Plastic and Reconstructive Surgery • July 2014 DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Mulliken JB, Kim DC. Repair of bilateral incomplete cleft lip: Techniques and outcomes. Plast Reconstr Surg. 2013;132:923–932. 2. Wolfe SA, Ghurani R, Mejia M. Use of staged rotation-advancement procedures for the treatment of incomplete bilateral clefts of the lip. Ann Plast Surg. 2004;52:263–268; discussion 269. 3. Wolfe SA, Mejia ML. Staged rotation advancements provide improved nasal results compared to 1-stage repairs in patients with complete bilateral cleft lip and palate. Ann Plast Surg. 2014;72:307–311. 4. Farkas LG. Anthropometry of the Head and Face. New York: Raven; 1994.
Assessing Risk Factors of Respiratory Complications following Abdominal Wall Reconstruction Sir: n a retrospective study by Fischer et al.1 assessing associations of perioperative factors with postoperative respiratory morbidity in patients undergoing abdominal wall reconstruction, they had attempted to control most of the known factors that could affect postoperative respiratory complications, such as age, body mass index, smoking status, American Society of Anesthesiologists physical status, preoperative comorbidities, use of steroids, intraoperative blood loss and transfusion, and others. Furthermore, they used appropriate methods to determine risk factors for postoperative respiratory complications. However, this study is a retrospective analysis with observational designs, which are inevitably subject to uncontrolled and unmeasured confounding. In our view, several important issues of this study were not well addressed. First, the authors did not describe use of opioid drugs or neuromuscular blocking agents during surgery, the duration of postoperative assessment, or methods of postoperative analgesia. Fair evidence suggests that intraoperative short-acting rather than long-acting neuromuscular blocking agents reduce the risk of postoperative respiratory complications.2 It has been shown that the first 24 hours after surgery represent the highest risk of unanticipated respiratory failure because of opioid drugs, whereas postoperative hypoxemia is most common by the third night after major surgery.3 Thus, assessment of postoperative respiratory complications is frequently focused on the early postoperative period of 3 days after surgery. Following abdominal surgery, moreover, pain is recognized as being the most frequent postoperative problem, and inadequate postoperative analgesia may result in splinting, with rapid and shallow breathing. As a result, ensuring adequate analgesia in the postoperative period is of great importance, not only for patient comfort but also for improvement of pulmonary function and a reduction in the risk of respiratory complications.4
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Second, in this study, 67.2 percent of patients had at least one defined comorbidity preoperatively. Moreover, the most common comorbid condition was hypertension (53.0 percent), and 9.7 percent of patients suffered from coronary artery disease. Thus, preoperative assessment of cardiac function should be included in the study design. Good-quality evidence identifies preoperative cardiac insufficiency as a significant risk factor for postoperative pulmonary complications.2 To exclude the possible influence of existing lung lesions on the postoperative respiratory outcome, preoperative chest radiography is required, especially for patients with new or unstable cardiopulmonary signs or symptoms and patients at increased risk of postoperative pulmonary complications.2 Finally, ventilator-induced lung injury is a possible confounding factor. It is generally believed that use of large tidal volume or high pressure during general anesthesia may adversely influence postoperative pulmonary complications. In this study, the authors assessed the effects of inspiratory pressure on postoperative respiratory morbidities, and showed that the highest peak intraoperative airway pressure was associated with postoperative respiratory complications. We would like to know whether an identical ventilation strategy, with the same settings of ventilation mode, ventilation rate, and tidal volume, was used in all patients. A randomized clinical trial in patients undergoing elective laparotomy confirms that, compared with standard ventilation strategy, a protective ventilation strategy with lower tidal volumes, positive end-expiratory pressure, and recruitment maneuvers during anesthesia improves postoperative respiratory function and reduces the clinical signs of postoperative pulmonary infection.5 In addition, transfusion-related acute lung injury is a well-known issue. To assess associations of intraoperative transfusions with postoperative respiratory morbidity, transfusion indications during surgery should at least be provided. We believe that addressing the above confounding factors would further clarify the transparency of this retrospective study. DOI: 10.1097/PRS.0000000000000297
Fu S. Xue, M.D. Shi Y. Wang, M.D. Xin L. Cui, M.D. Rui P. Li, M.D. Department of Anesthesiology Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing, People’s Republic of China Correspondence to Dr. Xue Department of Anesthesiology Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College 33 Ba-Da-Chu Road Shi-Jing-Shan District Beijing 100144, People’s Republic of China [email protected]
Volume 134, Number 1 • Letters DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. No external funding was received. REFERENCES 1. Fischer JP, Wes AM, Wink JD, Nelson JA, Braslow BM, Kovach SJ. Analysis of risk factors, morbidity, and cost associated with respiratory complications following abdominal wall reconstruction. Plast Reconstr Surg. 2014;133:147–156. 2. Qaseem A, Snow V, Fitterman N, et al. Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: A guideline from the American College of Physicians. Ann Intern Med. 2006;144:575–580. 3. Young A, Ramachandran SK. Clinical prediction of postoperative respiratory failure. Anesthesiology 2013;118:1247–1249. 4. Duggan M, Kavanagh BP. Perioperative modifications of respiratory function. Best Pract Res Clin Anaesthesiol. 2010;24:145–155. 5. Severgnini P, Selmo G, Lanza C, et al. Protective mechanical ventilation during general anesthesia for open abdominal surgery improves postoperative pulmonary function. Anesthesiology 2013;118:1307–1321.
