AJA Asian Journal of Anesthesiology

Advancing, Capability, Improving lives

Research Paper
Volume 56, Issue 1, Pages 33-38
Hou-Chuan Lai 1 , Shu-I Pao 2 , Yuan-Shiou Huang 1 , Shun-Ming Chan 1 , Bo-Feng Lin 1 , Zhi-Fu Wu 1
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Abstract

Objective

Postoperative pneumonia is the third most common postoperative complication. It may result from aspiration of secretions accumulating in the subglottic space during general anesthesia (GA). However, the relationship between endotracheal suctioning (ETS) during extubation from GA emergence and postoperative pneumonia has not been well investigated. Therefore, the aim of this study was to investigate the effectiveness of ETS during extubation in prevention of postoperative pneumonia in ophthalmic surgery under GA in our medical center from 2011 through 2015.

Methods

Three thousand, seven hundred and ninety-four patients receiving ophthalmic surgery under GA were included and divided into two groups by the anesthesiologists. The first group underwent the conventional ETS during extubation, while the other group was extubated without ETS. The incidences of postoperative pneumonia were compared between the two groups to find the correlation between ETS during extubation and postoperative pneumonia. In addition, other complication such as postoperative hemorrhage was also recorded.

Results

Of the 3,794 patients undergoing ophthalmic surgery under GA, 2,187 (58%) patients underwent extubation with ETS, whilst 1,607 (42%) patients were extubated without ETS. The incidence rates of postoperative pneumonia with or without ETS during extubation were both 0%. Besides, the incidence rates of postoperative hemorrhage were also both 0% in two groups.

Conclusion

Extubation from GA without ETS seemed not to increase the risk of postoperative pneumonia. Thus, no routine ETS during extubation seemed not to be a risk factor for postoperative pneumonia under GA in ophthalmic surgery.

Keywords

Keywords: postoperative pneumonia; endotracheal suctioning; general anesthesia; ophthalmic surgery;


1.Introduction

The incidence of postoperative pneumoniawas from 0.5% to 5.3% due to the different surgicalsubspecialties and the cardiothoracic surgery had thehighest incidence.1 Up to now, however, the incidenceof postoperative pneumonia following minorsurgeries such as ophthalmic or breast surgeries isstill uncertain.

During endotracheal tube (ETT) intubated generalanesthesia (GA), secretions accumulate in thesubglottic space posing an aspiration risk during cuffdeflation and extubation. To minimize this risk, bothendotracheal suctioning (ETS) during tube removaland applying positive pressure with a manual resuscitatorhave been advocated.2 However, coughingrelated to ETS is very common during emergencefrom GA and is accompanied by hypertension, and tachycardia, and it may result in postoperative hemorrhage,intracranial hypertension, or intraocularhypertension.3 Many strategies have been studied toprevent coughing during emergence, including extubationin a deep plane of anesthesia, the use of laryngealmask airway (LMA), and topical or intracuffapplication of lidocaine.3 These strategies are generallyconsidered to increase the risk of aspiration, orthey proved unreliable.3

ETT intubation and use of a LMA are the commonestmethods used for managing the airway inelective ophthalmic cases.4 Previous studies demonstratedthe use of a LMA, extubated without anyETS, in patients undergoing ophthalmic surgery.4-6And in these LMA studies, there was no postoperativepneumonia being reported. Pedersen et al.7also reported that routine ETS was not suggested inintensive care patients based on ETS associated withcomplications and risks.8 Besides, ETS was not abenign procedure, and operators might remain sensitiveto possible hazards and complications and takeall necessary precautions to ensure patient safety.9Therefore, the benefit of ETS in minor surgeries andlow risk patients was need to investigate further.

As our best knowledge, a rigorous comparisonof the incidence of postoperative pneumoniabetween ETS and non-ETS during extubation fromemergence of GA has not yet been performed inophthalmic surgery. Therefore, in this study, we retrospectivelyinvestigated the the incidence of postoperativepneumonia with or without ETS duringextubation in ophthalmic surgery under GA.

2.Methods

This retrospective study was approved by theEthics Committee (TSGHIRB No: 1-106-05-057) ofTri-Service General Hospital, Taipei, Taiwan (Chairperson,Professor Mu-Hsien Yu) on May 5, 2017.Institutional Review Board (IRB) allow waivingthe requirement for obtaining informed consent andpatient records was anonymized and de-identifiedprior to analysis. The information was retrievedfrom the medical records and the electronic databaseof Tri-Service General Hospital (TSGH; Taipei, Taiwan).All methods were performed in accordancewith the relevant guidelines and regulations by ourIRB. We retrospectively analyzed 4,218 patients(American Society of Anesthesiologists [ASA] classI–III) who received elective ophthalmic surgery fromJanuary 2011 to December 2015. The incidence ofpostoperative pneumonia was identified as the totalnumber of cases under each identifying InternationalClassification of Diseases, Ninth Revision (ICD-9)or ICD-10 codes for postoperative pneumonia, andend of follow-up in August 2017. We followed upthese patients at least 4 weeks postoperatively, andall of them visited our outpatient department withoutpneumonia after surgery. Patients with smoking,10chronic obstructive pulmonary disease (COPD),11morbidly obese (body mass index [BMI] ≥ 40 kg/m2),12 obstructive sleep apnea (OSA),13 and olderage10 have higher risks for postoperative pulmonarycomplications such as postoperative pneumonia orrespiratory failure. Accordingly, patients were excludedif incomplete data, smoking, COPD, morbidlyobese (BMI ≥ 40 kg/m2), and age < 20 years or >80 years.

