Background: While acute lung injury (ALI) is among the most serious postoperative pulmonary complications, its incidence, risk factors and outcome have not been prospectively studied. Objective: To determine the incidence and survival of ALI associated postoperative respiratory failure and its association with intraoperative ventilator settings, specifically tidal volume. Design: Prospective, nested, case control study. Setting: Single tertiary referral centre. Patients: 4420 consecutive patients without ALI undergoing high risk elective surgeries for postoperative pulmonary complications. Measurements: Incidence of ALI, survival and 2:1 matched case control comparison of intraoperative exposures. Results: 238 (5.4%) patients developed postoperative respiratory failure. Causes included ALI in 83 (35%), hydrostatic pulmonary oedema in 74 (31%), shock in 27 (11.3%), pneumonia in nine (4%), carbon dioxide retention in eight (3.4%) and miscellaneous in 37 (15%). Compared with match controls (n = 166), ALI cases had lower 60 day and 1 year survival (99% vs 73% and 92% vs 56%; p,0.001). Cases were more likely to have a history of smoking, chronic obstructive pulmonary disease and diabetes, and to be exposed to longer duration of surgery, intraoperative hypotension and larger amount of fluid and transfusions. After adjustment for non-ventilator parameters, mean first hour peak airway pressure (OR 1.07; 95% CI 1.02 to 1.15 cm H 2 O) but not tidal volume (OR 1.03; 95% CI 0.84 to 1.26 ml/kg), positive end expiratory pressure (OR 0.89; 95% CI 0.77 to 1.04 cm H 2 O) or fraction of inspired oxygen (OR 1.0; 95% CI 0.98 to 1.03) were associated with ALI. Conclusion: ALI is the most common cause of postoperative respiratory failure and is associated with markedly lower postoperative survival. Intraoperative tidal volume was not associated with an increased risk for early postoperative ALI.Postoperative pulmonary complications, and in particular postoperative respiratory failure, are important causes of perioperative morbidity and mortality.
T he impact of obstetric anesthesia on short and long-term behavior and development of a neonate/child is not thoroughly understood. In animal studies, exposure of fetuses/neonates to anesthetics administered to the mother causes histopathologic changes in the brain; even single, relatively brief administrations may be associated with a diminished capacity to retain learned behavior and/or abnormal behaviors resembling autism. The significance of this in humans is not clear, but the authors of this study recently showed that repeated (not single) exposures to anesthesia before the age of 4 years may double the risk of learning disabilities (LD) in a child. Using data from the same population-based birth cohort, they examined the possible association between fetal exposure to anesthesia during cesarean delivery (CS) and the subsequent development of LD in the child.Records of all children born in Rochester, Minnesota, between January 1, 1976 and December 31, 1982 to women living in one county school district (n = 8548) were reviewed. Those still living in the district at 5 years of age (n = 5718) were identified for the cohort. School, medical, and Reading Center/ Dyslexia Institute records were used to identify those with a potential LD [n = 1510 (26%)]. Finally, children meeting criteria based on standard measures of intelligent quotient and/or achievement within the same calendar year and before the age of 19 years having at least 1 of 3 LD (reading, written language, and math disorders) were considered cases.From the total possible subjects, exclusion of 19 children with severe mental retardation and 379 with authorization issues left the cohort with 5320 children; 4823 (90.7%) delivered vaginally, 193 (3.6%) by CS with general anesthesia (most including sodium thiopental, nitrous oxide, and potent inhalational anesthetics), and 304 (5.7%) by CS with regional anesthesia. Mean exposures to anesthetics were: epidural, 63.5 minutes; spinal, 21 minutes; and general, 14 minutes. Among 921 (17.3%) actual LD cases, incidence for children whose mothers delivered vaginally was 20.8% versus 19.4% for children delivered through CS with general anesthesia and 15.4% for children born through CS with regional anesthesia. With unadjusted proportional hazard regression, the incidence of LD was not increased in children born through CS compared with those born through vaginal delivery (overall, P = 0.135). However, after adjusting for risk factors for LD, the data suggested the risk of LD may be decreased in children delivered through CS under regional anesthesia compared with those delivered vaginally. The authors concluded that these results suggest that brief perinatal exposure to anesthetic drugs does not adversely affect long-term neurodevelopment. As children born by CS under regional anesthesia had a lower incidence of LD than the other 2 groups, they hypothesize that regional anesthesia for CS may attenuate the neonatal stress response to delivery sufficiently to have significant effects on later neural development. Li...
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