PART 2. Diaphragm thickening fraction as a prognostic imaging marker for postoperative pulmonary
2.5 CONCLUSION
Figure 2.1. Measurement of diaphragm thickening fraction (TF) by ultrasonography. The diaphragm thicknesses at peak inspiration (Tpi) (a) and end expiration (Tee) (b) were measured. Diaphragm TF was calculated as follows: TF = (Tpi– Tee)/Tee.
Figure 2.2.Study flow diagram of patients. PPC, postoperative pulmonary complication.
Figure 2.3. Comparison of the preoperative diaphragm TF between the PPC group and non-PPC group in patients undergoing RALP. Note that diaphragm TF is significantly lower in the PPC group than in the non-PPC group. TF, thickening fraction; PPC, postoperative pulmonary complication; RALP, robot-assisted laparoscopic prostatectomy.
Figure 2.4.Receiver operating characteristic curve analysis of diaphragm TF for predicting PPCs in patients undergoing RALP. The AUC is 0.714, with an optimal cut-off value of 0.28. TF, thickening fraction; PPCs, postoperative pulmonary complications; RALP, robot-assisted laparoscopic prostatectomy; AUC, area under the curve.
Figure 2.5.Comparison of the incidence of PPCs between the TF ≥0.28 group and TF <0.28 group. Note that the TF <0.28 group has a higher incidence of PPCs than TF ≥0.28 group. PPCs, postoperative pulmonary complications; TF, thickening fraction.
Figure 2.6.Predictive ability of diaphragm TF ≥0.28 for the occurrence of PPCs in patients undergoing RALP.
*The multivariate-adjusted odds ratio was adjusted using the variables shown in Table 2.2. TF, thickening fraction; PPCs, postoperative pulmonary complications; RALP, robot-assisted laparoscopic prostatectomy.
Table 2.1. Diagnostic criteria for postoperative pulmonary complications in robot-assisted laparoscopic prostatectomy
Atelectasis, pleural effusion, and pneumothorax were diagnosed with radiologist’s description of chest X-rays.
Complication Definition
Atelectasis Atelectasis was defined as lung opacification with a shift of the hilum, hemidiaphragm, or mediastinum toward the affected side and compensatory overinflation in the adjacent non-atelectatic lung.
Pleural effusion Pleural effusion was defined as chest X-ray showing loss of the sharp silhouette of the ipsilateral hemidiaphragm in the upright position, evidence of displacement of adjacent anatomical structures, blunting of the costophrenic angle, or a hazy opacity in one hemithorax with preserved vascular shadows.
Bronchospasm Bronchospasm was defined as newly developed expiratory wheezing that needed treatment with bronchodilators.
Pneumothorax Pneumothorax was defined as air in the pleural space without vascular bed surrounding the visceral pleura.
Respiratory infection Respiratory infection was diagnosed as the need of treatment with antibiotics for suspected respiratory infection and as the occurrence of one or more of the following symptoms: new or changed sputum, fever, new or changed lung opacities, or leukocyte count more than 12,000/mm3.
Aspiration pneumonitis
Aspiration pneumonitis was defined as an acute lung injury due to aspiration of gastric contents.
Respiratory failure Respiratory failure was defined as a partial arterial oxygen pressure/fractional inspired oxygen concentration <300 mmHg, partial arterial oxygen pressure
<60 mmHg in room air, or arterial oxygen saturation measured with pulse oximeter <90% and requiring oxygen therapy.
