From the Department of Anesthesiology and Pain Medicine.
Section of Pulmonary Medicine.
Anesth Analg. 2021 May 1;132(5):1380-1388. doi: 10.1213/ANE.0000000000005219.
Pneumonia is a common lower respiratory tract infection (LRI) and the leading cause of pediatric hospitalization in the United States. Given its frequency, children with pneumonia may require surgery during their hospital course. This poses serious anesthetic and surgical challenges because preoperative pulmonary status is among the most important risk factors for postoperative complications. Although recent adult data indicated that preoperative pneumonia was associated with poor surgical outcomes, comparable data in children are lacking. Therefore, our objective was to investigate the association of preoperative pneumonia with postoperative mortality and morbidity in children.
Using the National Surgical Quality Improvement Program database, we assembled a retrospective cohort of children (<18 years) who underwent inpatient surgery between 2012 and 2015. Our primary outcome was the time to all-cause 30-day postoperative mortality that we evaluated using Cox proportional hazards regression models. For the secondary outcomes, including 30-day postoperative morbidity events, we used Fine-Gray models to account for competing risk by mortality. We also evaluated the association of preoperative pneumonia with duration of postoperative mechanical ventilation and postoperative hospital length of stay. We used propensity score weighting methods to adjust for potential confounding factors, whose distributions differ across the pneumonia groups.
Among 153,242 children who underwent inpatient surgery, 0.7% (n = 867) had preoperative pneumonia. Compared with those without preoperative pneumonia, children with preoperative pneumonia had a higher risk of mortality throughout the 30-day postoperative period (hazard ratio [HR], 4.10; 95% confidence intervals [CI], 2.42-6.97; P < .001). Although not statistically significant, children with preoperative pneumonia were twice as likely to develop cardiovascular complications compared to children without preoperative pneumonia (HR, 2.10; 95% CI, 1.17-3.75; P = .012). Furthermore, children with preoperative pneumonia had longer duration of postoperative ventilation (incidence rate ratio, 1.47; 95% CI, 1.26-1.71; P < .001). Finally, children with preoperative pneumonia were estimated to be 56% less likely to be discharged within the 30 days following surgery, compared to children without preoperative pneumonia (HR, 0.44; 95% CI, 0.40-0.47; P < .001).
Preoperative pneumonia was strongly associated with increased incidence of postoperative mortality and complications in children. Clinicians should make concerted efforts to screen for preoperative pneumonia and consider whether proceeding with surgery is the most expedient course of action. Our findings may be helpful in preoperative discussions with parents of children with preoperative pneumonia for risk stratification and postoperative resource allocation purposes.
肺炎是一种常见的下呼吸道感染（LRI），也是美国儿科住院的主要原因。鉴于其频率，患有肺炎的儿童在住院期间可能需要手术。这带来了严重的麻醉和手术挑战，因为术前肺部状况是术后并发症的最重要危险因素之一。尽管最近的成人数据表明术前肺炎与术后不良结果相关，但儿童中缺乏可比数据。因此，我们的目的是研究术前肺炎与儿童术后死亡率和发病率的关系。
我们使用国家手术质量改进计划数据库，组建了一个回顾性队列，纳入 2012 年至 2015 年间接受住院手术的儿童（<18 岁）。我们的主要结局是所有原因的 30 天术后死亡率，我们使用 Cox 比例风险回归模型进行评估。对于次要结局，包括 30 天术后发病率事件，我们使用 Fine-Gray 模型来考虑由死亡率引起的竞争风险。我们还评估了术前肺炎与术后机械通气时间和术后住院时间之间的关系。我们使用倾向评分加权方法来调整潜在的混杂因素，这些因素在肺炎组之间分布不同。
在接受住院手术的 153242 名儿童中，0.7%（n=867）患有术前肺炎。与没有术前肺炎的儿童相比，患有术前肺炎的儿童在整个 30 天术后期间死亡风险更高（风险比[HR]，4.10；95%置信区间[CI]，2.42-6.97；P<.001）。尽管没有统计学意义，但与没有术前肺炎的儿童相比，患有术前肺炎的儿童发生心血管并发症的可能性几乎翻了一番（HR，2.10；95%CI，1.17-3.75；P=0.012）。此外，患有术前肺炎的儿童术后通气时间更长（发病率比，1.47；95%CI，1.26-1.71；P<.001）。最后，与没有术前肺炎的儿童相比，患有术前肺炎的儿童在术后 30 天内出院的可能性估计降低了 56%（HR，0.44；95%CI，0.40-0.47；P<.001）。
术前肺炎与儿童术后死亡率和并发症发生率增加密切相关。临床医生应共同努力筛查术前肺炎，并考虑是否进行手术是最快捷的治疗方案。我们的研究结果可能有助于与术前肺炎儿童的父母进行术前讨论，以便进行风险分层和术后资源分配。
