Preoperative Pulmonary Risk Stratification for Noncardiothoracic Surgery: Systematic Review for the American College of Physicians

18 April 2006 | Volume 144 Issue 8 | Pages 581-595

Background: The importance of clinical risk factors for postoperative pulmonary complications and the value of preoperative testing to stratify risk are the subject of debate.

Purpose: To systematically review the literature on preoperative pulmonary risk stratification before noncardiothoracic surgery.

Data Sources: MEDLINE search from 1 January 1980 through 30 June 2005 and hand search of the bibliographies of retrieved articles.

Study Selection: English-language studies that reported the effect of patient- and procedure-related risk factors and laboratory predictors on postoperative pulmonary complication rates after noncardiothoracic surgery and that met predefined inclusion criteria.

Data Extraction: The authors used standardized abstraction instruments to extract data on study characteristics, hierarchy of research design, study quality, risk factors, and laboratory predictors.

Data Synthesis: The authors determined random-effects pooled estimate odds ratios and, when appropriate, trim-and-fill estimates for patient- and procedure-related risk factors from studies that used multivariable analyses. They assigned summary strength of evidence scores for each factor. Good evidence supports patient-related risk factors for postoperative pulmonary complications, including advanced age, American Society of Anesthesiologists class 2 or higher, functional dependence, chronic obstructive pulmonary disease, and congestive heart failure. Good evidence supports procedure-related risk factors for postoperative pulmonary complications, including aortic aneurysm repair, nonresective thoracic surgery, abdominal surgery, neurosurgery, emergency surgery, general anesthesia, head and neck surgery, vascular surgery, and prolonged surgery. Among laboratory predictors, good evidence exists only for serum albumin level less than 30 g/L. Insufficient evidence supports preoperative spirometry as a tool to stratify risk.

Limitations: For certain risk factors and laboratory predictors, the literature provides only unadjusted estimates of risk. Prescreening, variable selection algorithms, and publication bias limited reporting of risk factors among studies using multivariable analysis.

Conclusions: Selected clinical and laboratory factors allow risk stratification for postoperative pulmonary complications after noncardiothoracic surgery.

Author and Article Information

From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, and South Texas Veterans Health Care System and The University of Texas Health Science Center at San Antonio, San Antonio, Texas.

Acknowledgments: The authors gratefully acknowledge the tremendous contribution of medical librarian Martha R. Harris, MA, for her time and expertise in searching the medical literature and managing the resulting project database.

Grant Support: By the Veterans Evidence-based Research, Dissemination, and Implementation Center (VERDICT) (Veterans Affairs Health Services Research and Development, HFP 98-002).

Potential Financial Conflicts of Interest: Stock ownership or options (other than mutual funds): G.W. Smetana (SafeMed Harvard Imaging); Other: G.W. Smetana (Novartis Pharma Schweiz).

Requests for Single Reprints: Gerald W. Smetana, MD, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215; e-mail, gsmetana{at}bidmc.harvard.edu.

Current Author Addresses: Dr. Smetana: Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215.

Drs. Lawrence and Cornell: Medicine/General Medicine, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, Mail Code 7879, San Antonio, TX 78229-3900.