Postoperative outcomes in surgical COVID-19 patients

COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet. 2020 Jul 4;396(10243):27-38. Erratum in: Lancet. 2020 Jun 9.

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Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28-2·40], p<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65-3·22], p<0·0001), American Society of Anesthesiologists grades 3-5 versus grades 1-2 (2·35 [1·57-3·53], p<0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01-2·39], p=0·046), emergency versus elective surgery (1·67 [1·06-2·63], p=0·026), and major versus minor surgery (1·52 [1·01-2·31], p=0·047).

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Article of interest: Does Atelectasis Cause Fever After Surgery? Putting a Damper on Dogma.

Crompton JG, Crompton PD, Matzinger P. Does Atelectasis Cause Fever After Surgery? Putting a Damper on Dogma. JAMA Surg. 2019 May 1;154(5):375-376.

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fever after an operationFigure. Damage-Associated Molecular Patterns (DAMPs) and Pathogen-Associated Molecular Patterns (PAMPs)

“The danger model of immunity challenges the premise of our current therapeutic approach in treating noninfectious causes of postoperative fever. The clinical benefit of interventions targeting atelectasis as a cause of postoperative fever, such as incentive spirometry, need to be reassessed. Continue reading

Postoperative negative pressure pulmonary edema

Liu R, Wang J, Zhao G, Su Z. Negative pressure pulmonary edema after general anesthesia: A case report and literature review. Medicine (Baltimore). 2019 Apr;98(17): e15389. doi: 10.1097/MD.0000000000015389.

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It is widely accepted that the central mechanism of postoperative NPPE is related to rapid negative intrapleural pressure increasing due to forceful inspiration against the obstruction, which can be up to 10 times or more that of normal breathing. [7] A typical event leading to acute airway obstruction associated with postoperative NPPE is laryngospasm. Other procedure that increases the risk of NPPE includes oropharyngeal, head, and neck surgery. Five [8–12] of the reported 29 cases involved upper respiratory tract surgery, and 10 [1,3,6,7,13–18] of the cases involved head and neck surgery, which may be related to tissue swelling and the sensitive dilator muscle of the upper airway in head and neck surgeries.

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Article of interest: ECMO for Severe ARDS

Combes A, Hajage D, Capellier G, et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. N Engl J Med. 2018;378(21):1965–1975.

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Results: At 60 days, 44 of 124 patients (35%) in the ECMO group and 57 of 125 (46%) in the control group had died (relative risk, 0.76; 95% confidence interval [CI], 0.55 to 1.04; P=0.09). Crossover to ECMO occurred a mean (±SD) of 6.5±9.7 days after randomization in 35 patients (28%) in the control group, with 20 of these patients (57%) dying. The frequency of complications did not differ significantly between groups, except that there were more bleeding events leading to transfusion in the ECMO group than in the control group (in 46% vs. 28% of patients; absolute risk difference, 18 percentage points; 95% CI, 6 to 30) as well as more cases of severe thrombocytopenia (in 27% vs. 16%; absolute risk difference, 11 percentage points; 95% CI, 0 to 21) and fewer cases of ischemic stroke (in no patients vs. 5%; absolute risk difference, -5 percentage points; 95% CI, -10 to -2).