Table 2.2. Preoperative and intraoperative data
Variables All patients
(n = 145)
Non-PPC group (n = 105)
PPC group
(n = 40) p-value*
Age (years) 67.2 ± 6.3 67.0 ± 6.7 67.9 ± 5.2 0.418
Body mass index (kg/m2) 24.8 ± 2.6 24.8 ± 2.7 24.9 ± 2.4 0.912
ASA physical status 0.637
2 119 (82.1) 85 (81.0) 34 (85.0)
3 26 (17.9) 20 (19.0) 6 (15.0)
Hypertension 61 (42.1) 46 (43.8) 15 (37.5) 0.492
Diabetes mellitus 20 (13.8) 15 (14.3) 5 (12.5) 0.800
Cerebrovascular disease 10 (6.9) 9 (8.6) 1 (2.5) 0.285
Coronary artery disease 14 (9.7) 9 (8.6) 5 (12.5) 0.532
COPD 19 (13.1) 14 (13.3) 5 (12.5) >0.999
Interstitial lung disease 0 (0) 0 (0) 0 (0) >0.999
Pulmonary tuberculosis 0 (0) 0 (0) 0 (0) >0.999
Pulmonary function test
FVC (L) 3.8 ± 0.6 3.8 ± 0.6 3.6 ± 0.6 0.104
FEV1 (L) 2.8 ± 0.5 2.8 ± 0.5 2.6 ± 0.5 0.051
FEV1/FVC ratio (%) 73.2 ± 11.2 73.6 ± 11.7 72.2 ± 10.1 0.477
Pre-induction hemodynamics
Mean blood pressure (mmHg) 90 ± 11 90 ± 10 90 ± 12 0.743
Systolic blood pressure (mmHg) 137 ± 18 136 ± 18 138 ± 19 0.437
Diastolic blood pressure (mmHg) 75 ± 11 75 ± 10 75 ± 13 0.728
Body temperature ( ) 36.6 ± 0.3 36.6 ± 0.3 36.6 ± 0.3 0.850
Heart rate (beats/min) 71 ± 13 70 ± 13 71 ±12 0.642
SpO2 (%) 97.9 ± 1.8 98.0 ± 1.8 97.7 ± 1.8 0.343
Arterial blood gas analysis after induction
pH 7.46 ± 0.03 7.46 ± 0.03 7.46 ± 0.03 0.722
PaO2(mmHg) 288.4 ± 72.8 287.5 ± 70.9 290.6 ±78.6 0.822
PaCO2 (mmHg) 39.1 ± 4.8 39.2 ± 5.0 38.9 ± 4.1 0.713
HCO3-(mmol/L) 28.1 ± 2.3 28.2 ± 2.3 27.7 ± 2.3 0.248
Base excess (mmol/L) 4.0 ± 2.1 4.1 ± 2.1 3.7 ± 2.1 0.236
SaO2 (%) 99.9 ± 0.5 99.9 ± 0.4 99.9 ± 0.6 0.566
Arterial blood gas analysis at skin closure
Continuous variables are presented as mean ± standard deviation, and categorical variables are presented as number (percentage). * For comparisons between the PPC and non-PPC groups. ASA, American Society of Anesthesiologists;
COPD, chronic obstructive pulmonary disease; FEV1, forced expiratory volume in the first second; FVC, forced vital capacity; SpO2, peripheral oxygen saturation; pH, hydrogen ion concentration; PaCO2, arterial carbon dioxide partial pressure; PaO2, arterial oxygen partial pressure; HCO3-, bicarbonate; SaO2, arterial oxygen saturation.
pH 7.42 ± 0.03 7.42 ± 0.03 7.41 ± 0.04 0.055
PaO2(mmHg) 189.0 ± 45.0 191.8 ± 43.4 181.7 ± 48.8 0.230
PaCO2(mmHg) 40.5 ± 3.3 40.2 ± 3.2 41.3 ± 3.3 0.071
HCO3-(mmol/L) 26.1 ± 1.9 26.1 ± 1.9 26.2 ± 2.2 0.934
Base excess (mmol/L) 1.5 ± 2.0 1.6 ± 1.9 1.3 ± 2.4 0.408
SaO2(%) 99.6 ± 0.8 99.7 ± 0.6 99.4 ± 1.0 0.051
Anesthesia duration (min) 160.9 ± 25.8 160.9 ± 24.6 160.9 ± 28.9 0.988 Operation duration (min) 120.8 ± 25.6 120.8 ± 24.5 121.0 ± 28.8 0.963 Crystalloid amount (mL) 838.7 ± 540.5 848.2 ± 596.9 813.8 ± 357.3 0.733
Table 2.3. Preoperative and intraoperative data of the two groups categorized according to the optimal diaphragm TF cut-off value
Variables TF ≥0.28 group
(n = 114)
TF <0.28 group
(n = 31) p-value
Age (years) 67.5 ± 6.1 66.3 ± 7.0 0.349
Body mass index (kg/m2) 24.8 ± 2.6 24.9 ± 2.5 0.926
ASA physical status 0.598
2 92 (80.7) 27 (87.1)