In our hospital, the non-ETS patients were givenGA by Dr. Wu and Dr. Lai due to their bad experiencesabout postoperative hemorrhage consistentwith the previous research.14 By contrast, the conventionalETS patients were given GA by the otheranesthesiologists routinely, and that was proved byanesthetic practitioners privately.

No medication was administered before inductionof anesthesia; however, regular monitoring,such as electrocardiography (lead II) and measurementof pulse oximetry, noninvasive arterial bloodpressure, respiratory rate, and end-tidal carbon dioxidepressure (EtCO2), was performed. In all patients,anesthesia was induced with propofol and fentanyl.The patients were then tracheally intubated andmaintained with the anesthetics desflurane or propofoland the analgesic fentanyl.

The patients were induced with intravenous(i.v.) fentanyl, lidocaine, and propofol. When patientslose of consciousness, i.v. rocuronium orcisatracurium was administered, followed by ETTintubation. Anesthesia was maintained by using desfluraneor continuous infusion of propofol deliveredsubsequently by using Schneider’s kinetic model oftarget-controlled infusion (TCI) (Fresenius OrchestraPrimea, Fresenius Kabi AG, Bad Homburg, Germany).15-23 In addition, there was no glycopyrrolate oratropine used for the induction.

Maintenance of the propofol or desflurane concentrationwas adjusted to keep mean blood pressureat 80–100 mmHg or within 20% of baseline. The EtCO2 pressure was maintained at 35–45 mmHg byadjusting the ventilation rate and maximum airwaypressure below 30 cmH2O. Repetitive bolus injectionsof i.v. rocuronium or cisatracurium were prescribedas required throughout the procedure.15-23

At the end of surgery, propofol or desfluranewas discontinued, and the lungs were ventilatedwith 100% oxygen at a fresh gas flow of 6 L/min.Reversal of neuromuscular function was achieved byadministrating neostigmine (i.v.) with glycopyrrolate(i.v.) once spontaneous breathing returned to preventresidual paralysis. When the patient regained consciousnessby name with spontaneous and smoothrespiration, the ETT were ready to removed.15-23 Inthe ETS group, the cuff was deflated and the ETTwas removed together with ETS. By contrast, thecuff was deflated and the ETT was removed togetherwithout ETS in the non-ETS group. Then, the patientwas sent to the post-anesthesia care unit for furthercare.

Data are presented as the mean and standarddeviation (SD), number of patients, or percentage.Demographic and surgical time were compared usingStudent’s t-tests or Mann-Whitney test while thedata were not normally distributed. Categorical variableswere compared using chi-square test. Statisticalsignificance was accepted for two-tailed p valuesof < 0.05. The statistics was performed by usingSigmaStat 3.5 for Windows.

3.Results

Four hundred and twenty-four patients wereexcluded from the analysis. Of those excluded, 281patients with smoking, 16 patients with COPD, 19patients with morbidly obese (BMI ≥ 40 kg/m2), 26patients with OSA, 65 patients with age < 20 yerarsor > 80 years, and 17 patients had incomplete data.Our study included 3,794 patients, with 2,187 receivingETS and 1,607 receiving non-ETS duringextubation in ophthalmic surgery under GA.

Table 1  showed patient’s characteristics andsurgical procedures. And there was no significat differencein patient’s gender, age, height, weight, andsurgical time. Ophalmic surgical procedures includedvitrectomy, glaucoma surgery, and other surgeries.

Table 1. Patient’s characteristics and surgical procedures
Table 1.
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Analysis of the medical records revealed nopatient with postoperative pneumonia among 3,794operations, indicating a postoperative pneumonia incidenceof 0% in ophthalmic surgery under GA. Theage of the entire ophthalmic surgery was 55.3 ± 16.2years.

The incidence rates of postoperative pneumoniashowed both 0% in the two groups. Thus, the incidencerates of postoperative pneumonia revealed nosignificant difference between the two groups. However,1 case in ETS group received second operationon the same eye due to vitreous hemorrhage within1 month, and the discharge note reported no surgicalcomplication at the first time of surgey.

The incidence rates of postoperative hemorrhageshowed both 0% in the two groups. Thus, theincidence rates of postoperative hemorrhage revealedno significant difference between the twogroups.

