Annals of Internal Medicine Clinical Guidelines...diate-acting (atracurium, vecuronium) and long-acting (pancuronium) neuromuscular blocking agents among 691 patients undergoing elective

Strategies To Reduce Postoperative Pulmonary Complications afterNoncardiothoracic Surgery: Systematic Review for the AmericanCollege of PhysiciansValerie A. Lawrence, MD; John E. Cornell, PhD; and Gerald W. Smetana, MD

Background: Postoperative pulmonary complications are as fre-quent and clinically important as cardiac complications in terms ofmorbidity, mortality, and length of stay. However, there has beenmuch less research and no previous systematic reviews of theevidence of interventions to prevent pulmonary complications.

Purpose: To systematically review the literature on interventions toprevent postoperative pulmonary complications after noncardiotho-racic surgery.

Data Sources: MEDLINE English-language literature search, 1 Jan-uary 1980 through 30 June 2005, plus bibliographies of retrievedpublications.

Study Selection: Randomized, controlled trials (RCTs); systematicreviews; or meta-analyses that met predefined inclusion criteria.

Data Extraction: Using standardized forms, the authors abstracteddata on study methods, quality, intervention and control groups,patient characteristics, surgery, postoperative pulmonary complica-tions, and adverse events.

Data Synthesis: The authors qualitatively synthesized, withoutmeta-analysis, evidence from eligible studies. Good evidence (2systematic reviews, 5 additional RCTs) indicates that lung expansioninterventions (for example, incentive spirometry, deep breathing

exercises, and continuous positive airway pressure) reduce pulmo-nary risk. Fair evidence suggests that selective, rather than routine,use of nasogastric tubes after abdominal surgery (2 meta-analyses)and short-acting rather than long-acting intraoperative neuromus-cular blocking agents (1 RCT) reduce risk. The evidence is conflict-ing or insufficient for preoperative smoking cessation (1 RCT), epi-dural anesthesia (2 meta-analyses), epidural analgesia (6 RCTs, 1meta-analysis), and laparoscopic (vs. open) operations (1 systematicreview, 1 meta-analysis, 2 additional RCTs), although laparoscopicoperations reduce pain and pulmonary compromise as measured byspirometry. While malnutrition is associated with increased pulmo-nary risk, routine total enteral or parenteral nutrition does notreduce risk (1 meta-analysis, 3 additional RCTs). Enteral formula-tions designed to improve immune status (immunonutrition) mayprevent postoperative pneumonia (1 meta-analysis, 1 additionalRCT).

Limitations: The overall quality of the literature was fair: Ten of 20RCTs and 6 of 11 systematic reviews were good quality.

Conclusions: Few interventions have been shown to clearly orpossibly reduce postoperative pulmonary complications.

Ann Intern Med. 2006;144:596-608. www.annals.orgFor author affiliations, see end of text.

Postoperative pulmonary complications are as commonas cardiac complications for patients undergoing non-

cardiothoracic surgery (1–6). Further, these complicationshave similar mortality rates and length of stay after electiveabdominal surgery or hip fracture repair (1, 2). In an ac-companying systematic review (7), we identify patient,procedure, and laboratory risk factors for postoperativepulmonary complications. Our current systematic reviewsynthesizes the evidence on preventive strategies and fo-cuses on atelectasis, pneumonia, and respiratory failure.While we have written the review primarily for internists,this field crosses specialty disciplines.

METHODS

Literature Search and Selection CriteriaWe performed a systematic MEDLINE English-lan-

guage literature search from 1 January 1980 to 30 June2005. The search strategy and inclusion and exclusion cri-teria are described in the accompanying review of risk fac-tors and in further detail in its Appendix, available at www.annals.org (7). The search strategy used 1) the MedicalSubject Heading (MeSH) terms preoperative care, intraop-erative care, postoperative care, intraoperative complications,

and postoperative complications as a focus of the article; 2)the MeSH text term perioperative complications as a textterm in the title or abstract; and 3) additional MeSH andtext terms for pulmonary, respiratory, or cardiopulmonaryconditions, complications, or care. In addition, we per-formed additional focused searches for preoperative chestradiography and spirometry, laparoscopic versus open ma-jor abdominal operations, general versus spinal or epiduralanesthesia, intraoperative neuromuscular blockade, postop-erative pain management, and postoperative lung expan-sion techniques. Eligible studies were randomized, con-trolled trials; systematic reviews; or meta-analyses. We

See also:

PrintRelated articles . . . . . . . . . . . . . . . . . . . . . . . . 575, 581Summary for Patients. . . . . . . . . . . . . . . . . . . . . . . I-40

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excluded studies with less than 25 participants per group;studies from developing countries (because of potential dif-ferences in respiratory and intensive care technology); stud-ies that used physiologic (for example, lung volumes andflow, oximetry) rather than clinical outcome measures;studies of gastric pH manipulation; studies of complica-tions that are unique to the surgery (for example, upperairway obstruction after uvulectomy); studies of cardiopul-monary, pediatric, or organ transplantation surgery (be-cause of profoundly immunosuppressive drugs); and stud-ies that used only administrative data to identifypostoperative complications (for example, InternationalClassification of Diseases, Ninth Revision, Clinical Modi-fication [ICD-9-CM], codes) because of recent evidencethat administrative data have poor validity for postopera-tive complications (8, 9).

Assessment of Study QualityWe used the Quality of Reporting of Meta-analyses

(QUOROM) statement for reporting meta-analyses andthe U.S. Preventive Services Task Force criteria for hierar-chy of research design to assess internal validity and studyquality (good, fair, or poor) and to make conclusions aboutstrength of the evidence (10, 11).

Statistical AnalysisWe used simple means and chi-square tests to calculate

CIs and P values when they were not provided in publica-tions. We did not perform quantitative pooling becausemultiple meta-analyses were beyond the scope of a broadreview of multiple potential interventions. We reportpooled results from previous meta-analyses when applicable.

Role of the Funding SourceThe Veterans Evidence-based Research, Dissemina-

tion, and Implementation Center (VERDICT) (VeteransAffairs Health Services Research and Development, HFP98-002) provided the research librarian and administrativesupport for the study. The funding source had no role inthe design, conduct, or reporting of the study or in thedecision to submit the manuscript for publication.

RESULTS

The search and inclusion criteria identified 20 ran-domized clinical trials and 11 systematic reviews or meta-analyses (12–42). Figure 1 in the accompanying review (7)of risk factors for postoperative pulmonary complicationsdetails the search results. Appendix Tables 1 through 7(available at www.annals.org) provide detailed characteris-tics of the eligible randomized trials and systematic reviews.

Preoperative Smoking CessationIn the only trial of preoperative smoking cessation

(12), 108 older, relatively healthy men undergoing hip orknee replacement were randomly assigned to usual care orweekly meetings with a nurse for advice about smokingcessation and nicotine withdrawal plus individualized nic-otine replacement for 6 to 8 weeks before surgery until 10

days after surgery. The mean age of the men was 65 years,and 95% were American Society of Anesthesiologists(ASA) physical status class I or II. Of 56 patients in theintervention group, 36 stopped smoking and 14 reducedsmoking before surgery. Overall complications rates werelower in the intervention group (18% vs. 52%; P �0.001), primarily due to fewer wound complications andurinary tract infections. The only pulmonary outcome,postoperative ventilator support, occurred in 1 patient ineach group. Non–statistically significant trends favoredshorter mean hospital stay (11 days vs. 13 days; P � 0.41)and fewer cardiac complications (0% vs. 10%; P � 0.08)in the intervention group.

Although the trial was of good quality, several factorslimit its ability to demonstrate decreased risk for postoper-ative pulmonary complications. Pulmonary risk is inher-ently low with hip and knee replacement. Furthermore, thetiming of smoking cessation seems important. A previouscohort study showed paradoxically higher postoperativepulmonary complication rates for smokers who stopped orreduced smoking within 2 months before noncardiotho-racic surgery (43). Smoking cessation may increase short-term risk because of transiently increased mucus produc-tion due to improved mucociliary activity and reducedcoughing due to less bronchial irritation.

Anesthetic and Analgesic TechniquesAnesthetics disrupt central regulation of breathing and

result in uncoordinated neural messaging. Due to resultinghypoventilation plus positional dependence, regional atel-ectasis occurs shortly after induction. It persists postopera-tively and is compounded by ongoing disruption of respi-ratory muscles, limited respiratory excursion due to pain,and disruption of neurally mediated diaphragmatic func-tions after manipulation of abdominal viscera (43).

Neuromuscular Blockade

One good-quality trial found no difference in rates ofpostoperative pulmonary complications between interme-diate-acting (atracurium, vecuronium) and long-acting(pancuronium) neuromuscular blocking agents among 691patients undergoing elective abdominal, gynecologic, or or-thopedic surgery (13). However, the incidence of residualneuromuscular block was higher among patients receivingpancuronium (26% vs. 5%; P � 0.001). Patients with re-sidual blockade after pancuronium were 3 times morelikely to develop postoperative pulmonary complicationsthan those without residual block (17% vs. 5%; P � 0.02).In contrast, among patients receiving intermediate-actingagents, postoperative pulmonary complication rates didnot differ between those with (4%) and without (5%) pro-longed blockade. Therefore, pancuronium may directlylead to higher rates of prolonged neuromuscular blockadeand indirectly to increased pulmonary risk compared withshorter-acting agents.

Clinical GuidelinesStrategies To Reduce Postoperative Pulmonary Complications after Noncardiothoracic Surgery

www.annals.org 18 April 2006 Annals of Internal Medicine Volume 144 • Number 8 597


Anesthesia and Analgesia

Neuraxial blockade (either spinal or epidural anesthe-sia) blocks a constellation of stress responses to surgery(neuroendocrine, cytokine, and pain threshold) and mayimprove recovery and prevent complications (44). Postop-erative epidural analgesia may reduce respiratory muscledysfunction and pain-related hypoventilation. The epi-dural approach involves either a single injection or an in-fusion and can be used for both intraoperative anesthesiaand postoperative analgesia. Spinal anesthesia has a fasteronset (5 to 10 minutes vs. 15 to 20 minutes), producesdenser sensory and motor block, and is technically easierthan epidural anesthesia. However, spinal anesthesia is ad-ministered only as a single injection because of practicalconstraints of indwelling intrathecal catheters. The possiblebenefit of neuraxial blockade has generated studies of gen-eral versus neuraxial blockade anesthesia, followed by trialscomparing epidural analgesia to other modes of analgesicdelivery (for example, oral, intramuscular, intravenous, pa-tient-controlled analgesia) and, more recently, trials ofcombined epidural intraoperative anesthesia and epiduralpostoperative analgesia.

Intraoperative General Anesthesia versus Neuraxial Blockade

A recent good-quality meta-analysis combined 141 tri-als (n � 9559) comparing general anesthesia and neuraxial

blockade in patients undergoing a variety of operations(32). The authors compared patients receiving neuraxialblockade (with or without concomitant general anesthesia)with those receiving only general anesthesia. Neuraxialblockade reduced overall mortality (2% vs. 3%; odds ratio,0.70 [95% CI, 0.54 to 0.90]), pneumonia (3% vs. 5%;odds ratio, 0.61 [CI, 0.48 to 0.76]), and respiratory failure(0.5% vs. 0.8%; odds ratio, 0.41 [CI, 0.23 to 0.73]). In asubgroup analysis of trials of neuraxial blockade alone ver-sus general anesthesia alone, results were similar (odds ra-tio, 0.63 [CI, 0.46 to 0.87] for pneumonia; odds ratio,0.37 [CI, 0.11 to 1.21] for respiratory failure).

Potential sources of bias in the meta-analysis include1) clinically heterogeneous studies; 2) unusually high mor-tality rates in several trials; 3) older literature (82% of in-cluded studies were published before 1990); 4) small stud-ies (81% of included studies had � 50 patients); and 5)statistically significant benefit only for orthopedic surgeryin subgroup analyses (45–47).

A smaller good-quality systematic review identified 15randomized or quasi-randomized trials of 2162 patientsundergoing hip fracture repair (33). Postoperative pneu-monia rates were almost identical: 5.1% of 529 patientshaving neuraxial blockade and 5.5% of 567 patients havinggeneral anesthesia (odds ratio, 0.92 [CI, 0.53 to 1.59]).Twelve of the 15 trials were also included in the larger

Table 1. Randomized, Controlled Trials of Combined Intraoperative Anesthesia and Postoperative Analgesia*

Author, Year(Reference)

Type of Surgery Intervention Group Patients

Total,n

Men,n

Age, y

Norris et al.,2001 (14)

Elective abdominal aorticsurgery

Four groups: 1) intraoperative GETA � postoperative IV PCA; 2)intraoperative GETA � postoperative epidural PCEA; 3)intraoperative GETA � supplemental epidural � postoperativeIV PCA; 4) intraoperative GETA � supplemental epidural �postoperative PCEA

168 115 Mean, 68(SD, 9.5)

Rigg et al.,2002 (15)

Elective abdominal oresophageal surgery

Two groups: 1) intraoperative GETA � postoperative IV opioid;2) intraoperative GETA � epidural local anesthetic �postoperative epidural local anesthetic and additional opioidas needed

915 NR‡ NR‡

Park et al.,2001 (16)

Elective abdominal surgery(Veterans Hospitals)

Two groups: 1) intraoperative GETA � postoperative IV or IMopioid; 2) intraoperative GETA � epidural anesthesia �postoperative epidural opioid

1021 1021 Mean, 67(SD, 8.8)

Fleron et al.,2003 (17)

Elective abdominal aorticsurgery

Two groups: 1) intraoperative GETA � IV opioid �postoperative IV opioid; 2) intraoperative GETA � epiduralopioid � postoperative IV opioid

217 192 Mean, 66.5(SD, 10.5)

Mann et al.,2000 (18)

Elective major abdominalsurgery for cancer

Two groups: 1) intraoperative GETA � postoperative IV PCAwith morphine; 2) intraoperative GETA � epidural �postoperative PCEA with combined local anesthetic andsufentanil

70 38 Mean, 76.5(SD, 5.2)

Cuschieri et al.,1985 (19)

Elective cholecystectomy Three groups: 1) intraoperative GETA � postoperative IMmorphine; 2) intraoperative GETA � postoperative IVmorphine; 3) intraoperative GETA � epidural local anesthetic� postoperative epidural local anesthetic for 12 h thenmorphine as needed

75 16 52 (range,18–75)

* GETA � general endotracheal anesthesia; IM � intramuscular; IV � intravenous; NR � not reported; NS � not significant; PCA � patient-controlled analgesia; PCEA �patient-controlled epidural analgesia; PPC � postoperative pulmonary complication.† Level of evidence for all studies is I � randomized clinical trial.‡ Sex and age not given in primary publication or previous methods publication.

