High risk patients in major thoracic surgery

Lung resections are correlated to high mortality (4–6%) and morbidity (20–40%) that can increase in high risk patients. Objectives of this study is to analyze preoperative risk factors, in a group of high risk patients undergoing thoracotomy for lung cancer and to assess the relationship with postoperative complications.

Methods

From January 1996 to December 1997 43 patients, undergone pulmonary resection for lung cancer, were considered at high risk and enrolled in this study according to one or more of the following including criteria: age older than 70 years; previous cardiovascular disease; poor pulmonary function (FEV1 <65% predicted values. PaO₂ <65 mmHg or PaCO₂ >42 mmHg); chronic systemic disease. Patients clinical data are reported in the Table. Anesthetic technique was the same for all patients. All the patients were monitored with EKG, pulse oxymetry (Nellcor N200), invasive arterial pressure, pulmonary artery catheter when necessary and in-end expiratory gas analysis. Preoperatively an epidural catheter was inserted in T6-T11 space. Anesthesia was maintained with isoflurane 0.5% vecuronium and fentanyl combined with epidural analgesia (bupivacaine 0.5% and fentanyl). A continuous infusion through the epidural catheter of morphine 20 mg in 250 ml normal saline 0.9% at 5 ml/h was used for postoperative pain relief. Surgical procedures included: 33 lobectomy, 4 bilobectomy, 3 sleeve resections, 2 pneumonectomy. Relationship among different preoperarive risk factors and postoperative complications were performed with χ² test and corrected with Fisher's exact test.

Results

Mean age was 69 yrs (range 50–83 years). All patients were extubated in the operative room at the end of surgical procedures.

Complications occurred in 25.5% of patients (11/43): 3 arrhythmias, 2 myocardial infarctions, 2 pulmonary edema, 2 acute renal failures, 2 pulmonary complications (prolonged air leakage) (Table). The perioperative mortality rate was 4.6% (2/43). The mean length of staying in hospital was 11 days for all patients, 12.5 for respiratory group, 9.6 for cardiac group, 10.9 for age group.

Conclusion

In our experience lung resections in high risk patients have low mortality and morbidity. Therefore, age over 70 years alone has no longer to be considered a limiting factor in patients undergoing surgery for lung cancer. High risk patients need a very careful preoperative evaluation of cardiovascular and pulmonary function in order to avoid perioperative complications and to reduce the morbidity. An appropiate surgical and anesthetic technique, and postoperative pain relief improves outcome in high risk patients.

Table. Preoperative risk factors and perioperative complications