3 22 (19.3) 4 (12.9)
Hypertension 42 (43.0) 12 (38.7) 0.838
Diabetes mellitus 16 (14.0) 4 (12.9) >0.999
Cerebrovascular disease 8 (7.0) 2 (6.5) >0.999
Coronary artery disease 12 (10.5) 2 (6.5) 0.388
COPD 14 (12.3) 5 (16.1) 0.765
Interstitial lung disease 0 (0) 0 (0) >0.999
Pulmonary tuberculosis 0 (0) 0 (0) >0.999
Pulmonary function test
FVC (L) 3.8 ± 0.6 3.8 ± 0.7 0.731
FEV1 (L) 2.8 ± 0.5 2.8 ± 0.7 0.549
FEV1/FVC ratio (%) 73.1 ± 11.2 73.7 ± 11.5 0.796
Pre-induction hemodynamics
Mean blood pressure (mmHg) 90.5 ± 10.3 87.6 ± 12.1 0.173
Systolic blood pressure (mmHg) 137.0 ± 18.2 134.7 ± 17.6 0.538
Diastolic blood pressure (mmHg) 76.0 ± 10.4 72.0 ± 12.2 0.075
Body temperature ( ) 36.6 ± 0.3 36.6 ± 0.3 0.943
Heart rate (beats/min) 70.6 ± 12.9 70.4 ± 12.1 0.931
SpO2 (%) 98.0 ± 1.8 97.5 ± 1.6 0.140
Arterial blood gas analysis after induction
pH 7.5 ± 0.03 7.5 ± 0.03 0.472
PaO2(mmHg) 283.9 ± 70.6 304.7 ± 79.4 0.193
PaCO2 (mmHg) 38.9 ± 4.9 40.0 ± 4.5 0.235
HCO3-(mmol/L) 28.0 ± 2.2 28.4 ± 2.7 0.442
Base excess (mmol/L) 4.0 ± 2.0 4.2 ± 2.4 0.648
SaO2 (%) 99.9 ± 0.4 99.9 ± 0.7 0.709
Arterial blood gas analysis at skin closure
pH 7.4 ± 0.04 7.4 ± 0.05 0.460
PaO2(mmHg) 188.9 ± 43.6 189.6 ± 50.5 0.939
Continuous variables are presented as mean ± standard deviation, and categorical variables are presented as number (percentage). TF, thickening fraction; ASA, American Society of Anesthesiologists; COPD, chronic obstructive pulmonary disease; FEV1, forced expiratory volume in the first second; FVC, forced vital capacity; SpO2, peripheral oxygen saturation;
pH, hydrogen ion concentration; PaCO2, arterial carbon dioxide partial pressure; PaO2, arterial oxygen partial pressure;
HCO3-, bicarbonate; SaO2, arterial oxygen saturation.
PaCO2(mmHg) 40.2 ± 3.3 41.3 ± 3.0 0.093
HCO3-(mmol/L) 26.2 ± 1.9 26.0 ± 2.2 0.625
Base excess (mmol/L) 1.6 ± 1.9 1.2 ± 2.4 0.412
SaO2(%) 99.6 ± 0.7 99.4 ± 1.0 0.070
Anesthesia duration (min) 159.3 ± 24.8 166.7 ± 28.6 0.200
Operation duration (min) 119.4 ± 24.9 126.2 ± 28.0 0.192
Crystalloid amount (mL) 845.7 ± 577.3 812.9 ± 382.1 0.766
CONCLUSION
In this doctoral thesis, the author evaluated the predictive ability of clinically available indices such as PNI and diaphragm TF for PPCs in urologic surgery.
In Part 1, the incidence of PPCs was 13.6% after radical cystectomy. PPCs were associated with PNI, age, and serum creatinine level. A PNI ≤45 was significantly associated with a higher likelihood of PPCs in radical cystectomy. Moreover, the rates of ICU admission and prolonged ICU stay were higher in radical cystectomy patients with PPCs than in those without.
In Part 2, in a prospective observational study, the incidence of PPCs was 27.6% in RALP. Diaphragm TF <0.28 was associated with a higher likelihood of PPCs in RALP.
These results suggest that preoperative evaluations of PNI as a simple laboratory test and diaphragm TF as a noninvasive imaging marker can provide useful information for the prediction of PPCs in urologic surgery.
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