Clinical Guidelines Strategies To Reduce Postoperative Pulmonary Complications after Noncardiothoracic Surgery



meta-analysis (32), which included 44 trials of orthopedicsurgery (n � 3617). Why the results for pneumonia differbetween the 2 meta-analyses is not clear, but importantvariables may include type or duration of procedure (hipfracture repair is inherently low risk for postoperative pul-monary complications), intraoperative fluids, and postop-erative pain and rehabilitative management.

Combined Intraoperative and Postoperative Anesthesia andAnalgesia

Table 1 summarizes 6 eligible trials that comparedvarious regimens of intraoperative anesthesia and postop-erative analgesia. In a double-blind, good-quality efficacytrial of patients undergoing abdominal aortic surgery (14),investigators randomly assigned patients to 1 of 4 com-bined anesthetic and analgesic protocols. The trial stan-dardized the entire episode of anesthesia and pain manage-ment to optimize efficacy in all 4 groups. The primaryoutcome measure was length of stay; secondary outcomesincluded postoperative pulmonary complications. Samplesizes were small (37, 38, 39, and 46 participants, respec-tively), and median length of stay (7 to 8 days for allgroups) or postoperative pulmonary complication rates didnot differ among the groups.

Strengths of the trial include the double-blind designand equally highly standardized protocols for both anesthe-

sia and analgesia (48, 49). Unequally optimized regimenscan introduce bias that systematically favors one type ofintervention. Potential weaknesses, regarding prevention ofpostoperative pulmonary complication, include length ofstay as the primary outcome measure and small sample size(50–52).

In a subsequent fair-quality effectiveness trial (15),915 patients undergoing major abdominal surgery wererandomly assigned to general anesthesia and 1) postopera-tive intravenous opioid or 2) intraoperative epidural localanesthetic plus postoperative epidural analgesia. Overall in-fections did not differ, and the authors did not report re-sults for pneumonia. Statistically significantly less pain andrespiratory failure occurred with epidural anesthesia, butonly 225 of 447 patients in the epidural group completedthe protocol.

In a subgroup analysis of high-risk patients (respira-tory insufficiency by arterial blood gas analysis, severe ob-structive or restrictive lung disease, acute respiratory failurewithin the past 2 years, or morbid obesity), rates of pneu-monia (11% vs. 12%; P � 0.71) or mechanical ventilationfor more than 24 hours (8% for both groups) did notdiffer. Respiratory failure (ventilation � 24 hours, reintu-bation, PaO2 � 50 mm Hg, or PaCO2 � 50 mm Hg onroom air) occurred significantly less often with epidural(45% vs. 29%; odds ratio, 0.5 [CI, 0.29 to 0.88]) (53).

Table 1—Continued

RandomAllocationConcealed

BlindedOutcomeAssessment

PPCs Level ofEvidence†;Study Quality

Results

Yes Yes Reintubation, prolonged intubation, pneumonia (primaryoutcome was length of stay; PPCs were secondaryoutcomes)

I; good Overall PPCs: 20% vs. 17% vs. 25% vs. 9%; P � NSReintubation: 0%–2.9%; P � 0.9Prolonged intubation: 7%–22%; P � 0.3Pneumonia: 0%–2.8%; P � 0.6

No No Respiratory failure, overall infection I; fair Infection: 47% in IV group, 43% in epidural group; P �0.26

Respiratory failure: 30% in IV group, 23% in epiduralgroup; P � 0.02

Yes No Primary outcomes: death, respiratory failure; secondaryoutcome: pneumonia

I; fair Mortality: 4% vs. 3%Respiratory failure: 10% with epidural vs. 14%; P � 0.06Pneumonia: 5% with epidural vs. 8%; P � 0.15

Yes No Pneumonia, lobar atelectasis, respiratory failure I; fair Overall PPCs: 16% with epidural, 23% with IV opioid;P � 0.32

Yes No Segmental or lobar atelectasis, pneumonia, major PPCsdefined by clinical score based on physicalexamination

I; poor Atelectasis: 23% with epidural vs. 18%; P � 0.77Major PPCs: 3% vs. 3%

Unclear No Atelectasis, pneumonia I; poor Atelectasis: 20% with epidural vs. 28% with IV and 40%with IM morphine; P � NS

Pneumonia: 4% with epidural vs. 20% with IV morphine(P � 0.20) and 24% with IM morphine (P � 0.11)




In a large fair-quality trial (16), 1021 patients under-going abdominal surgery were randomly assigned to gen-eral anesthesia and 1) postoperative systemic opioid or 2)intraoperative epidural anesthesia plus postoperative epi-dural morphine. Mortality rates did not differ, and non–statistically significant trends favored the epidural approachfor pneumonia and respiratory failure.

In 1 fair-quality trial (17), 217 patients undergoingelective abdominal aortic surgery were randomly assignedto general anesthesia alone or general anesthesia plus intra-operative epidural opioid. Both groups received the samepostoperative pain management. A non–statistically signif-icant trend favored intraoperative epidural for overall post-operative pulmonary complications. Rates of individualtypes of postoperative pulmonary complications did notdiffer, but statistical power was low.

In a smaller poor-quality trial (18), 70 elderly patientsundergoing major abdominal surgery were randomly as-signed to general anesthesia and 1) postoperative patient-controlled morphine or 2) intraoperative neuraxial blockadeplus postoperative patient-controlled epidural analgesia.Rates of atelectasis or major pulmonary complications didnot differ. In an additional, small poor-quality trial (19), 75patients undergoing elective cholecystectomy were ran-domly assigned to general anesthesia and 1) postoperativeintramuscular morphine, 2) continuous intravenous mor-phine, or 3) intraoperative epidural local anesthesia plus post-operative epidural local anesthetic for 12 hours. Postoperativepneumonia occurred less often with epidural (4%) than witheither intramuscular morphine (24%; P � 0.05) or intravenousmorphine (20%; P � 0.11).

Postoperative Analgesic Technique

A fair-quality meta-analysis examined the evidence for3 epidural techniques: intercostal nerve block, systemicopioids, and wound infiltration with local anesthetic (34).The number of trials that compared any 2 strategies variedfrom 2 to 11. Compared with systemic opioids, epiduralopioids reduced atelectasis (relative risk, 0.53 [CI, 0.33 to0.85]; 11 studies) but not pneumonia (relative risk, 0.53[CI, 0.18 to 1.53]; 5 studies). Compared with systemicopioids, epidural local anesthetic reduced “pulmonary in-fection” (relative risk, 0.36 [CI, 0.21 to 0.65]; 5 studies)but not atelectasis (relative risk, 0.74 [CI, 0.50 to 1.11]; 4studies). However, the authors pooled studies of both on-demand (that is, as requested) and patient-controlled intra-venous analgesia, which could bias the results of the meta-analysis in favor of epidural analgesia.

In contrast, a good-quality meta-analysis identified 32trials (n � 1029) of patient-controlled opioid analgesiaversus the same drug given intravenously, intramuscularly,or subcutaneously (35). Opioid consumption, pain scores,length of stay, or adverse effects did not differ. In the 2trials reporting postoperative pulmonary complications,fewer complications occurred in the patient-controlled an-

algesia group (odds ratio, 0.93 [CI, 0.86 to 0.99]; numberneeded to treat, 15 [CI, 8 to 98]).

Summary

Evidence from 1 good-quality trial suggests that shorter-acting neuromuscular blocking drugs may prevent postop-erative pulmonary complications. Intraoperative neuraxialblockade, either alone or in combination with general an-esthesia, may prevent postoperative pulmonary complica-tions, but the evidence is conflicting. Several meta-analyses(which included small unblinded studies) suggest that epi-dural anesthesia may reduce pulmonary risk, but recentlarge randomized trials do not confirm benefit. Random-ized trials of combined intraoperative and postoperativeanesthetic or analgesic regimens do not clearly indicate thata combined epidural approach prevents postoperative pul-monary complications. Two meta-analyses of postoperativeanalgesic regimens suggest that part of the variability maybe due to on-demand analgesia (intravenous, intramuscu-lar, or subcutaneous) versus patient-controlled analgesia(intravenous or epidural). Postoperative epidural and pa-tient-controlled intravenous analgesia both seem superiorto on-demand delivery of opioids in preventing postoper-ative pulmonary complications. Epidural analgesia mayfurther reduce postoperative pulmonary complications.More good-quality efficacy trials with standardized optimalregimens for all groups and sufficient size to examine pul-monary complication rates are needed (14). The risk forepidural bleeding due to postoperative epidural catheters inpatients receiving heparin (especially low-molecular-weightheparin) makes timing of catheter placement importantand may influence decisions about modalities for pain con-trol and thromboembolism prophylaxis (54–56).

Laparoscopic versus Open ProceduresOur search identified many trials comparing laparo-

scopic and open procedures, but few reported postopera-tive pulmonary complication rates. Those that did focusedon cholecystectomy and colorectal surgery. Downs and col-leagues (36) performed a good-quality systematic reviewthrough March 1995 of open and laparoscopic cholecys-tectomy. They identified 18 trials (n � 1645) that werepublished with sufficient detail to judge methodologicquality. Twelve trials had at least 40 patients per studygroup, and the largest study had 150 participants pergroup. Since the authors did not quantitatively pool databecause of clinical heterogeneity and methodologic prob-lems, we examined the studies individually. None met thecriteria for inclusion in our review (�25 participants pergroup [8 studies] or no clinical postoperative pulmonarycomplications reported [10 studies]).

Among the 4 highest-quality trials reporting spiromet-ric outcomes, unblinded outcome assessment found statis-tically significantly greater compromise in FVC and FEV1

at 24 hours and 48 hours postoperatively with open cho-lecystectomy. In 1 study that followed patients until pul-




monary function recovered to within 10% to 15% of pre-operative levels, pulmonary function recovered 4 to 10days earlier with laparoscopic cholecystectomy. Only 1very small (n � 40) blinded trial assessed whether reducedpulmonary dysfunction translated into clinically importantdifferences in postoperative pulmonary complication rates.On postoperative chest radiography, atelectasis occurredsignificantly less often with laparoscopic operations (40%vs. 90%; P � 0.001).

We identified 1 subsequent, poor-quality trial of lapa-roscopic versus open cholecystectomy (20). Among 82 pa-tients, the frequency and severity of atelectasis, assessed byradiologists who were blinded to type of procedure, weresignificantly less among patients randomly assigned tolaparoscopic cholecystectomy (frequency, 29% vs. 63%[P � 0.05]; severity, chi-square for trend P � 0.05). How-ever, the analysis was not intention-to-treat: Patients whoconverted from laparoscopic to open operations were ex-cluded from analysis.

Table 2 summarizes the results of a good-qualitymeta-analysis of laparoscopic versus open resection of colo-rectal cancer (37). Overall mortality did not differ. Riskwas consistently less with laparoscopic operations for sev-eral complications but was not statistically significantly lesswith the more conservative statistical approach of random-effects modeling. The reduced risk for overall complica-tions was primarily due to fewer wound complications,especially wound infection. Regarding pulmonary compli-cations, a non–statistically significant trend favored laparo-scopic resection. Three studies that evaluated postoperativepulmonary complications reported that respiratory recovery(defined by spirometry) was statistically significantly faster.Nine studies reporting data confirmed shorter length of hos-pital stay (mean, 21% shorter [range, 14% to 38%]) afterlaparoscopic operations (37).

We identified 1 additional good-quality trial of lapa-roscopic versus open colorectal resection in 384 patients;269 were in an earlier publication that was included in theprevious meta-analysis discussed (21). Again, a nonsignifi-cant trend favored lower rates of pneumonia after laparo-scopic operations (3 of 190 [1.8%] patients and 6 of 194[3.5%] patients; P � 0.52) (21).

