The Impact of Initial Postoperative Destination on Unplanned Critical Care Admissions After Lung Resection.

OBJECTIVES: Despite an increasing proportion of patients undergoing lung resection being managed postoperatively in a ward-based environment, studies analyzing the impact of initial postoperative destination (IPD) on perioperative outcomes and unplanned critical care admission (UCCA) are lacking. DESIGN: A single-center retrospective review. SETTING: A cardiothoracic surgery center in the Northwest of England. PARTICIPANTS: A total of 3,841 patients between 2012 and 2018. INTERVENTIONS: All patients underwent lung resection. Patients were classified as either IPD ward or IPD critical care. MEASUREMENTS AND MAIN RESULTS: Outcomes assessed included in-hospital and 90-day mortality and UCCA. Differences in mortality rates between groups were assessed using the chi-square test. Multivariate logistic regression analyses were performed to identify variables independently associated with 90-day mortality and UCCA. In total, 23.8% (n = 913) of patients went to critical care as their IPD. Overall in-hospital mortality was 1.6% (n = 62), and 90-day mortality was 2.9% (n = 112). The rate of UCCA was 10.5% (n = 404) and was significantly higher for IPD ward patients compared to IPD critical care patients (11.9% v 6.2%, p < 0.001). The 90-day mortality rates after UCCA were 5.2% (IPD ward) and 19.3% (IPD critical care) (p < 0.001). Advanced age, worse pulmonary function, IPD ward, and timing of surgery were all independently associated with UCCA. CONCLUSIONS: Most patients undergoing lung resection can be managed safely postoperatively in a ward-based environment. Short-term mortality is higher after UCCA, with patients who experience readmission to critical care at the highest risk of death. Patients should receive additional monitoring immediately following discharge from critical care.

Surgical factors associated with new-onset postoperative atrial fibrillation after lung resection: the EPAFT multicentre study.

PURPOSE OF THE STUDY: Postoperative atrial fibrillation (POAF) is a recognised complication in approximately 10% of major lung resections. In order to best target preoperative treatment, this study aimed at determining the association of incidence of POAF in patients undergoing lung resection to surgical and anatomical factors, such as surgical approach, extent of resection and laterality. STUDY DESIGN: Evaluation of Post-operative Atrial Fibrillation in Thoracic surgery (EPAFT): a multicentre, population-based, retrospective, cross-sectional, observational study including 1367 patients undergoing lung resections between April 2016 and March 2017. The primary outcome was the presence of POAF following resection. POAF was defined as at least one episode of symptomatic or asymptomatic AF confirmed by ECG within 7 days from the thoracic procedure or prior to discharge from the hospital. RESULTS: POAF was observed in 7.4% of patients: 3.1% in minor resection (video-assisted thoracoscopic surgery (VATS): 2.5%; thoracotomy: 3.8%), 9.0% in simple lobectomy (VATS: 7.3%, thoracotomy: 9.9%), 6.0% in complex resection (thoracotomy: 6.3%) and 11.4% in pneumonectomy. POAF was higher in left (4.0%) vs right (2.4%) minor resections, and in left (9.9%) vs right (8.3%) lobectomy, but higher in right (7.5%) complex resections, and the highest in right pneumonectomy (17.6%). No significant variations were observed as per sex, laterality or resected lobes. A positive univariable and multivariable association was observed for increasing age and increasing extent of resection, but not thoracotomy. Median (Q1-Q3) hospital stay was 9 (7-14) days in POAF and 5 (4-7) days in non-AF patients (p<0.001), with an increased cerebrovascular accident burden (p<0.001) and long-term mortality (p<0.001). CONCLUSIONS: Among patients undergoing lung resection, POAF was significantly associated with age, increasing invasiveness of approach and increasing extent of resection. In addition, POAF carried a significant long-term mortality rate and burden of cerebrovascular accident. Appropriate prophylaxis should be targeted at these groups.

Preoperative Anemia is Associated With Worse Long-Term Survival After Lung Cancer Resection: A Multicenter Cohort Study of 5,029 Patients.

OBJECTIVES: Although some evidence to suggest an association between preoperative anemia and reduced overall survival exists, contemporary studies investigating the impact of preoperative anemia on outcomes after resection for primary lung cancer are lacking. DESIGN: A multicenter retrospective review. SETTING: Two tertiary cardiothoracic surgery centers in the Northwest of England. PARTICIPANTS: A total of 5,029 patients between 2012 and 2018. INTERVENTIONS: All patients underwent lung resection for primary lung cancer. Patients were classified as anemic based on the World Health Organization definition. Men with hemoglobin <130 g/L and women with hemoglobin <120 g/L were considered to be anemic. MEASUREMENTS AND MAIN RESULTS: Outcomes assessed included perioperative mortality, 90-day mortality, and overall survival. Multivariate logistic and Cox regression analyses were used to assess the impact of preoperative anemia on 90-day mortality and overall survival, respectively. Overall, preoperatively, 24.0% (n = 1207) of patients were anemic. The 90-day mortality for anemic and nonanemic patients was 5.6% and 3.1%, respectively (p < 0.001). After multivariate adjustment, preoperative anemia was not associated with increased 90-day mortality. However, a log-rank analysis demonstrated reduced overall survival for anemic patients (p < 0.001). After multivariate adjustment, preoperative anemia was found to be independently associated with reduced overall survival (hazard ratio 1.287, 95% confidence interval 1.141-1.451, p < 0.001). CONCLUSIONS: Although anemia was not an independent predictor of short-term outcomes, it was independently associated with significantly reduced survival for patients undergoing resection for lung cancer. Further work is required to understand why anemia reduces long-term survival and whether pathways for anemic patients can be adapted to improve long-term outcomes.