Harpole D H, DeCamp M M, Daley J, Hur K, Oprian C A, Henderson W G, Khuri S F
Veterans Affairs Medical Center/Harvard Medical School, Brockton/West Roxbury, MA, USA.
J Thorac Cardiovasc Surg. 1999 May;117(5):969-79. doi: 10.1016/S0022-5223(99)70378-8.
A part of the prospective, multi-institutional National Veterans Affairs Surgical Quality Improvement Program was developed to predict 30-day mortality and morbidity for patients undergoing a major pulmonary resection.
Perioperative data were acquired from 194,319 noncardiac surgical operations at 123 Veterans Affairs Medical Centers between October 1, 1991, and August 31, 1995. Current Procedural Terminology code-based analysis was undertaken for major pulmonary resections (lobectomy and pneumonectomy). Preoperative, intraoperative, and outcome variables were collected. The 30-day mortality and morbidity models were developed by means of multivariable stepwise logistic regression with the preoperative and intraoperative variables used as independent predictors of outcome.
A total of 3516 patients (mean age 64 9 years) underwent either lobectomy (n = 2949) or pneumonectomy (n = 567). Thirty-day mortality was 4.0% for lobectomy (119/2949) and 11.5% for pneumonectomy (65/567). The preoperative predictors of 30-day mortality were albumin, do not resuscitate status, transfusion of more than 4 units, age, disseminated cancer, impaired sensorium, prothrombin time more than 12 seconds, type of operation, and dyspnea. When the intraoperative variables were considered, intraoperative blood loss was added to the preoperative model. In the presence of these intraoperative variables in the model, do not resuscitate status and prothrombin time more than 12 seconds were only marginally significant. Thirty-day morbidity, defined as the presence of 1 or more of the 21 predefined complications, was 23.8% for lobectomy (703/2949) and 25.7% for pneumonectomy (146/567). In multivariable models, independent preoperative predictors (P <.05) of 30-day morbidity were age, weight loss greater than 10% in the 6 months before surgery, history of chronic obstructive pulmonary disease, transfusion of more than 4 units, albumin, hemiplegia, smoking, and dyspnea. When intraoperative variables were added to the preoperative model, the duration of operation time and intraoperative transfusions were included in the model and albumin became marginally significant.
This analysis identifies independent patient risk factors that are associated with 30-day mortality and morbidity for patients undergoing a major pulmonary resection. This series provides an initial risk-adjustment model for major pulmonary resections. Future refinements will allow comparative assessment of surgical outcomes and quality of care at many institutions.
前瞻性、多机构的美国退伍军人事务部外科质量改进计划的一部分旨在预测接受大型肺切除术患者的30天死亡率和发病率。
收集了1991年10月1日至1995年8月31日期间123家退伍军人事务医疗中心194319例非心脏外科手术的围手术期数据。对大型肺切除术（肺叶切除术和全肺切除术）进行基于当前手术操作术语编码的分析。收集术前、术中和结果变量。通过多变量逐步逻辑回归建立30天死亡率和发病率模型，将术前和术中变量用作结果的独立预测因素。
共有3516例患者（平均年龄64.9岁）接受了肺叶切除术（n = 2949）或全肺切除术（n = 567）。肺叶切除术的30天死亡率为4.0%（119/2949），全肺切除术为11.5%（65/567）。30天死亡率的术前预测因素包括白蛋白、不进行心肺复苏状态、输血超过4单位、年龄、播散性癌症、意识障碍、凝血酶原时间超过12秒、手术类型和呼吸困难。当考虑术中变量时，术中失血被纳入术前模型。在模型中存在这些术中变量的情况下，不进行心肺复苏状态和凝血酶原时间超过12秒仅具有边缘显著性。30天发病率定义为存在21种预定义并发症中的1种或更多种，肺叶切除术的发病率为23.8%（703/2949），全肺切除术为25.7%（146/567）。在多变量模型中，30天发病率的独立术前预测因素（P <.05）包括年龄、术前6个月体重减轻超过10%、慢性阻塞性肺疾病史、输血超过4单位、白蛋白、偏瘫、吸烟和呼吸困难。当将术中变量添加到术前模型中时，手术时间和术中输血时间被纳入模型，白蛋白变得具有边缘显著性。
该分析确定了与接受大型肺切除术患者的30天死亡率和发病率相关的独立患者风险因素。本系列研究为大型肺切除术提供了一个初始风险调整模型。未来的改进将允许对许多机构的手术结果和护理质量进行比较评估。