Two large retrospective cohort studies highlight theproblems with using designs other than a randomized trialand ICD-9-CM codes to identify postoperative pulmonarycomplications to compare open and laparoscopic opera-tions (57, 58). Atelectasis (the only postoperative pulmo-nary complication studied) occurred significantly less oftenwith laparoscopic (n � 19 662) compared with open (n �23 771) cholecystectomy (4% vs. 2%; P � 0.001) (57).Overall postoperative pulmonary complications were sig-nificantly less frequent after laparoscopic (n � 709) com-pared with open (n � 17 735) sigmoid resection (2.5% vs.6%; P � 0.001) (58). The results of these 2 studies may beunreliable because of lack of systematic prospective surveil-lance. Clinicians may have been biased to order more post-

operative chest radiographs (and therefore identify moreatelectasis) after open procedures. Furthermore, in a recentstudy comparing discharge ICD-9-CM codes and system-atic chart review for complications (8), specificity of ICD-9codes was high but sensitivity was low: 35% (CI, 30% to41%) for all complications and 32% (CI, 19% to 45%) forall infectious complications.

In summary, while supported by spirometric, postop-erative pain, and length of stay data, whether laparoscopicprocedures reduce the risk for clinically important pulmo-nary complications is not clear. The literature did not sys-tematically assess or report pulmonary complications, andmost studies did not have sufficient statistical power todetect differences in postoperative pulmonary complicationrates.

Nasogastric Decompression after Abdominal SurgerySelective use of nasogastric decompression, or tubes,

refers to use only for postoperative nausea or vomiting,inability to tolerate oral intake, or symptomatic abdominaldistension. Routine decompression (that is, standard useuntil bowel function returns) has been thought to speedbowel recovery and decrease risk for aspiration. We iden-tified 2 meta-analyses of studies of routine versus selectivenasogastric decompression (38, 39, 59). One or both meta-analyses included all the trials that we identified.

The first meta-analysis was of good methodologicquality up to quantitative analyses, which pooled data fromrandomized trials, nonrandomized trials, “uncontrolled”trials, and case–control studies (38). For the overall groupof 26 studies (which comprised 15 RCTs, 3 nonrandom-ized trials, and 8 case–control studies [n � 3964]), pa-tients receiving selective decompression had significantlylower rates of pneumonia (odds ratio, 0.49; P � 0.001)and atelectasis (odds ratio, 0.46; P � 0.001) and shortertime to oral intake (3.5 days vs. 4.6 days; P � 0.04). As-piration rates (odds ratio, 0.61; P � 0.88) did not differ.Selective decompression did not statistically significantlyincrease nausea, vomiting, or abdominal distension. For 20higher-quality studies (15 trials and 5 case–control stud-ies), patients receiving selective decompression also had

Table 2. Summary of Results of Meta-Analysis of 12Randomized, Controlled Trials for Laparoscopic OperationsRelative to Open Operations for Colorectal Cancer*

Result Odds Ratio (95% CI)

Fixed-Effects Model Random-Effects Model

Mortality Data not given 0.85 (0.33–2.21)Overall morbidity 0.62 (0.45–0.85) 0.68 (0.38–1.24)Overall complications 0.60 (0.45–0.79) 0.62 (0.38–1.03)Wound complications 0.47 (0.28–0.78) 0.47 (0.28–0.78)Wound infection 0.47 (0.28–0.80) 0.47 (0.28–0.80)Respiratory complications 0.65 (0.28–1.49) 0.65 (0.28–1.49)

* Data from Abraham et al. (37).




lower rates of pneumonia (odds ratio, 0.59; P � 0.01) andatelectasis (odds ratio, 0.52; P � 0.002), a trend towardshorter time to oral intake (3.5 days vs. 4.5 days; P �0.07), no difference in aspiration rates, and significantlyhigher rates of vomiting (odds ratio, 1.45; P � 0.005) andabdominal distension (odds ratio, 1.34; P � 0.02)

The recent meta-analysis was of good quality, and itidentified 28 eligible trials (n � 4194) of routine versusselective nasogastric decompression after open laparotomy(39, 59). It included 15 of the 17 RCTs in the previousmeta-analysis. Of 19 trials (n � 2892) reporting postoper-ative pulmonary complication, 18 included only electiveoperations (39, 59). Patients who were randomly assignedto selective decompression had fewer postoperative pulmo-nary complications, and the benefit approached statistical

significance (relative benefit increase, 1.35 [CI, 0.98 to1.86]; P � 0.07; calculated relative risk reduction, 0.74[CI, 0.54 to 1.02]). Selective decompression also resultedin earlier bowel recovery (8 studies; n � 862; 0.46 day [CI,0.28 day to 0.64 day]; P � 0.001).

In summary, the evidence suggests that selective naso-gastric decompression (that is, for specific indicationsrather than routine decompression) improves return of bowelfunction and may reduce the incidence of postoperative pul-monary complications after elective abdominal operations.

Lung Expansion ModalitiesDecreased lung volumes and atelectasis due to surgery-

related shallow breathing, bed rest, diaphragmatic dysfunc-tion, pain, and impaired mucociliary clearance may be the

Table 3. Meta-Analyses and Randomized, Controlled Trials of Lung Expansion Interventions To Prevent Postoperative PulmonaryComplications*

Author, Year (Reference) Type of Surgery Intervention StudiesIdentified/EligibleRCTs, n/n

RandomAllocationConcealed

BlindedOutcomeAssessment

Systematic reviews ormeta-analyses

Thomas and McIntosh,1994 (40)

Any upperabdominalsurgery

IS, IPPB, DBEs 116/14 NA NA

Overend et al.,2001 (41)

Upper and lowerabdominalsurgery

IS, IPPB, DBEs, CPAP, PEP, orCPAP with PT

85/4 NA NA

Subsequent RCTsChumillas et al.,

1998 (22)Elective upper

abdominalsurgery

DBEs vs. no prophylaxis Unclear Unclear

Fagevik Olsen et al.,1997 (23)

Elective openabdominalsurgery

Low risk: DBEs vs. noprophylaxis; high risk: DBEsplus PEP vs. no prophylaxis‡

Unclear Unclear

Hall et al., 1991 (24) Abdominal surgery IS, chest PT (control) Yes Yes

Hall et al., 1996 (25) Abdominal surgery Low risk: IS vs. DBEs; high risk:IS vs. IS plus chest PT§

Yes Yes

Bohner et al., 2002 (26) Electiveintra-abdominalvascular surgery

Nasal CPAP for 12 h aftersurgery vs. O2 by nasalcannula to keep saturation� 95%

Yes Unclear

* CDC � Centers for Disease Control and Prevention; CPAP � continuous positive airway pressure; DBE � deep breathing exercise; FiO2 � fraction of inspired oxygen;IPPB � intermittent positive-pressure breathing; IQR � interquartile range; IS � incentive spirometry; NA � data not available; OR � odds ratio; PEP � positiverespiratory pressure throughout expiration; PPC � postoperative pulmonary complication; PT � physical therapy; RCT � randomized, controlled trial.† Level of evidence for all studies is I � randomized controlled trial.‡ High risk � age � 50 y and current smoker or body mass index � 30 kg/m2 or lung disease requiring daily medication.§ High risk � American Society of Anesthesiologists class � I or age � 60 y.




first events in a cascade leading to postoperative pulmonarycomplication. However, the evidence on prophylactic lungexpansion is limited by variable techniques, inconsistentdefinitions of postoperative pulmonary complications, andpoor-quality trials. Techniques include incentive spirome-try, deep breathing exercises, chest physical therapy (whichmay include variable combinations of deep breathing,cough, postural drainage, percussion and vibration, suc-tioning, and ambulation), intermittent positive-pressurebreathing, and continuous positive airway pressure. Table3 summarizes the evidence.

The first of 2 poor-quality systematic reviews focusedon upper abdominal surgery and identified 14 randomizedtrials (sample size, 17 to 200 participants) (40). Across alllung expansion modalities, a trend favored fewer postoper-

ative pulmonary complications compared with controls(odds ratio, 0.85 [CI, 0.59 to 1.2)], but heterogeneity wasstatistically significant. In 2 studies, postoperative pulmo-nary complications occurred less often in patients receivingincentive spirometry compared with control (odds ratio,0.44 [CI, 0.18 to 0.99]). In 4 studies, postoperative pul-monary complications occurred less often in patients whowere randomly assigned to deep breathing exercises (oddsratio, 0.43 [CI, 0.27 to 0.63]), but heterogeneity was againstatistically significant. Across other studies, no single mo-dality was clearly superior. The second systematic reviewidentified 4 randomized trials of patients undergoing ab-dominal surgery (41). The authors did not report raw orpooled postoperative pulmonary complication rates. In theonly trial in our systematic review that met our sample size

Table 3—Continued

Participants PPCs/Outcomes Level ofEvidence†;StudyQuality

Results

Total,n

Men,n

Age, y

1337 NA NA Atelectasis or infiltrate on chestradiograph

I; poor IS vs. no treatment: 2 studies (n � unclear)(OR, 0.44 [95% CI, 0.18–0.99])IS vs. IPPB: 3 studies (n � unclear)(OR, 0.73 [CI, 0.39–1.36])IS vs. DBE: 4 studies (n � unclear)(OR, 0.91 [CI, 0.57–1.4])IPPB vs. DBE: 2 studies (n � unclear)(OR, 0.94 [CI, 0.28–3.17])

NA NA NA No data except wide variabilitynoted

I; poor No quantitative pooling due to clinical heterogeneity; noquantitative results for individual studies reported. In 3 studies(all with � 25 participants per group), IS was no better thanDBEs or no treatment and was inferior to CPAP or PEP. In afourth study (41–44 participants per group), IS, DBEs, and IPPB(PPC rates of 21%, 22%, and 22%, respectively) were equallysuperior to no prophylaxis (PPC rate 48%; P � 0.05 for allcomparisons).

81 35 Mean, 64.1(range, 18–84)

Bronchitis, atelectasis, pneumonia I; poor DBEs: fewer abnormalities on chest radiograph (15% vs. 39%; P �0.02) and trend toward fewer PPCs (8% vs. 20%; P � 0.11)

368; 79(20%) werehigh-risk‡

158 Mean, 53.4(range, 19–92)

Pneumonia I; poor DBEs: lower rate of overall pneumonia (0.6% vs. 7%; P � 0.05)

876 430 Median, 55 (IQR,32–72)

Clinical examination of collapse orconsolidation plus abnormal chestradiograph or positive sputum“microbiology”

I; poor No difference between IS and chest PT in rates of PPCs (16% vs.15%) and abnormal chest radiograph (22% both groups)

456 209 Low-risk: median,36 (IQR,29–44); highrisk: median,68 (IQR,58–76)

Clinical examination of collapse orconsolidation plus abnormal chestradiograph or positive sputum“microbiology”

I; poor No difference in rate of PPCs: low risk: 8% vs. 11% (P � 0.50);high risk: 19% vs. 13% (P � 0.18)

204 166 Mean, 64 (SD11.8)

Pneumonia per CDC criteria, severehypoxemia (PaO2 � 70 mm Hgat FiO2 � 0.70)

I; good Nasal CPAP: lower rate of severe hypoxemia (5% vs. 16%; P �0.01); trends toward lower rate of pneumonia (2% vs. 5%; P �0.45) and reintubation (1% vs. 5%; P � 0.21)




criteria, incentive spirometry, deep breathing exercises, andintermittent positive-pressure breathing equally preventedpostoperative pulmonary complications compared with nointervention.

We identified 5 other trials in patients undergoing ma-jor abdominal surgery. The first 4 trials were of poor qual-ity. Two trials compared chest physiotherapy with no pro-phylaxis (22, 23). In the first study, patients who wererandomly assigned to chest expansion, maximum inspira-tion exercises, cough, and early ambulation had fewer ab-normalities on postoperative chest radiography and a non–statistically significant trend toward fewer postoperativepulmonary complications (22). In the second trial, patientswho were randomly assigned to cough and deep breathingexercises had significantly lower rates of pneumonia (0.6%vs. 7%; P � 0.05) (23).

The third trial compared “conventional chest physio-therapy” with incentive spirometry in 876 patients under-going abdominal surgery and found no difference in ratesof overall postoperative pulmonary complication, abnor-mal postoperative chest radiography, or PaO2 less than 60mm Hg (24). The fourth poor-quality study compared 1)incentive spirometry and deep breathing exercises in 155low-risk patients and 2) incentive spirometry versus incen-tive spirometry plus chest physiotherapy in 301 high-riskpatients (ASA class � I or age � 60 years) undergoingabdominal surgery (25). Among high- or low-risk patients,postoperative pulmonary complication rates did not differwith any intervention.

In the fifth and only good-quality trial (26), 204 pa-tients undergoing intra-abdominal vascular surgery wererandomly assigned to supplemental oxygen to maintain ar-terial oxygen saturation greater than 95% or to nasal con-tinuous positive airway pressure for 12 hours after surgery.Severe hypoxemia (PaO2 � 70 mm Hg at fraction of in-spired oxygen � 0.70%) occurred statistically significantlyless often (5% vs. 16%; P � 0.01), and non–statisticallysignificant trends favored less pneumonia and reintubationwith continuous positive airway pressure.

For patients having abdominal surgery, the evidencesuggests that any type of lung expansion intervention isbetter than no prophylaxis. No modality seems superior,and combined modalities do not seem to provide addi-tional risk reduction. Incentive spirometry may be the leastlabor-intensive, while continuous positive airway pressuremay be particularly beneficial for patients who cannot par-ticipate in incentive spirometry or deep breathing exercises.

Nutritional SupportTotal Parenteral or Total Enteral Hyperalimentation

A fair-quality meta-analysis of 14 randomized or qua-si-randomized trials of total parenteral nutrition (TPN)versus no TPN through August 1986 concluded that rou-tine TPN in major surgery was not beneficial, except per-haps for severe malnutrition or for extended periods (10days to 14 days) of inadequate enteral nutrition (60). The

meta-analysis did not report results specific to pulmonarycomplications and was therefore ineligible for our review.