Reply: Assessing Risk Factors of Respiratory Complications following Abdominal Wall Reconstruction Sir:
We appreciate the thoughtful response by Dr. Xue et al. to our article.1 In their letter, three main issues were raised regarding the study’s methodology and patient assessment: (1) intraoperative neuromuscular blockade and perioperative opioid analgesia; (2) preoperative assessment of cardiac function; and (3) ventilator-induced lung injury and blood transfusion strategies. We agree with the comments and insightful critiques presented by Dr. Xue et al. Further clarification on these issues is warranted. Several important overarching issues are worth mentioning first. Ventral hernia repair represents an extremely common disease process that creates a tremendous burden and adverse functional impact for patients. Complex abdominal wall reconstruction for large hernias represents a unique procedure in which high rates of both surgical and medical morbidity can occur, despite the best efforts at optimizing patient selection, refined surgical techniques, and multidisciplinary perioperative collaboration. Our study aimed to better delineate the incidence, risk factors, and downstream healthcare impact of respiratory morbidity in these procedures. We acknowledge that retrospective study design is fraught with intrinsic limitations that impact the applicability (and potentially the validity) of our data. Our work does, however, offer a unique assessment of postoperative respiratory morbidity in an area of surgery in need of clinical outcomes research. We approach this analysis with complete transparency of our outcomes and with an interest in improving processes of care for our patients.
Intraoperative neuromuscular blockade and opioid administration are performed at the discretion of the attending anesthesiologist of record for the case. Shortacting neuromuscular blockage agents may be utilized for induction (i.e., succinylcholine); however, intermediateacting neuromuscular blockade agents (i.e., vecuronium) are utilized most commonly during the remainder of the case. Long-acting agents are almost never utilized, and all patients are fully reversed at the conclusion of the case. The senior author (J.P.F.) favors complete neuromuscular blockade during repair, such that any undue tension generated by abdominal wall contractile forces is mitigated. The scope of this article did not focus directly on the use or type of neuromuscular blockade, since this is typical of institutional practice pattern and as such was not individually assessed for each patient. Perioperative pain management, however, is a slightly more challenging issue. Studies have demonstrated that epidural use can significantly improve perioperative metrics following open intra-abdominal operations.2 We have recently examined this in our ventral hernia population,3 and have demonstrated that epidurals may be associated with reduced perioperative morbidity and cost following abdominal wall reconstruction specifically. As such, we advocate for their use in all patients deemed appropriate by our anesthesiology team. When epidurals are placed, typically a combination of fentanyl and bupivacaine is utilized for analgesia. No opioids are administered, and this pattern is continued postoperatively with patientcontrolled epidural analgesia devices for at least 48 hours postoperatively, assuming a working epidural. However, in cases where epidurals are not placed or if the patient has an underlying opioid requirement, intraoperative and postoperative analgesia is achieved initially by intravenous opioids. Intraoperatively, opioids are administered as morphine equivalents based on changes in vital signs as monitored by the anesthesiologist. Postoperatively, patients utilize patient-controlled analgesia devices, most commonly utilizing morphine or Dilaudid, with an initial maximum dose of 1 mg or morphine or its equivalent every 10 minutes. If pain is uncontrolled, this dosage is titrated accordingly. Of note, epidural patients with an underlying preoperative opioid requirement receive only bupivacaine in their epidural, and do receive opioid patient-controlled analgesia. Our study did not directly assess pain or total opioid use following ventral hernia repair, but anecdotally we do note improved pain control with epidurals. This is an area necessitating further research that exceeded the scope of this current analysis. Regarding the preoperative assessment of cardiac function, in our preoperative history and physical, if a cardiac condition is noted or if there is significant concern, medical clearance from a cardiologist is obtained. It is therefore at the discretion of the cardiologist to obtain cardiac imaging to assess function (i.e., echocardiography). Certainly patients with known coronary artery disease underwent appropriate assessment and imaging. We do not routinely order cardiac imaging, but preoperative chest radiographs are obtained according to published recommendations,4 especially in older patients or patients
