001/jamasurg.2016.4065
PMC
PMC5334462
OpenAlex
W2552081789
Cited by
653
References
33
Citations by year
2026: 88 · 2025: 89 · 2024: 103 · 2023: 76 · 2022: 87 · 2021: 67 · 2020: 76 · 2019: 36 · 2018: 18 · 2017: 11 · 2014: 1
FWCI
17.84
Type
journal article
Language
en
Open access
Locations
  • JAMA Surgery (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Heart, Lung, and Blood Institute (R34HL123438, K23HL112855)
  • National Institute on Drug Abuse (K23DA040923)
Topics
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac, Anesthesia and Surgical Outcomes
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Respiratory Support and Mechanisms
  • Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Intensive Care Unit Cognitive Disorders
Keywords
postoperative pulmonary complications, early postoperative mortality, length of hospital stay, atelectasis, oxygen therapy, respiratory failure, mechanical ventilation, colloid administration, emergency surgery, abdominal surgery, intensive care unit admission, risk factors, general anesthesia, high-risk surgical patients, perioperative care
MeSH terms
Abdomen, Age Factors, Aged, Aged, 80 and over, Anesthesia, Colloids, Emergencies, Female, Humans, Intensive Care Units, Length of Stay, Lung Diseases, Male, Middle Aged, Oxygen Inhalation Therapy, Pelvis, Postoperative Complications, Preoperative Care, Prospective Studies, Respiration, Artificial, Respiratory Insufficiency, Risk Factors, Tidal Volume, Time Factors, Blood Loss, Surgical, Neurosurgical Procedures, Orthopedic Procedures

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