Subsequently, a good-quality multisite trial randomlyassigned 395 patients undergoing laparotomy or noncar-diac thoracotomy to perioperative TPN or no TPN (27).Overall rates of major complications (26% vs. 25%) and90-day mortality (13% vs. 11%) were similar between thegroups. Total parenteral nutrition was associated withnon–statistically significant trends toward higher rates ofpneumonia and empyema but significantly lower rates ofnoninfectious complications (5.3% vs. 42.9%; P � 0.03).

We identified 1 poor-quality meta-analysis (230 pa-tients) and 2 additional, good-quality trials of TPN versustotal enteral nutrition (TEN) (28, 29, 42). In the meta-analysis, infections were twice as common among patientsreceiving TPN (35% vs. 16%; P � 0.01) even after exclud-ing patients with catheter sepsis from analysis (29% vs.16%; P � 0.03) (42). There was a nonstatistically signifi-cant trend toward more frequent pneumonia in patientsreceiving TPN. In a trial of 241 patients, there was a non–statistically significant trend toward more postoperativepulmonary complications with TEN (7% vs. 13%; P �0.12) (28). In a second, larger trial, 317 malnourished pa-tients (�10% weight loss in previous 6 months) were ran-domly assigned to TPN or TEN (29). Rates of overallcomplications and infectious complications were statisti-cally significantly lower with TEN, but rates of pneumonia(9 of 159 patients vs. 14 of 158 patients; P � 0.39) or thecombined outcome of pneumonia and respiratory failure(13 of 159 patients vs. 20 of 158 patients; P � 0.27) didnot differ.

Immunonutrition

Immunonutrition refers to enteral feedings with addi-tional ingredients (variable combinations of arginine, �-3fatty acids, or ribonucleic acids) to enhance the immunesystem and to possibly prevent infection. A good-qualitymeta-analysis of trials found that for patients undergoingelective surgery, enteral immunonutrition had no mortalitybenefit but resulted in significantly fewer overall infectiouscomplications (relative risk, 0.53 [CI, 0.42 to 0.68]) (61).The authors did not report results for respiratory infec-tions; therefore, the study was not eligible for our review.

In a subsequent good-quality trial of enteral immu-nonutrition (30), 305 patients undergoing elective resec-tion of gastrointestinal cancer were randomly assigned toan enteral solution enriched with arginine, �-3 fatty acids,and ribonucleic acids preoperatively (5 days before surgery;n � 102) or perioperatively (5 days before surgery plusjejunal tube feeding begun within 12 hours of surgery andcontinued until oral intake was resumed; n � 101) or to acontrol group (n � 102) of postoperative intravenous glu-cose and electrolytes. Overall infection rates were signifi-cantly lower with immunonutrition (14% and 16% vs.30%; P � 0.006 and 0.02, respectively), but rates of pneu-




monia (3 of 102 patients and 6 of 101 patients vs. 8 of 102patients) did not differ (30).

In summary, while hypoalbuminemia and malnutri-tion increase postoperative complications, including pneu-monia, routine TPN has no benefit over either TEN or nohyperalimentation, except perhaps for patients with severemalnutrition or for long periods of inadequate oral nutri-tion. More research is needed on enteral formulations thatmay enhance immune status. Prompt resumption of oralintake after surgery is important because atrophy of intes-tinal villi occurs quickly with inadequate intake and in-creases the risk for bacterial translocation across gut mu-cosa and subsequent sepsis (62).

Intervention of No Benefit: Pulmonary ArteryCatheterization

After observational data suggested higher rates of re-spiratory failure and pneumonia in patients receiving right-heart catheterization for noncardiac surgery (63), Sandhamand colleagues (31) performed a good-quality RCT. High-risk patients (n � 1994; age � 60 years; ASA class III orIV) undergoing urgent or elective major noncardiac oper-ations were randomly assigned to usual care or treatmentguided by perioperative pulmonary artery catheter. Pulmo-nary artery catheterization did not reduce the primary out-come of in-hospital all-cause mortality (7.8% vs. 7.7%) orthe rate of postoperative pneumonia, a secondary outcome(6.7% vs. 7.3%; P � 0.70).

DISCUSSION

Recent evidence has shown that postoperative pulmo-nary and cardiac complications are equally prevalent andclinically important in morbidity, mortality, and length ofstay. However, compared with postoperative cardiac com-plications, much less research on prevention of pulmonarycomplications has been published. Table 4 summarizes the

strength of available evidence, based on our systematic re-view, on interventions to reduce the risk for postoperativepulmonary complications.

Strategies of Proven BenefitGood evidence suggests that lung expansion therapy

(for example, incentive spirometry, deep breathing exer-cises, and continuous positive airway pressure) reducespostoperative pulmonary risk after abdominal surgery.Well-designed trials are needed to clarify the magnitude ofbenefit and the comparative effectiveness of different mo-dalities.

Strategies of Probable BenefitFair evidence suggests that selective nasogastric tube

decompression after abdominal surgery reduces risk. Fairevidence also suggests that short-acting neuromuscularblocking agents result in lower rates of residual neuromus-cular blockade and may reduce risk for pulmonary compli-cations.

Strategies of Possible BenefitLaparoscopic, compared with open, abdominal opera-

tions reduce pain and pulmonary compromise as measuredby spirometry and oxygenation. However, the evidence isinsufficient to determine whether laparoscopic operationsprevent clinically important pulmonary complications.Given the benefits of laparoscopic procedures in pain con-trol and length of stay, future trials to adequately assessclinical pulmonary outcomes are unlikely.

Strategies of Unclear BenefitEvidence is insufficient to judge the potential benefit

of preoperative smoking cessation in reducing risk. Riskmay actually increase transiently after stopping or reducingsmoking within 2 months of surgery due to increased se-cretions. We need trials of preoperative smoking cessation

Table 4. Strength of the Evidence for Specific Interventions To Reduce the Risk for Postoperative Pulmonary Complications

Risk Reduction Strategy Strength of Evidence* Type of Complication Studied

Postoperative lung expansion modalities A Atelectasis, pneumonia, bronchitis, severe hypoxemiaSelective postoperative nasogastric decompression B Atelectasis, pneumonia, aspirationShort-acting neuromuscular blockade B Atelectasis, pneumoniaLaparoscopic (vs. open) operation C Spirometry, atelectasis, pneumonia, overall respiratory complicationsSmoking cessation I Postoperative ventilator supportIntraoperative neuraxial blockade I Pneumonia, postoperative hypoxia, respiratory failurePostoperative epidural analgesia I Atelectasis, pneumonia, respiratory failureImmunonutrition I Overall infectious complications, pneumonia, respiratory failureRoutine total parenteral or enteral nutrition† D Atelectasis, pneumonia, empyema, respiratory failureRight-heart catheterization D Pneumonia

* Definitions for categories of strength of evidence, modified from the U.S. Preventive Services Task Force categories (11). A � good evidence that the strategy reducespostoperative pulmonary complications and benefit outweighs harm; B � at least fair evidence that the strategy reduces postoperative pulmonary complications and benefitoutweighs harm; C � at least fair evidence that the strategy may reduce postoperative pulmonary complications, but the balance between benefit and harm is too close tojustify a general recommendation; D � at least fair evidence that the strategy does not reduce postoperative pulmonary complications or harm outweighs benefit; I � evidenceof effectiveness of the strategy to reduce postoperative pulmonary complications is conflicting, of poor quality, lacking, or insufficient or the balance between benefit and harmcannot be determined.† Evidence remains uncertain (strength of evidence I) on total parenteral or enteral nutrition for severely malnourished patients or when a protracted time of inadequatenutritional intake is anticipated.




before higher-risk surgeries that adequately address optimalduration of cessation.

Evidence on intraoperative epidural anesthesia andpostoperative epidural analgesia is insufficient. More good-quality efficacy trials of sufficient size (in which all groupsreceive equally standardized and optimized regimens) areneeded to accurately examine complication rates.

Strategies of No BenefitAlthough malnutrition is associated with increased risk

for postoperative pulmonary complications, good evidenceindicates that routine total parenteral or enteral hyperali-mentation nutrition does not reduce risk, except perhapsfor patients with severe malnutrition or for those undergo-ing long periods with inadequate oral intake. Enteral for-mulations that are tailored to enhance immune status andreduce postoperative infections may be promising.

Evidence from 1 well-done randomized trial indicatesthat invasive perioperative monitoring with pulmonary ar-tery catheterization does not reduce risk of pulmonarycomplications.

LimitationsA limitation of our review is the overall quality of the

literature. Only 10 of 20 RCTs and 6 of 11 systematicreviews or meta-analyses were of good quality.

Future ResearchFuture studies of interventions to reduce postoperative

pulmonary complications should be randomized trials thatare designed to overcome methodologic problems in earlierliterature. Cohort studies using secondary analyses of ad-ministrative databases should use measures for pulmonarycomplications that are proven valid and reliable by directclinical assessment or medical chart audit. Studies shouldbe large enough to adjust for known potential risk factorsand confounding variables (as synthesized in the accompa-nying systematic review of preoperative risk stratification[7]) and should go beyond surrogate or intermediate phys-iologic or spirometric outcomes to detect clinically mean-ingful differences in clinical pulmonary complications.This is important for 2 reasons: to base patient care onclinically meaningful evidence and to determine when it isappropriate to substitute intermediate outcomes to shortenstudy timelines and reduce study cost. Researchers shoulddefine postoperative pulmonary complications a priori ac-cording to explicit criteria and, whenever possible, use out-come assessment that is masked, or blinded, to interven-tion assignment.

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

Disclosure: Members of the American Society of Anesthesiologists alsoreviewed the manuscript. Their review implies neither agreement withnor endorsement of this document.

Acknowledgments: The authors gratefully acknowledge the tremendouscontribution of medical librarian Martha R. Harris, MA, for her timeand expertise in searching the medical literature and managing the re-sulting project database. They also thank the Department of Anesthesi-ology, especially Christopher Jankowski, MD, of the Mayo Clinic, Roch-ester, Minnesota, for assistance in interpreting the anesthesiologyliterature.

Grant Support: By the Veterans Evidence-based Research, Dissemina-tion, and Implementation Center (VERDICT) (Veterans Affairs HealthServices 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: Valerie A. Lawrence, MD, Medicine/General Medicine, University of Texas Health Science Center at SanAntonio, 7703 Floyd Curl Drive, Mail Code 7879, San Antonio, TX78229-3900; e-mail, [email protected].

Current author addresses are available at www.annals.org.

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Current Author Addresses: Drs. Lawrence and Cornell: Medicine/Gen-eral Medicine, University of Texas Health Science Center at San Anto-nio, 7703 Floyd Curl Drive, Mail Code 7879, San Antonio, TX 78229-3900.

Dr. Smetana: Division of General Medicine and Primary Care, BethIsrael Deaconess Medical Center, 330 Brookline Avenue, Boston, MA02215.

Annals of Internal Medicine

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-nee

ded

IVco

ntin

uous

mor

phin

eor

inte

rmitt

ent

IMm

orph

ine

Elec

tive

chol

ecys

tect

omy

Age

�75

yN

oad

ditio

nali

nfor

mat

ion

No

Unc

lear

No

Unc

lear

Yes

Kar

ayia

nnak

iset

al.,

1996

(20)

LCLC

with

4-tr

ocar

tech

niqu

eO

Cw

ithtr

ansv

erse

right

subc

osta

linc

isio

nEl

ectiv

ech

olec

yste

ctom

yA

llpa

tient

sw

ithsy

mpt

omat

icch

olel

ithia

sis

Acu

tech

olec

ystit

is,

chol

edoc

holit

hias

is,

age

�65

y,bo

dym

ass

inde

x�

29kg

/m2 ,

hist

ory

ofpu

lmon

ary

dise

ase,

�10

ciga

rett

es/d

No

Yes

for

ches

tra

diog

raph

yNo

Yes

No

Vig

nali

etal

.,20

04(2

1)LC

RLC

RO

CR

Elec

tive

colo

rect

alre

sect

ion

Age

�18

yan

dca

ndid

ate

for

lapa

rosc

opic

rese

ctio

n

Can

cer

infil

trat

ing

adja

cent

orga

nsby

imag

ing,

NY

HA

clas

s�

3,ar

teria

lPO

2�

70m

mH

g,liv

erdy

sfun

ctio

n(C

hild

–Pug

hcl

ass

C),

�ong

oing

infe

ctio

n,�

neut

roph

ilco

unt

�2

�10

9ce

lls/L

No

Yes

No

Yes

Yes

Chu

mill

aset

al.,

1998

(22)

�Res

pira

tory

reha

bilit

atio

n�w

ithbr

eath

ing

exer

cise

s

Inst

ruct

ion

abou

tfo

rced

expi

ratio

nte

chni

que

and

coug

h,ch

est

expa

nsio

nex

erci

ses

and

diap

hrag

mm

obili

zatio

n,m

axim

umin

spira

tion

for

3–5

s,an

dea

rlyam

bula

tion

afte

rsu

rger

y;ex

erci

ses

wer

edo

nefo

r10

–15

min

QID

befo

resu

rger

yan

dfo

r10

min

ever

y2

hon

post

oper

ativ

eda

ys1

and

2

No

desc

riptio

nEl

ectiv

esu

prau

mbi

lical

lapa

roto

my

Age

�15

yN

otst

ated

apr

iori

No

Unc

lear

No

Unc

lear

No

Fage

vik

Ols

enet

al.,

1997

(23)