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Assessing Risk Factors of Respiratory Complications following Abdominal Wall Reconstruction Sir: n a retrospective study by Fischer et al.1 assessing associations of perioperative factors with postoperative respiratory morbidity in patients undergoing abdominal wall reconstruction, they had attempted to control most of the known factors that could affect postoperative respiratory complications, such as age, body mass index, smoking status, American Society of Anesthesiologists physical status, preoperative comorbidities, use of steroids, intraoperative blood loss and transfusion, and others. Furthermore, they used appropriate methods to determine risk factors for postoperative respiratory complications. However, this study is a retrospective analysis with observational designs, which are inevitably subject to uncontrolled and unmeasured confounding. In our view, several important issues of this study were not well addressed. First, the authors did not describe use of opioid drugs or neuromuscular blocking agents during surgery, the duration of postoperative assessment, or methods of postoperative analgesia. Fair evidence suggests that intraoperative short-acting rather than long-acting neuromuscular blocking agents reduce the risk of postoperative respiratory complications.2 It has been shown that the first 24 hours after surgery represent the highest risk of unanticipated respiratory failure because of opioid drugs, whereas postoperative hypoxemia is most common by the third night after major surgery.3 Thus, assessment of postoperative respiratory complications is frequently focused on the early postoperative period of 3 days after surgery. Following abdominal surgery, moreover, pain is recognized as being the most frequent postoperative problem, and inadequate postoperative analgesia may result in splinting, with rapid and shallow breathing. As a result, ensuring adequate analgesia in the postoperative period is of great importance, not only for patient comfort but also for improvement of pulmonary function and a reduction in the risk of respiratory complications.4
I
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Second, in this study, 67.2 percent of patients had at least one defined comorbidity preoperatively. Moreover, the most common comorbid condition was hypertension (53.0 percent), and 9.7 percent of patients suffered from coronary artery disease. Thus, preoperative assessment of cardiac function should be included in the study design. Good-quality evidence identifies preoperative cardiac insufficiency as a significant risk factor for postoperative pulmonary complications.2 To exclude the possible influence of existing lung lesions on the postoperative respiratory outcome, preoperative chest radiography is required, especially for patients with new or unstable cardiopulmonary signs or symptoms and patients at increased risk of postoperative pulmonary complications.2 Finally, ventilator-induced lung injury is a possible confounding factor. It is generally believed that use of large tidal volume or high pressure during general anesthesia may adversely influence postoperative pulmonary complications. In this study, the authors assessed the effects of inspiratory pressure on postoperative respiratory morbidities, and showed that the highest peak intraoperative airway pressure was associated with postoperative respiratory complications. We would like to know whether an identical ventilation strategy, with the same settings of ventilation mode, ventilation rate, and tidal volume, was used in all patients. A randomized clinical trial in patients undergoing elective laparotomy confirms that, compared with standard ventilation strategy, a protective ventilation strategy with lower tidal volumes, positive end-expiratory pressure, and recruitment maneuvers during anesthesia improves postoperative respiratory function and reduces the clinical signs of postoperative pulmonary infection.5 In addition, transfusion-related acute lung injury is a well-known issue. To assess associations of intraoperative transfusions with postoperative respiratory morbidity, transfusion indications during surgery should at least be provided. We believe that addressing the above confounding factors would further clarify the transparency of this retrospective study. DOI: 10.1097/PRS.0000000000000297
Fu S. Xue, M.D. Shi Y. Wang, M.D. Xin L. Cui, M.D. Rui P. Li, M.D. Department of Anesthesiology Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing, People’s Republic of China Correspondence to Dr. Xue Department of Anesthesiology Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College 33 Ba-Da-Chu Road Shi-Jing-Shan District Beijing 100144, People’s Republic of China [email protected]
Volume 134, Number 1 • Letters DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. No external funding was received. REFERENCES 1. Fischer JP, Wes AM, Wink JD, Nelson JA, Braslow BM, Kovach SJ. Analysis of risk factors, morbidity, and cost associated with respiratory complications following abdominal wall reconstruction. Plast Reconstr Surg. 2014;133:147–156. 2. Qaseem A, Snow V, Fitterman N, et al. Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: A guideline from the American College of Physicians. Ann Intern Med. 2006;144:575–580. 3. Young A, Ramachandran SK. Clinical prediction of postoperative respiratory failure. Anesthesiology 2013;118:1247–1249. 4. Duggan M, Kavanagh BP. Perioperative modifications of respiratory function. Best Pract Res Clin Anaesthesiol. 2010;24:145–155. 5. Severgnini P, Selmo G, Lanza C, et al. Protective mechanical ventilation during general anesthesia for open abdominal surgery improves postoperative pulmonary function. Anesthesiology 2013;118:1307–1321.
