Impaired oxygenation after lung resection: Incidence and perioperative risk factors

Alexander Nagrebetsky; Min Zhu; Hao Deng; Henning A Gaissert; Marcelo Gama de Abreu; Gyorgy Frendl; Maximilian S Schaefer; Marcos F Vidal Melo

doi:10.1016/j.jclinane.2024.111485

Impaired oxygenation after lung resection: Incidence and perioperative risk factors

J Clin Anesth. 2024 May 7:96:111485. doi: 10.1016/j.jclinane.2024.111485. Online ahead of print.

Authors

Alexander Nagrebetsky¹, Min Zhu², Hao Deng², Henning A Gaissert³, Marcelo Gama de Abreu⁴, Gyorgy Frendl⁵, Maximilian S Schaefer⁶, Marcos F Vidal Melo⁷

Affiliations

¹ Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. Electronic address: anagrebetsky@mgh.harvard.edu.
² Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
³ Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
⁴ Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
⁵ Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
⁶ Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany.
⁷ Division of Adult Cardiothoracic Anesthesiology, Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, USA.

PMID: 38718685
DOI: 10.1016/j.jclinane.2024.111485

Abstract

Study objective: To estimate the incidence of postoperative oxygenation impairment after lung resection in the era of lung-protective management, and to identify perioperative factors associated with that impairment.

Design: Registry-based retrospective cohort study.

Setting: Two large academic hospitals in the United States.

Patients: 3081 ASA I-IV patients undergoing lung resection.

Measurements: 79 pre- and intraoperative variables, selected for inclusion based on a causal inference framework. The primary outcome of impaired oxygenation, an early marker of lung injury, was defined as at least one of the following within seven postoperative days: (1) SpO₂ < 92%; (2) imputed PaO₂/FiO₂ < 300 mmHg [(1) or (2) occurring at least twice within 24 h]; (3) intensive oxygen therapy (mechanical ventilation or > 50% oxygen or high-flow oxygen).

Main results: Oxygenation was impaired within seven postoperative days in 70.8% of patients (26.6% with PaO₂/FiO₂ < 200 mmHg or intensive oxygen therapy). In multivariable analysis, each additional cmH₂O of intraoperative median driving pressure was associated with a 7% higher risk of impaired oxygenation (OR 1.07; 95%CI 1.04 to 1.10). Higher median intraoperative FiO₂ (OR 1.23; 95%CI 1.14 to 1.31 per 0.1) and PEEP (OR 1.12; 95%CI 1.04 to 1.21 per 1 cm H₂O) were also associated with increased risk. History of COPD (OR 2.55; 95%CI 1.95 to 3.35) and intraoperative albuterol administration (OR 2.07; 95%CI 1.17 to 3.67) also showed reliable effects.

Conclusions: Impaired postoperative oxygenation is common after lung resection and is associated with potentially modifiable pre- and intraoperative respiratory factors.

Keywords: Driving pressure; Hypoxemia; Intraoperative mechanical ventilation; Lung injury; Lung protective ventilation; Thoracic surgery.