Che

stph

ysio

ther

apy

Preo

pera

tive

trai

ning

inD

BEs

with

purs

edlip

s,hu

ffin

g,co

ughi

ngev

ery

tent

hbr

eath

hour

lyaf

ter

surg

ery;

impo

rtan

ceof

posi

tion

chan

gein

bed

and

early

mob

iliza

tion;

high

-ris

kpa

tient

sw

ere

also

give

nPE

P;po

stop

erat

ive

ther

apy

was

adju

sted

per

phys

ioth

erap

ist

orph

ysic

ian

�acc

ordi

ngto

pulm

onar

yst

atus

�;du

ratio

nof

trea

tmen

tw

as10

–15

min

befo

rean

d15

–20

min

afte

rsu

rger

y

No

trai

ning

befo

resu

rger

y,no

ther

apy

afte

rsu

rger

yun

less

pulm

onar

yco

mpl

icat

ions

occu

rred

,th

enpa

tient

sgi

ven

phys

ioth

erap

yw

ithPE

P

Elec

tive

open

abdo

min

alsu

rger

y

No

data

No

data

No

No

data

No

No:

�[T]

oav

oid

patie

ntin

terf

eren

ce,

clus

ter

rand

omiz

atio

nw

aspe

rfor

med

inal

tern

ate

mon

ths�

Unc

lear

Hal

let

al.,

1991

(24)

ISvs

.ch

est

phys

ioth

erap

yIS

devi

ceon

beds

ide

tabl

e,pa

tient

inst

ruct

edin

use;

atte

ndin

gph

ysic

ians

’re

spon

sibi

lity

topr

omot

eits

use

perio

pera

tivel

y,pr

efer

ably

for

5m

inin

each

wak

ing

hour

Trea

tmen

tac

cord

ing

toth

ecl

inic

alju

dgm

ent

ofat

tend

ing

phys

icia

nsan

dph

ysio

ther

apis

ts

Lapa

roto

my

�with

man

ipul

atio

nof

visc

era�

Lapa

roto

my

�with

man

ipul

atio

nof

visc

era�

Age

�14

y,pr

eope

rativ

epu

lmon

ary

com

plic

atio

npe

rou

tcom

ede

finiti

ons

No

Yes

No

Yes

Yes

Hal

let

al.,

1996

(25)

Low

-ris

kpa

tient

s:1)

ISvs

.2)

DBE

s;hi

gh-r

isk

patie

nts:

3)IS

vs.

4)IS

�ch

est

phys

ioth

erap

y

1)an

d3)

IS:

info

rmat

ion

shee

tan

den

cour

agem

ent

tous

eIS

atle

ast

10tim

esho

urly

2)D

BEs:

seen

once

and

enco

urag

edto

take

10de

epbr

eath

sho

urly

;4)

IS�

ches

tph

ysio

ther

apy

had

phys

ioth

erap

yai

med

atpr

oduc

ing

max

imum

insp

irato

ryef

fort

atle

ast

once

daily

for

post

oper

ativ

eda

ys1–

3,th

enat

furt

her

rate

per

phys

ioth

erap

ist

Lapa

roto

my

�with

man

ipul

atio

nof

visc

era�

Lapa

roto

my

�with

man

ipul

atio

nof

visc

era�

;hi

gh-r

isk

patie

nts

defin

edas

ASA

clas

s�

Ior

age

�60

y

Lang

uage

,pu

lmon

ary

com

plic

atio

nbe

fore

surg

ery,

lack

ofco

nsen

tdu

eto

decl

ined

part

icip

atio

nor

insu

ffic

ient

time

befo

resu

rger

y

No

Yes

No

Yes

Yes

Con

tinue

don

follo

win

gpa

ge



App

endi

xT

able

1—C

onti

nued

Aut

hor,

Yea

r(R

efer

ence

)In

terv

enti

onIn

terv

enti

onD

escr

ipti

onC

ontr

olD

escr

ipti

onTy

peof

Surg

ery

Incl

usio

nC

rite

ria

Excl

usio

nC

rite

ria

Pati

ents

Blin

ded

Out

com

eA

sses

smen

tB

linde

d

Mul

tice

nter

Ran

dom

izat

ion

Allo

cati

onC

once

alm

ent

ITT

Ana

lysi

s

Bohn

eret

al.,

2002

(26)

Nas

alC

PAP

for

12h

afte

rsu

rger

yIn

term

edia

teca

refo

rat

leas

t24

haf

ter

surg

ery

with

nasa

lCPA

Pat

10cm

H2O

for

atle

ast

12h

afte

rsu

rger

yto

keep

O2

satu

ratio

n�

95%

Inte

rmed

iate

care

for

atle

ast

24h

afte

rsu

rger

yw

ithox

ygen

byfa

cem

ask

orna

salc

annu

lato

keep

oxyg

ensa

tura

tion

�95

%

Elec

tive

mid

line

abdo

min

alva

scul

arsu

rger

y

Elec

tive

mid

line

abdo

min

alva

scul

arsu

rger

ysc

hedu

led

tobe

extu

bate

din

the

oper

atin

gro

om

Emer

genc

ysu

rger

y,re

pair

ofth

orac

oabd

omin

alan

eury

sm,

excl

usiv

ely

retr

oper

itone

alap

proa

ch

No

No

data

No

Yes

Yes

VA

TPN

Coo

pera

tive

Stud

yG

roup

,19

91(2

7)

Preo

pera

tive

TPN

TPN

toca

loric

goal

of10

00kc

al�

rest

ing

met

abol

icex

pend

iture

;op

timal

was

7–15

dbe

fore

surg

ery;

subo

ptim

alw

as�

7d;

TPN

cont

inue

d72

haf

ter

surg

ery;

oral

inta

keas

clin

ical

lyal

low

edor

tole

rate

d

No

TPN

orfo

rced

ente

ral

inta

kebe

fore

surg

ery

oraf

ter

surg

ery

for

72h,

then

TPN

oren

tera

lif

indi

cate

d

Elec

tive

lapa

roto

my

orth

orac

otom

yA

ge�

21y,

elec

tive

lapa

roto

my

orth

orac

otom

y

Dea

thex

pect

edw

ithin

90d,

TPN

inpr

evio

us15

d,ot

her

surg

ery

with

inpr

evio

us30

d,co

ntra

indi

catio

nto

dela

yin

surg

ery

for

TPN

,TP

Nco

ntra

indi

cate

d,m

ajor

conc

urre

ntill

ness

,TP

Nes

sent

ial,

wel

l-no

uris

hed

No

No

Yes

Yes

Yes

Pace

lliet

al.,

2001

(28)

TEN

vs.

TPN

Post

oper

ativ

eTE

N(d

urin

gin

duct

ion

ofTE

N,

TPN

was

adde

dto

achi

eve

the

sam

eca

loric

inta

keas

inth

eTP

Ngr

oup)

Post

oper

ativ

eTP

NM

ajor

elec

tive

abdo

min

alop

erat

ions

Age

18–8

0y,

mal

nour

ishe

d,nu

triti

onal

risk

inde

x�

90%

Emer

genc

ysu

rger

y,el

ectiv

eap

pend

ecto

my,

chol

ecys

tect

omy

orvi

scer

olys

is

No

Unc

lear

Yes

Yes

Yes

Bozz

etti

etal

.,20

01(2

9)

TEN

vs.

TPN

Post

oper

ativ

eTE

N:

jeju

nost

omy

feed

ing

tube

orna

soje

juna

lfee

ding

tube

plac

eddu

ring

surg

ery

Post

oper

ativ

eTP

NEl

ectiv

em

ajor

rese

ctio

nfo

rga

stro

inte

stin

alca

ncer

Wei

ght

loss

�10

%us

ualb

ody

wei

ght

inpr

evio

us6

mo,

hist

olog

ical

lypr

oven

canc

er

Age

�18

y,liv

erdy

sfun

ctio

n(C

hild

–Pug

hcl

ass

�2)

,se

rum

crea

tinin

ele

vel�

265.

2�

mol

/L(�

3m

g/dL

)or

hem

odia

lysi

s,N

YH

Afu

nctio

nalc

lass

�III

,hi

stor

yof

stro

ke,

preg

nanc

y,on

goin

gin

fect

ion,

prev

ious

inte

stin

alan

asto

mos

isof

the

larg

ebo

wel

with

out

adi

vert

ing

stom

a

No

No

Yes

Yes

Yes

Gia

nott

iet

al.,

2002

(30)

Ente

ral

imm

unon

utrit

ion

1)O

rali

mm

unon

utrit

ion

for

5d

befo

resu

rger

y,no

supp

lem

enta

tion

afte

rsu

rger

y;2)

oral

imm

unon

utrit

ion

for

5d

befo

resu

rger

yan

dby

jeju

nalf

eedi

ngaf

ter

surg

ery

until

oral

inta

kere

sum

ed

3)U

sual

care

,no

ente

ral

supp

lem

ent,

IV5%

gluc

ose

and

elec

trol

ytes

Elec

tive

maj

orre

sect

ion

for

gast

roin

test

inal

canc

er

His

tolo

gica

llypr

oven

canc

erW

eigh

tlo

ss�

10%

ofus

ualb

ody

wei

ght

inpa

st6

mo,

age

�18

y,liv

erdy

sfun

ctio

n(C

hild

–Pug

hcl

ass

�B)

,Pa

O2

�70

mm

Hg,

crea

tinin

ele

vel�

265.

2�

mol

/L(�

3m

g/dL

)or

hem

odia

lysi

s,N

YH

Acl

ass

�3,

Kar

nofs

ky�

60,

preg

nanc

y,on

goin

gin

fect

ion,

neoa

djuv

ant

radi

oche

mot

hera

pyor

neut

roph

ilco

unt

�2

�10

9ce

lls/L

No

Unc

lear

No

Yes

Yes

Sand

ham

etal

.,20

03(3

1)

Pulm

onar

yar

tery

cath

eter

inhi

gh-r

isk

surg

ical

patie

nts

Pulm

onar

yar

tery

cath

eter

plac

edbe

fore

surg

ery;

trea

tmen

tdi

rect

edto

apr

iori

esta

blis

hed

phys

iolo

gic

goal

san

dpr

iorit

ies

No

pulm

onar

yar

tery

cath

eter

,ce

ntra

lven

ous

cath

eter

allo

wed

Urg

ent

and

elec

tive

maj

orab

dom

inal

,th

orac

ic,

vasc

ular

,or

hip

frac

ture

surg

ery

Age

�60

y,A

SAcl

ass

IIIor

IVN

oad

ditio

nali

nclu

sion

crite

riaN

oY

esY

esY

esY

es

*A

SA�

Am

eric

anSo

ciet

yof

Ane

sthe

siol

ogis

ts;C

PAP

�co

ntin

uous

posi

tive

airw

aypr

essu

re;D

BE

�de

epbr

eath

ing

exer

cise

;IM

�in

tram

uscu

lar;

IS�

ince

ntiv

esp

irom

etry

;IT

T�

inte

ntio

n-to

-tre

at;I

V�

intr

aven

ous;

LC�

lapa

rosc

opic

chol

ecys

tect

omy;

LCR

�la

paro

scop

icco

lore

ctal

rese

ctio

n;N

SAID

�no

nste

roid

alan

ti-i

nflam

mat

ory

drug

;NY

HA

�N

ewY

ork

Hea

rtA

ssoc

iati

on;O

C�

open

chol

ecys

tect

omy;

OC

R�

open

colo

rect

alre

sect

ion;

PCA

�pa

tien

t-co

ntro

lled

anal

gesi

a;PC

EA

�pa

tien

t-co

ntro

lled

epid

ural

anal

gesi

a;PE

P�

posi

tive

expi

rato

rypr

essu

re;

QID

�fo

urti

mes

daily

;T

EN

�to

tal

ente

ral

nutr

itio

n;T

PN�

tota

lpa

rent

eral

nutr

itio

n;V

AT

PN�

Vet

eran

sA

ffai

rsT

otal

Pare

nter

alN

utri

tion

.



App

endi

xT

able

2.A

bstr

acte

dD

ata

for

Elig

ible

Ran

dom

ized

Tria

ls,

Con

tinu

ed*

Aut

hor,

Yea

r(R

efer

ence

)Sa

mpl

ing

Stra

tegy

Com

orbi

dC

ondi

tion

sIm

port

ant

Bas

elin

eD

iffe

renc

es?

Impo

rtan

tIn

trao

pera

tive

Dif

fere

nces

?A

nest

hesi

aFo

llow

-up

Impo

rtan

tD

iffe

renc

esin

Co-

Inte

rven

tions

Rel

evan

tfo

rPu

lmon

ary

Com

plic

atio

ns?