4.Discussion

This study is the first study of postoperativepneumonia occurring after ophthalmic surgery withor without ETS during extubation from emergenceof GA. The major finding in this retrospective studyshowed that non-ETS during extubation did not increasethe risk of postoperative pneumonia followingophthalmic surgery under GA.

Postoperative pneumonia is the third mostcommon postoperative complication and leading tomortality.1,24 However, its epidemiology varies widelyand is often difficult to assess.1 The overall incidencerate of postoperative pneumonia was 0.97%following orthopaedic, urologic, otorhinolaryngologic,cardiothoracic, neurosurgery, and general surgeries.1 Chughtai et al. reported that cardiothoracicsurgery had the highest incidence (3.3–5.3%).1 In theliterature, however, the incidence of postoperativepneumonia following ophthalmic surgery is stilluncertain. In this study, our finding showed that theoverall incidence rate of postoperative pneumoniawas 0%. Our overall incidence rate of postoperativepneumonia following ophthalmic surgery under GAwas lower than that reported in the above mentionedresearch.1 There are two possible reasons for this.First, many ophthalmic surgical cases were of minorsurgeries and brief durations, and shorter surgicaltime was associated with lower incidence of postoperativepneumonia.25 Second, we excluded thepatients with smoking, COPD, morbidly obese (BMI≥ 40 kg/m2), and older age (> 80 years)10-13 and weroutinely used ETS in these risky patients for postoperativepneumonia.

During GA, secretions accumulate in the subglotticspace and then result in an aspiration riskduring cuff deflation and extubation.2 To minimizethis risk, both ETS during tube removal and applyingpositive pressure with a manual resuscitatorhave been advocated.2 However, we found that theincidence rates of postoperative pneumonia showedboth 0% in the two groups. This result demonstratedthat non-ETS did not increase the risk of postoperativepneumonia compared with ETS in ophthalmicsurgery under GA. Similarly, Andreu et al.2 demonstratedthat non-ETS resulted in less leakage of oropharyngealcontents than ETS, and that implied thatnon-ETS during extubation might prevent from thedevelopment of postoperative pneumonia. Morevoer,Pedersen et al.7 reported that routine ETS wasnot suggested in intensive care patients as the ETSassociated with complications and risks and withoutincreasing the incidence of ventilator associatedpneumonia.

Coughing related to ETS is very commonduring emergence from GA is often not regardedas a complication because appropriate cough canremove respiratory secretion during emergence.3However, severe coughing during ETS is accompaniedby hypertension, and tachycardia, and it mayresult in postoperative hemorrhage, intracranial hypertension,or intraocular hypertension.3 Thus, ETSis not routinely suggested for patients undergoingsome ophthalmic surgeries. In this study, our findingshowed that the incidence rates of postoperativehemorrhage showed both 0% in the two groups.However, we found 1 case in ETS group receivedsecond operation on the same eye due to severe vitreoushemorrhage within 1 month, and there was nodiagnosis of postoperative hemorrhage. Accordingly,we postulated that ETS during extubation mightincrease the incidence rate of postoperative hemorrhagein ophthalmic surgery, and that was consistentwith previous study.3

ETT still plays an important role in patients receivingsurgery under GA to protect the lungs fromregurgitated stomach content, and that was associatedwith less aspiration and death than LMA.4,26-28 However, recently, LMA is used in pediatric andadult patients receiving ophthalmic surgery underGA, and that was extubated without any ETS withless coughing, less increase in intraocular pressure,and hemodynamics cahnges compared with ETT.4-6 In these LMA reports, there was no postoperativepneumonia being reported. Moreover, a previousstudy reported that pulmonary aspiration with theLMA is uncommon and comparable to that withETT.29 Therefore, as our result, non-ETS during extubationmight be an alternative method to preventcoughing without increase the incidence of postoperativepulmonary complications.

here were limitations in this study. First, informationabout blood pressure and heart rate duringextubation were not available. Our previous studyshowed that coughing durint ETS was accompaniedby hypertension, and tachycardia, and it might resultin postoperative hemorrhage.3 However, we foundno postoperative hemorrhage in this study. Second,information about intraocular pressure during extubation was not available. A previous study showedthat stable intraocular pressure is important for thesuccess of intraocular surgery, as a rise in intraocularpressure intraoperatively can cause prolapse of theiris or lens and loss of vitreous, resulting in permanentvisual loss.30 However, in our clinical practice,the re-operation rate in ophthalmic surgery is verylow (< 1%).

In conclusion, we did not found any postoperativepneumonia in ophthalmic surgery under GAeven without ETS during extubation. Thus, non-ETSseemed not to be a risk factor for pulmonary pneumoniain ophthalmic surgery. Further investigationsare needed to understand the impact of the ETSwhile extubation on the incidence rates of postoperativepneumonia in other minor or major operationswith low risk patients.

5.Conflicts of Interest

No external funding or competing interests declared.


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References

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