Reply: Assessing Risk Factors of Respiratory Complications following Abdominal Wall Reconstruction Sir:
We appreciate the thoughtful response by Dr. Xue et al. to our article.1 In their letter, three main issues were raised regarding the study’s methodology and patient assessment: (1) intraoperative neuromuscular blockade and perioperative opioid analgesia; (2) preoperative assessment of cardiac function; and (3) ventilator-induced lung injury and blood transfusion strategies. We agree with the comments and insightful critiques presented by Dr. Xue et al. Further clarification on these issues is warranted. Several important overarching issues are worth mentioning first. Ventral hernia repair represents an extremely common disease process that creates a tremendous burden and adverse functional impact for patients. Complex abdominal wall reconstruction for large hernias represents a unique procedure in which high rates of both surgical and medical morbidity can occur, despite the best efforts at optimizing patient selection, refined surgical techniques, and multidisciplinary perioperative collaboration. Our study aimed to better delineate the incidence, risk factors, and downstream healthcare impact of respiratory morbidity in these procedures. We acknowledge that retrospective study design is fraught with intrinsic limitations that impact the applicability (and potentially the validity) of our data. Our work does, however, offer a unique assessment of postoperative respiratory morbidity in an area of surgery in need of clinical outcomes research. We approach this analysis with complete transparency of our outcomes and with an interest in improving processes of care for our patients.
Intraoperative neuromuscular blockade and opioid administration are performed at the discretion of the attending anesthesiologist of record for the case. Shortacting neuromuscular blockage agents may be utilized for induction (i.e., succinylcholine); however, intermediateacting neuromuscular blockade agents (i.e., vecuronium) are utilized most commonly during the remainder of the case. Long-acting agents are almost never utilized, and all patients are fully reversed at the conclusion of the case. The senior author (J.P.F.) favors complete neuromuscular blockade during repair, such that any undue tension generated by abdominal wall contractile forces is mitigated. The scope of this article did not focus directly on the use or type of neuromuscular blockade, since this is typical of institutional practice pattern and as such was not individually assessed for each patient. Perioperative pain management, however, is a slightly more challenging issue. Studies have demonstrated that epidural use can significantly improve perioperative metrics following open intra-abdominal operations.2 We have recently examined this in our ventral hernia population,3 and have demonstrated that epidurals may be associated with reduced perioperative morbidity and cost following abdominal wall reconstruction specifically. As such, we advocate for their use in all patients deemed appropriate by our anesthesiology team. When epidurals are placed, typically a combination of fentanyl and bupivacaine is utilized for analgesia. No opioids are administered, and this pattern is continued postoperatively with patientcontrolled epidural analgesia devices for at least 48 hours postoperatively, assuming a working epidural. However, in cases where epidurals are not placed or if the patient has an underlying opioid requirement, intraoperative and postoperative analgesia is achieved initially by intravenous opioids. Intraoperatively, opioids are administered as morphine equivalents based on changes in vital signs as monitored by the anesthesiologist. Postoperatively, patients utilize patient-controlled analgesia devices, most commonly utilizing morphine or Dilaudid, with an initial maximum dose of 1 mg or morphine or its equivalent every 10 minutes. If pain is uncontrolled, this dosage is titrated accordingly. Of note, epidural patients with an underlying preoperative opioid requirement receive only bupivacaine in their epidural, and do receive opioid patient-controlled analgesia. Our study did not directly assess pain or total opioid use following ventral hernia repair, but anecdotally we do note improved pain control with epidurals. This is an area necessitating further research that exceeded the scope of this current analysis. Regarding the preoperative assessment of cardiac function, in our preoperative history and physical, if a cardiac condition is noted or if there is significant concern, medical clearance from a cardiologist is obtained. It is therefore at the discretion of the cardiologist to obtain cardiac imaging to assess function (i.e., echocardiography). Certainly patients with known coronary artery disease underwent appropriate assessment and imaging. We do not routinely order cardiac imaging, but preoperative chest radiographs are obtained according to published recommendations,4 especially in older patients or patients
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