Cro

ssov

ers

Part

icip

ant

Acc

rual

Part

icip

ant

Att

riti

on

Møl

ler

etal

.,20

02(1

2)C

onse

cutiv

eC

hron

iche

art

dise

ase,

chro

nic

obst

ruct

ive

lung

dise

ase,

diab

etes

No

Non

ere

gard

ing

perc

enta

geof

patie

nts

rece

ivin

gge

nera

lane

sthe

sia,

dura

tion

ofsu

rger

y,or

num

ber

ofhi

por

knee

oper

atio

ns

Gen

eral

orre

gion

alH

ospi

tals

tay

No

No

166

elig

ible

,46

decl

ined

,12

0ra

ndom

lyas

sign

ed4

(inte

rven

tion)

and

8(c

ontr

ol):

oper

atio

nde

laye

dor

canc

eled

Berg

etal

.,19

97(1

3)N

oda

taSm

okin

gst

atus

,pu

lmon

ary

dise

ase

No;

tren

dsto

war

dm

ore

smok

ers,

drop

erid

ol,

and

inha

led

anes

thet

icin

the

panc

uron

ium

grou

p

Sign

ifica

ntly

mor

ean

esth

etic

min

utes

,re

sidu

alne

urom

uscu

lar

bloc

kan

dm

inut

esto

extu

batio

nw

ithpa

ncur

oniu

mco

mpa

red

with

vecu

roni

umor

atra

curiu

m

Gen

eral

Post

oper

ativ

eda

y6

No

No

No

data

othe

rth

an69

3pa

tient

sel

igib

lean

den

rolle

d2

prot

ocol

viol

atio

ns

Nor

riset

al.,

2001

(14)

Con

secu

tive?

Dia

bete

s,hy

pert

ensi

on,

rena

lin

suff

icie

ncy,

card

iova

scul

aran

dpe

riphe

ralv

ascu

lar

dise

ase,

smok

ing

No

Gen

eral

anes

thes

iaas

soci

ated

with

sign

ifica

ntly

less

oper

atio

nan

dcr

oss-

clam

ping

time

com

pare

dw

ithge

nera

l�re

gion

alan

esth

esia

Post

oper

ativ

eda

y7

and

1,3,

6,an

d12

mo

for

mor

talit

y

No

No

309

eval

uate

d,62

inel

igib

le,

48de

clin

ed,

24�a

dmin

istr

ativ

eex

clus

ions

,�17

6co

nsen

ted,

7no

tra

ndom

lyas

sign

eddu

eto

faile

dep

idur

al,

8ra

ndom

lyas

sign

edto

pilo

tst

udy,

160

rand

omly

assi

gned

tore

port

edst

udy

Non

e

Rig

get

al.,

2002

(15)

Con

secu

tive?

Mor

bid

obes

ity,

diab

etes

,ch

roni

cre

nalf

ailu

re,

card

iac

failu

re,

resp

irato

ryin

suff

icie

ncy,

acut

em

yoca

rdia

lin

farc

tion,

exer

tiona

lang

ina,

myo

card

ial

isch

emia

,se

vere

liver

dise

ase

No

No

data

30d

for

mor

talit

y,co

mpl

icat

ions

;ho

spita

lsta

y?

No

data

Unc

lear

how

anal

gesi

aw

asha

ndle

dfo

r22

2pa

tient

sas

sign

edto

epid

ural

but

not

fully

adhe

rent

topr

otoc

ol

920

rand

omly

assi

gned

,32

excl

uded

afte

rra

ndom

izat

ion

32ex

clud

edaf

ter

rand

omiz

atio

n:5

ente

red

inst

udy

for

seco

ndop

erat

ion

and

27in

elig

ible

orca

ncel

edsu

rger

y

Park

etal

.,20

01(1

6)C

onse

cutiv

e?A

SAcl

ass

IIor

III,

Gol

dman

card

iac

risk

inde

x,pr

evio

usan

gina

,m

yoca

rdia

lin

farc

tion,

cong

estiv

ehe

art

failu

re,

hype

rten

sion

,ch

roni

cob

stru

ctiv

elu

ngdi

seas

e,di

abet

es,

rena

lfa

ilure

,ce

rebr

ovas

cula

rac

cide

nt,

curr

ent

smok

ing,

hist

ory

ofal

coho

lism

,al

coho

licliv

erdi

seas

e

No

No

diff

eren

ces

inop

erat

ion

seve

rity

ordu

ratio

n30

dG

roup

sre

ceiv

edsi

mila

ran

tibio

ticpr

ophy

laxi

s,bo

wel

prep

arat

ion,

and

intr

aope

rativ

em

onito

ring

Con

trol

toin

terv

entio

n:48

patie

nts;

inte

rven

tion

toco

ntro

l:32

patie

nts

2731

scre

ened

,13

60ex

clud

ed,

350

decl

ined

,10

21ra

ndom

lyas

sign

ed

26su

rger

ies

canc

eled

,11

with

draw

als

Fler

onet

al.,

2003

(17)

Con

secu

tive

Cor

onar

yar

tery

dise

ase,

hype

rten

sion

,co

nges

tive

hear

tfa

ilure

,ch

roni

cob

stru

ctiv

elu

ngdi

seas

e,di

abet

es

No

No

30d

No

Lum

bar

punc

ture

coul

dno

tbe

done

in3

patie

nts

inep

idur

algr

oup:

They

wer

esw

itche

dto

the

cont

rolg

roup

for

anal

ysis

�217

patie

nts

who

met

all

incl

usio

ncr

iteria

wer

era

ndom

ized

�

Man

net

al.,

2000

(18)

Con

secu

tive?

Cor

onar

yar

tery

dise

ase,

diab

etes

,hy

pert

ensi

on,

chro

nic

obst

ruct

ive

lung

dise

ase,

depr

essi

on

No

Patie

nts

rand

omly

assi

gned

toep

idur

alha

dsi

gnifi

cant

lyle

sssu

fent

anil

and

isof

lura

ne,

sign

ifica

ntly

mor

eep

hedr

ine,

and

sign

ifica

ntly

long

ertim

eto

extu

batio

n

Clin

ical

:da

ilyth

roug

hpo

stop

erat

ive

day

7;ch

est

radi

ogra

phy:

post

oper

ativ

eda

ys1,

3,5

No

No

data

108

eval

uate

d,4

decl

ined

,34

inel

igib

le,

70ra

ndom

lyas

sign

ed

4pa

tient

s:no

surg

ical

rese

ctio

n;2

patie

nts:

decl

ined

tous

epa

tient

-con

trol

led

anes

thes

ia

Con

tinue

don

follo

win

gpa

ge



App

endi

xT

able

2—C

onti

nued

Aut

hor,

Yea

r(R

efer

ence

)Sa

mpl

ing

Stra

tegy

Com

orbi

dC

ondi

tion

sIm

port

ant

Bas

elin

eD

iffe

renc

es?

Impo

rtan

tIn

trao

pera

tive

Dif

fere

nces

?A

nest

hesi

aFo

llow

-up

Impo

rtan

tD

iffe

renc

esin

Co-

Inte

rven

tions

Rel

evan

tfo

rPu

lmon

ary

Com

plic

atio

ns?

Cro

ssov

ers

Part

icip

ant

Acc

rual

Part

icip

ant

Att

riti

on

Cus

chie

riet

al.,

1985

(19)

Con

secu

tive?

Wei

ght,

smok

ing,

resp

irato

rydi

seas

eN

oN

ofo

rdu

ratio

nof

anes

thes

ia,

tren

dto

war

dm

ore

intr

aope

rativ

eop

ioid

san

dlo

nger

time

tofir

stdo

seof

post

oper

ativ

ean

alge

sia

inIM

mor

phin

egr

oup

Post

oper

ativ

eda

y3

No

data

4fa

iled

epid

ural

cath

eter

plac

emen

tan

dre

ceiv

edIM

mor

phin

e

�75

patie

nts

wer

ein

clud

edin

the

stud

y,25

inea

chgr

oup�

Non

e

Kar

ayia

nnak

iset

al.,

1996

(20)

Con

secu

tive

Non

ere

port

edN

ofo

rag

e,se

x,w

eigh

t,he

ight

,or

othe

rba

selin

eda

tare

port

ed

No

for

oper

atio

nan

dan

esth

esia

time

but

tren

dto

war

dsh

orte

rop

erat

ion

time

(97

min

�19

min

vs.

108

min

�23

min

)an

dan

esth

esia

time

(116

min

�15

min

vs.

139

min

�18

min

)w

ithLC

Gen

eral

Hos

pita

lsta

yN

o3

rand

omly

assi

gned

toLC

requ

ired

conv

ersi

onto

open

oper

atio

nan

dw

ere

excl

uded

from

anal

ysis

147

elig

ible

,49

decl

ined

,98

rand

omly

assi

gned

7(2

LCs,

5O

Cs)

decl

ined

afte

rra

ndom

izat

ion;

2LC

sex

clud

eddu

eto

inco

mpl

ete

pulm

onar

yte

sts;

3LC

sex

clud

eddu

eto

conv

ersi

onto

OC

;4

OC

sex

clud

eddu

eto

com

mon

bile

duct

expl

orat

ion

Vig

nali

etal

.,20

04(2

1)C

onse

cutiv

eA

SAcl

ass,

wei

ght

loss

�10

%,

canc

erPa

tient

sha

ving

OC

Rw

ere

olde

rth

anth

ose

havi

ngLC

R(6

2y

�13

.4y

vs.

66y

�12

.2y;

P�

0.02

);no di

ffer

ence

sfo

rot

her

repo

rted

com

orbi

dco

nditi

ons

No

for

intr

aope

rativ

etr

ansf

usio

nam

ount

,tu

mor

stag

e,or

reas

onfo

rop

erat

ion;

LCR

was

asso

ciat

edw

ithlo

nger

oper

atio

ntim

e(2

21m

in�

69m

invs

.17

8m

in�

68m

in;

P�

0.00

01),

less

intr

aope

rativ

ebl

ood

loss

(177

mL

�20

0m

Lvs

.26

4m

L�

292

mL;

P�

0.01

),le

ssfr

eque

nttr

ansf

usio

n(1

7%vs

.42

%;

P�

0.00

01).

Gen

eral

�th

orac

icep

idur

al

30d

afte

rdi

scha

rge

with

wee

kly

offic

evi

sits

No

10ra

ndom

lyas

sign

edto

LCR

requ

ired

conv

ersi

onto

OC

R

384

rand

omly

assi

gned

Non

e

Chu

mill

aset

al.,

1998

(22)

Con

secu

tive

No

data

No

data

exce

pt�n

osi

gnifi

cant

diff

eren

ces

insa

mpl

ech

arac

teris

tics

orris

kfa

ctor

sof

both

grou

ps,

incl

udin

gpr

eope

rativ

ech

est

x-ra

y,w

ithth

eex

cept

ion

ofse

xdi

strib

utio

n�

No

data

exce

pt�n

osi

gnifi

cant

diff

eren

ces

inav

erag

eop

erat

ion

dura

tion

orty

pes

ofin

cisi

on�

Gen

eral

Post

oper

ativ

eda

y6

No

No

data

115

rand

omly

assi

gned

,34

excl

uded

(em

erge

ncy

oper

atio

n,ex

trap

ulm

onar

yco

mpl

icat

ions

,in

frau

mbi

lical

exte

nsio

nof

inci

sion

,pa

tient

coop

erat

ion

with

inte

rven

tion)

,81

�eva

luab

lepa

tient

s�

Fage

vik

Ols

enet

al.,

1997

(23)

Con

secu

tive

Ove

rwei

ght

smok

ers

with

high

-ris

kA

SAcl

ass

�No

sign

ifica

ntdi

ffer

ence

sin

back

grou

ndva

riabl

es�

No

sign

ifica

ntdi

ffer

ence

indi

strib

utio

nof

oper

atio

nty

pes

but

tren

dto

war

dm

ore

uppe

rab

dom

inal

oper

atio

nsin

cont

rolg

roup

(30%

vs.

39%

)

Gen

eral

Hos

pita

lsta

yN

oda

taN

oda

ta36

8ra

ndom

lyas

sign

ed4

nonc

ompl

etio

ns:

2co

ntro

l,2

trea

tmen

t

Hal

let

al.,

1991

(24)

Con

secu

tive

Preo

pera

tive

hosp

ital

stay

�3

d,cu

rren

tsm

oker

,ch

roni

cbr

onch

itis,

abno

rmal

ches

tra

diog

raph

,P O

2�

80m

mH

g,A

SAcl

ass

No

No

for

anes

thes

iatim

e,di

strib

utio

nam

ong

12su

rgeo

ns,

intr

aper

itone

alin

fect

ion,

type

ofin

cisi

on,

post

oper

ativ

ena

soga

stric

deco

mpr

essi

on

Unc

lear

,pr

esum

ably

allg

ener

al

Hos

pita

lsta

yN

oda

taN

oda

ta10

32sc

reen

ed;

156

excl

uded

(5�

14y

ofag

e,3

reta

rdat

ion,

8la

ngua

ge,

14de

clin

ed,

25pr

eope

rativ

epu

lmon

ary

com

plic

atio

n,10

1in

suff

icie

nttim

eto

cons

ent)

;87

6ra

ndom

lyas

sign

ed

35ra

ndom

lyas

sign

edpa

tient

sdi

dno

tha

vesu

rger

y:21

IS,

14ch

est

phys

ioth

erap

y

Hal

let

al.,

1996

(25)

Con

secu

tive

ASA

clas

s,ca

ncer

,cu

rren

tsm

oker

,ch

roni

cbr

onch

itis

No

No

for

oper

atio

ntim

e,pr

oced

ure

type

,in

trap

erito

neal

infe

ctio

n,in

cisi

onty

peor

leng

th,

reop

erat

ion,

naso

gast

ricde

com

pres

sion

,ep

idur

alan

alge

sia

No

data

,pr

esum

ably

allg

ener

al,

som

ew

ithad

ditio

nal

epid

ural

anes

thes

ia

Hos

pita

lsta

yN

oda

taN

oda

ta61

9sc

reen

ed;

143

excl

uded

(13

lang

uage

,14

decl

ined

,15

preo

pera

tive

pulm

onar

yco

mpl

icat

ion,

115

lack

ofco

nsen

t);

476

rand

omly

assi

gned

20ra

ndom

lyas

sign

edpa

tient

sdi

dno

tha

vesu

rger

y

Con

tinue

don

follo

win

gpa

ge



App

endi

xT

able

2—C

onti

nued

Aut

hor,

Yea

r(R

efer

ence

)Sa

mpl

ing

Stra

tegy

Com

orbi

dC

ondi

tion

sIm

port

ant

Bas

elin

eD

iffe

renc

es?

