Chest
Volume 110, Issue 3, September 1996, Pages 744-750
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clinical investigations
Risk of Pulmonary Complications After Elective Abdominal Surgery

https://doi.org/10.1378/chest.110.3.744Get rights and content

Study objective

Intra−abdominal operations are relatively high risk for pulmonary complications. Previous research has more intensely investigated cardiac operative risk, but recent work suggests that significant pulmonary complications may be more common than cardiac complications and associated with longer length of stay. This study identified risk indicators for pulmonary complications after elective abdominal operations.

Design

Nested case−control.

Setting

University affiliated Veterans Affairs hospital.

Patients

We used a computerized registry of all 2,291 patients undergoing elective abdominal operations from 1982 to 1991. Ascertainment and verification of pulmonary and cardiac complications were systematic and explicit. Charts of all 116 patients identified by the registry as having complications and 412 (19%) randomly selected from 2,175 remaining patients were reviewed to verify complications, using explicit criteria and independent abstraction of preoperative and postoperative components of charts. From 528 validated subjects (23% of the cohort), 82 cases and 82 control subjects were closely matched by operation type and age, ± 10 years.

Measurements and results

The primary outcome measure was postoperative pulmonary complications. Among 82 cases with pulmonary complications, 27 (33%) also had cardiac complications. Preoperative variables independently associated with pulmonary complications by multivariable analysis (p≤0.05) included the following: Charlson comorbidity index (per point odds ratio [OR], 1.6; 95% confidence interval [CI], 1.004 to 2.6), Goldman cardiac risk index (per point OR, 2.04; 95% CI, 1.17 to 3.6), abnormal chest radiograph (OR, 3.2; 95% CI, 1.07 to 9.4), and abnormal findings on lung examination (OR, 5.8; 95% CI, 1.04 to 32). Equal proportions of cases and control subjects had preoperative diagnostic spirometry. No component of spirometry predicted complications, including severity of obstructive lung disease.

Conclusions

For pulmonary operative risk, abnormal results of lung examination and chest radiography plus cardiac and overall comorbidity were important. Spirometry was not helpful. Because 33% of cases had both cardiac and pulmonary complications, future studies should prospectively examine comparative incidence, outcomes, and predictors of both types of complications.

Section snippets

Study Cohort/Ascertainment of Cases

This study was approved by the Institutional Review Board at the University of Texas Health Science Center at San Antonio. The patient cohort included all elective intra−abdominal operations performed between 1982 and 1991 (n=2,291) at Audie L. Murphy Division of the South Texas Veterans Health Care System. This facility is a 650−bed hospital affiliated with the University of Texas Health Science Center at San Antonio and has a large South Texas catchment area. Patients were identified from a

Results

Table 1 shows overall characteristics of the 82 cases and 82 control subjects according to unmatched descriptive analyses. All 18 deaths occurred among cases. Hospital and ICU stays were significantly longer for cases than control subjects. Cases had significantly worse comorbidity scores and greater mean pack−years of smoking compared with control subjects. Preoperative diagnostic spirometry was obtained in similar proportions of cases (48%) and control subjects (46%), but no single

Discussion

In this study of veterans undergoing elective abdominal operations, preoperative clinical factors independently associated with pulmonary complications included abnormal results of lung examination or abnormal chest radiograph, the Goldman cardiac risk index, and overall comorbid disease burden as measured by the Charlson comorbidity index. Abnormal spirometric findings were not associated with complications on univariate or multivariable analysis. The degree of obstructive lung disease

Pulmonary

  • 1.

    Pneumonia: radiographic evidence and antibiotics

  • 2.

    Possible pneumonia: radiographic evidence but no IV antibiotics OR normal chest radiograph, but IV antibiotics given

  • 3.

    Respiratory failure: ventilator dependence for >1 postoperative day or reintubation

  • 4.

    Bronchospasm: clinical diagnosis resulting in change in therapy

  • 5.

    Tracheobronchitis: purulent sputum with normal chest radiograph, not treated with IV antibiotics

  • 6.

    Pleural effusion: resulting in thoracentesis

Cardiac

  • 1.

    Transient ischemia: angina or ECG read as ischemia by physician

  • 2.

    Supraventricular tachycardia: resulting in pharmacologic intervention or care in the ICU

  • 3.

    Ventricular ectopy: resulting in therapy

  • 4.

    Transmural myocardial infarction: increased MB fraction of creatinine phosphokinase plus Q waves or characteristic ST elevation on ECG

  • 5.

    Nontransmural myocardial infarction: increased MB fraction plus ST depression or T−wave changes on ECG for more than 24 h

  • 6.

    Possible infarction: suspected but criteria for

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