Predictors of pulmonary complications after bariatric surgery.

BACKGROUND: Postoperative pneumonia (PP) and respiratory failure (PRF) are known to be the most common nonwound complications after bariatric surgery. Our objective was to identify their current prevalence after bariatric surgery and to study the preoperative factors associated with them using data from the American College of Surgeons' National Surgical Quality Improvement Program. METHODS: Patients undergoing bariatric surgery were identified from the National Surgical Quality Improvement Program (2006-2008), a multicenter, prospective database. Univariate analysis and multivariate logistic regression analysis were performed. RESULTS: Of 32,889 patients, PP was diagnosed in 187 patients (.6%) and PRF in 204 patients (.6%). The overall 30-day morbidity rate was 6.4%, with PP and PRF accounting for 18.7%. The 30-day mortality rate was greater for the patients with PP and PRF than those without (4.3% versus .16% and 13.7% versus .10%, P < .0001). The hospital length of stay was also longer in patients with PP/PRF (P < .0001). On multivariate analysis, congestive heart failure (odds ratio 5.3, 95% confidence interval 1.20-23.26) and stroke (odds ratio 4.1, 95% confidence interval 1.42-11.49) were the greatest preoperative risk factors for PP. Previous percutaneous coronary intervention (odds ratio 2.8, 95% confidence interval 1.64-4.74) and dyspnea at rest (odds ratio 2.64, 95% confidence interval 1.13-6.13) were the factors most strongly associated with PRF. Bleeding disorder, age, chronic obstructive pulmonary disease, and type of surgery were risk factors for both (P < .05). Smoking also predisposed to PP, and diabetes mellitus, anesthesia time, and increasing weight also predisposed to PRF (P < .05 for all). CONCLUSION: Although PP and PRF are infrequent, they account for one fifth of the postoperative morbidity and are associated with significantly increased 30-day mortality. They can be predicted by various risk factors, emphasizing the importance of patient optimization and careful selection before bariatric surgery.

Team training can improve operating room performance.

BACKGROUND: This study was conducted to determine if team training using a federally sponsored team training program improves operating room (OR) performance and culture. METHODS: The TeamSTEPPS program, a team training program designed and tested for health care applications, was provided to the OR staff. The training occurred over 2 months to all members of the OR team, including scrub technicians, nurses, certified registered nurse anesthetists, anesthesiologists, surgeons, and all anesthesiology and surgical resident staff. RESULTS: After 9 months, there was a significant improvement in the OR staff team work (score 53.2 to 62.7; P < .05) and OR communications (score 47. 5 to 62.7; P < .05). There was significant improvement in OR first case starts (69% to 81%), Surgical Quality Improvement Program measures (antibiotic administration, 78% to 97% [P < .05]; venous thromboembolism administration, 74% to 91% [P < .05]; and beta blocker administration, 19.7% to 100%; P < .05) and patient satisfaction (willingness to recommend, 77% to 89.3% [P < .05]). NSQIP measured overall surgical morbidity and mortality, which were both significantly improved (mortality, 2.7% to 1% [P < .05]; morbidity, 20.2% to 11.0% [P < .05]), indicating a significant change in the overall OR culture. A year later, the data showed that factors linked to regulatory requirements, such as Surgical Quality Improvement Program measures linked to the time out remained improved while first case on time starts decreased (81% to 69%; P < .05), patient willingness to recommend decreased (89.3% to 80.8%; P < .05), surgical mortality increased (1% to 1.5%; P < .05), and surgical morbidity increased (11% to 13%; P < .05) reflecting a degree of culture deterioration which has persisted. CONCLUSION: These data confirm that team training improves OR performance, but continued team training is required to provide sustained improved OR culture.