Impo

rtan

tIn

trao

pera

tive

Dif

fere

nces

?A

nest

hesi

aFo

llow

-up

Impo

rtan

tD

iffe

renc

esin

Co-

Inte

rven

tions

Rel

evan

tfo

rPu

lmon

ary

Com

plic

atio

ns?

Cro

ssov

ers

Part

icip

ant

Acc

rual

Part

icip

ant

Att

riti

on

Bohn

eret

al.,

2002

(26)

Con

secu

tive

Smok

ing,

coro

nary

hear

tdi

seas

e,pu

l-m

onar

ydi

seas

e,A

SAcl

ass

No

No

for

dura

tion

ofsu

rger

y,bl

ood

loss

,cr

ysta

lloid

,tr

ansf

usio

n,au

totr

ansf

u-si

on,

hypo

tens

ion,

hype

r-te

nsio

n,ox

ygen

atio

n

No

data

,pr

esum

ably

gene

ral

Hos

pita

lsta

yN

o9

patie

nts

did

not

tole

rate

nasa

lC

PAP

237

rand

omly

assi

gned

33ex

clud

edaf

ter

rand

omiz

atio

nfo

rin

elig

ible

surg

ery

orpa

tient

coul

dno

tbe

extu

bate

din

oper

atin

gro

om:

17na

sal

CPA

P,16

cont

rol

VA

TPN

Coo

pera

tive

Stud

yG

roup

,19

91(2

7)

Con

secu

tive

Surg

ical

diag

nosi

s,nu

triti

onal

stat

us,

perc

enta

geof

usua

lbod

yw

eigh

t,se

rum

albu

min

leve

l,se

rum

prea

l-bu

min

leve

l,tr

icep

ssk

info

ld,

nutr

ition

risk

inde

xsc

ore,

subj

ectiv

egl

obal

asse

ssm

ent

No

diff

eren

ces

exce

ptlo

wer

seru

mal

bu-

min

leve

l(3

.65

�3.

6m

g/dL

vs.

3.71

�3.

7m

g/dL

;P

�0.

06†)

and

nutr

ition

alris

kin

dex

scor

e(9

2.3

�6.

4vs

.93

.8�

6.0;

P�

0.01

),m

ore

seve

rem

alnu

triti

on(1

5%vs

.9%

;P

�0.

03)

inTP

Ngr

oup

No

data

No

data

,pr

esum

ably

gene

ral

30d

afte

rsu

rger

yN

oda

taO

f19

2ra

ndom

lyas

-si

gned

toTP

N:

130

rece

ived

optim

alTP

N,

49re

ceiv

edsu

bopt

imal

TPN

,an

d13

rece

ived

noTP

N;

of20

3ra

n-do

mly

assi

gned

toco

ntro

l,3

rece

ived

TPN

3259

scre

ened

,81

1ex

clud

ed,

1497

did

not

mee

tnu

triti

oncr

iteria

,16

9no

surg

ery,

323

decl

ined

,45

9ra

ndom

lyas

-si

gned

Of

459

rand

omly

assi

gned

,64

did

not

have

surg

ery

(n�

395

stud

ypa

tient

s)

Pace

lliet

al.,

2001

(28)

Con

secu

tive

Wei

ght,

perc

enta

geof

usua

lwei

ght,

seru

mal

bum

inle

vel,

type

ofca

n-ce

r,be

nign

gast

ro-

inte

stin

aldi

seas

e

�Sim

ilar�

for

dem

ogra

phic

char

acte

ris-

tics,

nutr

i-tio

nals

tatu

s,an

dsu

rgic

aldi

agno

sis

No

for

type

ofsu

rger

y,bl

ood

loss

,in

trao

pera

tive

con-

tam

inat

ion

No

data

,pr

esum

ably

gene

ral

Hos

pita

lsta

yA

llre

ceiv

edhe

parin

subc

utan

eous

lyfo

rpr

ophy

laxi

san

dan

tibio

ticpr

ophy

laxi

s

14pa

tient

sre

ceiv

ing

TEN

conv

erte

dto

TPN

241

rand

omly

assi

gned

Non

e

Bozz

etti

etal

.,20

01(2

9)C

onse

cutiv

eH

yper

tens

ion;

hear

tva

lve

dise

ase;

dia-

bete

s;ar

rhyt

hmia

;at

hero

scle

rotic

dis-

ease

(car

diac

orpe

riphe

ral);

resp

ira-

tory

,liv

er,

and

cen-

tral

nerv

ous

syst

emdi

seas

e;ne

oadj

u-va

ntth

erap

y

No

No

for

site

ofpr

imar

ytu

mor

,ty

peof

surg

ery,

intr

aope

r-at

ive

cont

amin

atio

n,du

ra-

tion

ofsu

rger

y,bl

ood

loss

,tr

ansf

usio

n

No

data

,pr

esum

ably

gene

ral

Hos

pita

lsta

yN

oda

ta14

patie

nts

rece

ivin

gTE

Nco

nver

ted

toTP

N:

5tu

bepr

ob-

lem

s,3

diar

rhea

,5

anas

tom

otic

leak

orbl

eedi

ng,

1in

test

i-na

lobs

truc

tion

411

scre

ened

,31

7ra

ndom

lyas

sign

edN

one

Gia

nott

iet

al.,

2002

(30)

Con

secu

tive

Hyp

erte

nsio

n;he

art

valv

edi

seas

e;di

a-be

tes;

arrh

ythm

ia,

athe

rosc

lero

ticdi

s-ea

se(c

ardi

acor

perip

hera

l);re

spira

-to

ry,

liver

,an

dce

n-tr

alne

rvou

ssy

stem

dise

ase;

neoa

dju-

vant

ther

apy

No

No

for

type

ofsu

rger

y,bl

ood

loss

,or

tran

sfus

ion

No

data

,pr

esum

ably

gene

ral

30d

afte

rdi

scha

rge

No

data

exce

ptsi

mila

rbo

wel

prep

arat

ion

inal

lgro

ups

No

data

517

scre

ened

,21

2in

elig

ible

,30

5ra

ndom

lyas

sign

edN

one

Sand

ham

etal

.,20

03(3

1)C

onse

cutiv

eH

isto

ryof

angi

na,

myo

card

iali

nfar

c-tio

n,co

nges

tive

hear

tfa

ilure

,N

YH

Acl

ass,

ASA

risk

clas

s

No

No

for

type

ofsu

rger

yor

perc

enta

geof

urge

ntca

ses

No

data

Hos

pita

lsta

y,12

mo

for

mor

talit

y

No

Inte

rven

tion:

58di

dno

tre

ceiv

epl

anne

dth

erap

y,5

with

drew

cons

ent,

5pu

lmon

ary

arte

ryca

thet

erfa

iled;

cont

rol:

52di

dno

tre

ceiv

epl

anne

dth

erap

y,24

cros

sed

over

tous

eof

pul-

mon

ary

arte

ryca

thet

er

3803

scre

ened

,10

74de

clin

ed,

370

noIC

Ube

d,36

5ph

ysi-

cian

sdi

dno

tre

fer

tost

udy,

1994

rand

omly

assi

gned

Hos

pita

lsta

y,no

ne

*A

SA�

Am

eric

anSo

ciet

yof

Ane

sthe

siol

ogis

ts;C

PAP

�co

ntin

uous

posi

tive

airw

aypr

essu

re;I

CU

�in

tens

ive

care

unit

;IM

�in

tram

uscu

lar;

IS�

ince

ntiv

esp

irom

etry

;LC

�la

paro

scop

icch

olec

yste

ctom

y;LC

R�

lapa

rosc

opic

colo

rect

alre

sect

ion;

NY

HA

�N

ewY

ork

Hea

rtA

ssoc

iati

on;O

C�

open

chol

ecys

tect

omy;

OC

R�

open

colo

rect

alre

sect

ion;

TE

N�

tota

lent

eral

nutr

itio

n;T

PN�

tota

lpar

ente

raln

utri

tion

;VA

TPN

�V

eter

ans

Aff

airs

Tot

alPa

rent

eral

Nut

riti

on.

†T

oco

nver

tse

rum

albu

min

valu

esto

g/L,

mul

tipl

yby

10.



Appendix Table 3. Abstracted Data for Eligible Randomized Trials, Continued*


Lost to Follow-up orIncomplete Follow-up

Patients inIntervention Group,n

Patients inControl Group, n

Age Range,y

Mean (SD) Age,y

Men, n (%)

Møller et al.,2002 (12)

None 56 52 30–85 66 (64) 24 (22)

Berg et al.,1997 (13)

2 patients with clinical signsof pneumonia declinedchest radiography

230 pancuronium 230 vecuronium;231atracurium

24–81 53 pancuronium;54vecuronium;50 atracurium(no data givenfor SDs)

No data

Norris et al.,2001 (14)

None 1) 39 general �regional � IVPCA; 2) 46general �regional �epidural PCA

3) 37 general �IV PCA; 4) 38general �epidural PCA

1) 70 (9.5); 2)67 (10); 3)68 (9.9); 4)68 (8.4)

1) 29 (78); 2) 26 (69);3) 25 (63); 4)35 (77)

Rigg et al.,2002 (15)

None 441 447 Intervention:22–93;control:26–92

Intervention:69 (11);control:69 (11)

503 (57)

Park et al.,2001 (16)

Follow-up at 30 d notcompleted for 11patients

514 enrolled; 489completedfollow-up at 30 d

507 enrolled;495completedfollow-up at30 d

Intervention:66.5 (8.9);control:67 (8.8)

1021 (100); womenexcluded

Fleron et al.,2003 (17)

None 102 (105 randomlyassigned, epiduralcould not be donein 3 patients sothey wereassigned to thecontrol group foranalysis)

115 (3 patientswere from theinterventiongroup)

Intervention:67 (11);control:66 (10)

Intervention: 93 (89);control: 99 (88)

Mann et al.,2000 (18)

None 35 35 Epidural:76 (5.6);control:76.8 (4.7)

Epidural: 20 (57);control: 18 (51)

Cuschieri et al.,1985 (19)

None 25 25 and 25 18–75 Epidural: 51; IVmorphine: 52;IM morphine:52 (no datagiven for SDs)

Epidural: 5 (20); IVmorphine: 4 (28); IMmorphine: 7 (28)

Karayiannakis et al.,1996 (20)

None 42 40 LC: 32–79;OC:34–76

LC: 57 (range,32–79); OC:56 (range,34–76)

LC: 18 (43); OC:18 (45)

Vignali et al.,2004 (21)

None 190 194 LCR: 62 (13.4);OCR:66 (12.2)

LCR: 92 (48); OCR:108 (56)

Chumillas et al.,1998 (22)

None 40 41 18–85 64 (range,18–84)

35 (43)

Fagevik Olsen etal., 1997 (23)

None 172 192 19–92 Intervention:53.5 (17.4);control:52.9 (17.5)


Hall et al.,1991 (24)

None 431 IS 445 chestphysiotherapy

IS: IQR,32–70;chestphysiotherapy:IQR,32–72

IS: 54; chestphysiotherapy:56

IS: 221 (51); chestphysiotherapy:216 (49)

Hall et al.,1996 (25)

None 1) 79 low-risk IS; 3)152 high-risk IS

2) 76 low-riskDBE; 4) 149high-risk IS �chestphysiotherapy

1) IQR,29–44; 2)IQR,62–76; 3)IQR,29–43; 4)IQR,58–76

1) 38 (IQR,29–44); 2) 34(IQR, 29–43);3) 68 (IQR,62–76); 4) 67(IQR, 58–76)

1) Low-risk IS: 34 (43);2) high-risk IS:70 (46); 3) low-riskDBE: 34 (45); 4)high-risk IS � chestphysiotherapy:71 (48)

Bohner et al.,2002 (26)

None 99 105 Nasal CPAP:64.1 (12);control:64.5 (11)

Nasal CPAP: 84 (85);control: 82 (78)

VA TPNCooperativeStudy Group,1991 (27)

None 192 203 62.9 (9.9) 455 (99)

Pacelli et al.,2001 (28)

None 119 TEN 122 TPN TEN: 61.5 (10.8);TPN:61.6 (11.8)

TEN: 73 (61); TPN:72 (59)

Bozzetti et al.,2001 (29)

None 159 TEN 158 TPN TEN: 64.8 (11);TPN:64.1 (10)

TEN: 93 (58); TPN:92 (58)

Gianotti et al.,2002 (30)

None 1) 102; 2) 101 3) 102 1) 62.3 (12.3); 2)65.6 (11.5); 3)63.4 (11.9)

1) 50 (49); 2) 60 (59);3) 56 (55)

Sandham et al.,2003 (31)

101 patients, 5% for 6-momortality; 143 patients,7% for 12-mo mortality

997 997 Intervention:72.3 (7);control:72.6 (7)


* CPAP � continuous positive airway pressure; DBE � deep breathing exercise; IM � intramuscular; IQR � interquartile range; IS � incentive spirometry; IV �intravenous; LC � laparoscopic cholecystectomy; LCR � laparoscopic colorectal resection; OC � open cholecystectomy; OCR � open colorectal resection; PCA �patient-controlled analgesia; TEN � total enteral nutrition; TPN � total parenteral nutrition; VA TPN � Veterans Affairs Total Parenteral Nutrition.



App

endi

xT

able

4.A

bstr

acte

dD

ata

for

Elig

ible

Ran

dom

ized

Tria

ls,

Con

tinu

ed*

Aut

hor,

Yea

r(R

efer

ence

)O

utco

mes

Out

com

eM

easu

reIn

terv

enti

onC

ontr

olP

Val

ue

Møl

ler

etal

.,20

02(1

2)O

vera

llco

mpl

icat

ions

10(1

8%)

27(5

2%)

0.00

03W

ound

com

plic

atio

ns3

(5%

)16

(31%

)0.

001

Seco

ndop

erat

ion

2(4

%)

8(1

5%)

0.07

Car

diov

ascu

lar

insu

ffic

ienc

y0

5(1

0%)

0.08

Res

pira

tory

insu

ffic

ienc

y1

(2%

)1

(2%

)0.

97N

onor

thop

edic

hosp

itald

ays

2/75

2(0

.3%

)49

/816

(6%

)0.

0001

Berg

etal

.,19

97(1

3)Po

stop

erat

ive

O2

�3

L/m

in23

(10%

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8(6

%)

Panc

uron

ium

vs.

atra

curiu

m,

0.04

7;pa

ncur

oniu

mvs

.ve

curo

nium

,0.

16PP

C:

pneu

mon

iaor

atel

ecta

sis

19(8

%)

14(6

.1%

)D

iffer

ence

NS;

Pno

tgi

ven

Patie

nts

with

PPC

and

trai

n-of

-fou

rra

tio�

0.70

10/5

9(1

7%)

1/24

(4.2

%)

atra

curiu

mor

vecu

roni

um�

0.00

2,bu

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valu

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for

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ium

with

and

with

out

trai

n-of

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0.70

,no

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com

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vs.

vecu

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umor

atra

curiu

mM

edia

nen

dof

surg

ery

toex

tuba

tion

(5th

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hpe

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tile)

15m

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min

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min

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0.05

Med

ian

dura

tion

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(5th

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rcen

tile)

160

min

(75–

290

min

)15

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0–26

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152

min

(70–

280

min

)�

0.05

Post

oper

ativ

etr

ain-

of-f

our

ratio

�0.

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(26%

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(6%

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(5%

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0.00

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orris

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.,20

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1)19

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16h

3)19

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13h

0.01

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pita

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2(5

%);

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3(7

%);

4)2

(4%

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96C

ardi

acm

orta

lity

1)0;

2)1

(2.8

%)

3)0;

4)0

0.47

12-m

om

orta

lity

1)4

(10%

);2)

2(5

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3)4

(10%

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.4%

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ubat

ion

1)1/

35(3

%);

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363)

1/30

(3%

);4)

1/44

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)0.

9Pr

olon

ged

intu

batio

n1)

6/35

(17%

);2)

6/36

(17%

)3)

8/36

(22%

);4)

3/44

(7%

)0.

27Pn

eum

onia

1)0/

35;

2)1/

36(3

%)

3)1/

36(3

%);

4)0/

440.

58R

igg

etal

.,20

02(1

5)30

-dm

orta

lity

5.2%

4.3%

0.67

Res

pira

tory

failu

re23

.3%

30.2

%0.

02C

ardi

ovas

cula

rev

ent

25.7

%24

.0%

0.61

Park

etal

.,20

01(1

6)M

orta

lity

20(4

%)

17(3

%)

0.74

Res

pira

tory

failu

re51

(10%

)71

(14%

)0.

06Pn

eum

onia

28(5

%)

40(8

%)

0.15

Maj

orca

rdio

vasc

ular

com

plic

atio

n44

(9%

)57

(11%

)0.

12Su

bgro

upan

alys

is,

abdo

min

alao

rtic

surg

ery

Mor

talit

y4/

184

(2%

)5/

190

(3%

)0.

96R

espi

rato

ryfa

ilure

26/1

84(1

4%)

53/1

90(2

8%)

�0.

01Pn

eum

onia

8/18

4(4

%)

19/1

90(1

0%)

0.06

Maj

orca

rdio

vasc

ular

com

plic

atio

n18

/184

(10%

)34

/190

(18%

)0.

03Fl

eron

etal

.,20

03(1

7)M

orta

lity

2(2

%)

7(6

%)

NS;

Pno

tgi

ven

Loba

rat

elec

tasi

s3

(3%

)9

(8%

)N

S;P

not

give

nPn

eum

onia

5(5

%)

6(5

%)

NS;

Pno

tgi

ven

Res

pira

tory

failu

re7

(7%

)9

(8%

)N

S;P

not

give

nA

nypu

lmon

ary

com

plic

atio

n17

(16%

)26

(23%

)P

calc

ulat

e�

0.32

Man

net

al.,

2000

(18)

Segm

enta

lor

loba

rat

elec

tasi

s7/

31(2

3%)

6/33

(18%

)0.

77M

oder

ate

pulm

onar

yco

mpl

icat

ion

3/31

(10%

)2/

33(6

%)

NS

Maj

orpu

lmon

ary

com

plic

atio

n1/

31(3

%)

1/33

(3%

)N

SC

usch

ieri

etal

.,19

85(1

9)A

tele

ctas

is5

(20%

)IM

:10

(40%

);IV

:7

(28%

)IM

orIV

vs.

epid

ural

�N

S;IM

vs.

epid

ural

�0.

05re

port

ed;0

.11

calc

ulat

edfr

omra

wda

ta;I

Vvs

.epi

dura

l�0.

20;I

Mvs

.epi

dura

l�0.

01;I

Vvs

.epi

dura

l�N

SC

hest

infe

ctio

n1

(4%

)IM

:6

(24%

);IV

:5

(20%

)A

llpu

lmon

ary

com

plic

atio

ns6

(24%

)IM

:16

(64%

);IV

:12

(48%

)

Con

tinue

don

follo

win

gpa

ge



App

endi

xT

able

4—C

onti

nued

Aut

hor,

Yea

r(R

efer

ence

)O

utco

mes

Out

com

eM

easu

reIn

terv

enti

onC

ontr

olP

Val

ue

Kar

ayia

nnak

iset

al.,

1996

(20)

Hos

pita

lsta

y2.

04�

0.62

5.65

�1.

16�

0.05

Ate

lect

asis

inci

denc

e12

/42

(27%

)24

/40

(63%

)�

0.05

Ate

lect

asis

seve

rity

7m

icro

,3

foca

l,2

segm

enta

l,0

loba

r14

mic

ro,

7fo

cal,

3se

gmen

tal,

0lo

bar

�0.

05

Pneu

mon

iaN

opn

eum

onia

No

pneu

mon

iaN

otap

plic

able

Vig

nali

etal

.,20

04(2

1)R

espi

rato

rytr

act

infe

ctio

n3/

190

(1.8

%)

6/19

4(3

.5%

)0.

52C

hum

illas

etal

.,19

98(2

2)C

linic

alpu

lmon

ary

com

plic

atio

ns(a

tele

ctas

is,

bron

chiti

s,pn

eum

onia

)3

(7.5

%)

8(2

0%)

0.11

Ate

lect

asis

onch

est

radi

ogra

phy

6(1

5%)

16(3

9%)

0.01

7Fa

gevi

kO

lsen

etal

.,19

97(2

3)Pu

lmon

ary

com

plic

atio

ns(S

a O2

�92

%or

2of

tem

pera

ture

�38

.2°C

,pa

thol

ogic

ausc

ulta

tion,

atel

ecta

sis,

orpn

eum

onia

onch

est

radi

ogra

phy)

10/1

72(6

%)

52/1

92(2

7%)

�0.

001

Pneu

mon

ia1/

172

(0.6

%)

13/1

92(7

%)

�0.

05O

vera

llpu

lmon

ary

com

plic

atio

nsH

igh-

risk

patie

nts

6/40

(15%

)20

/39

(51%

)�

0.00

1Lo

w-r

isk

patie

nts

4/13

2(3

%)

32/1

53(2

1%)

�0.

001

Obe

sepa

tient

s3/

36(8

%)

27/4

8(5

6%)

�0.

001

Hal

let

al.,

1991

(24)

Clin

ical

feat

ures

ofco

nsol

idat

ion

orco

llaps

epl

uste

mpe

ratu

re�

38°C

and

abno

rmal

ches

tra

diog

raph

orsp

utum

cultu

re

IS:

68/4

71(1

6%)

Che

stph

ysio

ther

apy:

68/4

45(1

5%)

0.84

Abn

orm

alch

est

radi

ogra

phIS

:96

(22%

)C

hest

phys

ioth

erap

y:96

(22%

NS

Hal

let

al.,

1996

(25)

Clin

ical

feat

ures

ofco

nsol

idat

ion

orco

llaps

epl

uste

mpe

ratu

re�

38°C

and

abno

rmal

ches

tra

diog

raph

orsp

utum

cultu

re

1)Lo

w-r

isk

IS:

6/79

(8%

);3)

high

-ris

kIS

:29

/152

(19%

)2)

Low

-ris

kD

BE:

8/76

(11%

);4)

high

-ris

kIS

�ch

est

phys

ioth

erap

y:20

/149

(13%

)Lo

wris

k:1

vs.

3(P

�0.

53);

high

risk:

2vs

.4

(P�

0.18

)

Bohn

eret

al.,

2002

(26)

PaO

2�

70m

mH

gw

ithFi

O2

�0.

75

(5.1

%)

17(1

6.2%

)0.

012

2(2

%)

5(4

.8%

)0.

45R

eint

ubat

ion

1(1

%)

5(4

.8%

)0.

21V

ATP

NC

oope

rativ

eSt

udy

Gro

up,

1991

(27)

Pneu

mon

iaor

empy

ema

16(8

%)

9(4

%)

0.15

Res

pira

tory

failu

re�

4d

13(7

%)

11(5

%)

0.67

Ate

lect

asis

6(3

%)

8(4

%)

0.79

Tran

sien

tre

spira

tory

failu

re6

(3%

)6

(3%

)1.

0Pa

celli

etal

.,20

01(2

8)M

ajor

post

oper

ativ

eco

mpl

icat

ion

45(3

8%)

48(3

9%)

0.89

Dea

th7

(6%

)3

(2.5

%)

0.21

Maj

orin

fect

ious

com

plic

atio

n17

(14%

)14

(11%

)0.

57M

ajor

noni

nfec

tious

com

plic

atio

n28

(24%

)27

(9%

)0.

88Pn

eum

onia

10(8

%)

5(4

%)

0.19

Res

pira

tory

failu

re6

(5%

)4

(3%

)0.

54Pn

eum

onia

�re

spira

tory

failu

re16

(13%

)9

(7%

)0.

14M

inor

infe

ctio

n23

(19%

)23

(19%

)1.

0Bo

zzet

tiet

al.,

2001

(29)

Ove

rall

com

plic

atio

ns54

(34%

)78

(49%

)0.

005

Min

orco

mpl

icat

ions

40(2

5%)

57(3

6%)

0.03

5M

ajor

com

plic

atio

ns14

(9%

)21

(13%

)0.

207

Infe

ctio

usco

mpl

icat

ions

25(1

6%)

42(2

7%)

0.01

8N

onin

fect

ious

com

plic

atio

ns42

(26%

)57

(36%

)0.

064

Res

pira

tory

trac

tin

fect

ion

9(6

%)

14(9

%)

0.39

Res

pira

tory

failu

re4

(3%

)6

(4%

)0.

75R

espi

rato

ryin

fect

ion

�fa

ilure

13(8

%)

20(1

3%)

0.27

Con

tinue

don

follo

win

gpa

ge



App

endi

xT

able

4—C

onti

nued

Aut

hor,

Yea

r(R

efer

ence

)O

utco

mes

Out

com

eM

easu

reIn

terv

enti

onC

ontr

olP

Val

ue

Gia

nott

iet

al.,

2002

(30)

Dea

th1)

1(1

%);

2)2

(2%

)3)

1(1

%)

NS

Infe

ctio

usco

mpl

icat

ions

1)14

(14%

);2)

16(1

6%)

3)31

(30%

)1

vs.

3�

0.00

6;2

vs.

3�

0.02

Non

infe

ctio

usco

mpl

icat

ions

1)30

(29%

);2)

28(2

8%)

3)36

(35%

)N

SA

nyco

mpl

icat

ion

1)36

(35%

);2)

34(3

4%)

3)49

(48%

)N

SR

espi

rato

rytr

act

infe

ctio

n1)

3(3

%);

2)6

(6%

)3)

8(8

%)

1vs

.3

�0.

21;

2vs

.3

�0.

78R

espi

rato

ryfa

ilure

1)6

(6%

);2)

9(9

%)

3)6

(6%

)1

vs.

3�

1.0;

2vs

.3

�0.

59R

espi

rato

ryin

fect

ion

orfa

ilure

1)9

(9%

);2)

15(1

5%)

3)14

(14%

)1

vs.

3�

0.38

;2

vs.

3�

1.0

Sand

ham

etal

.,20

03(3

1)In

-hos

pita

lmor

talit

y78

(7.8

%)

77(7

.7%

)0.

93Pn

eum

onia

63(6

.6%

)70

(7.3

%)

0.70

*D

BE

�de

epbr

eath

ing

exer

cise

;FiO

2�

frac

tion

ofin

spir

edox

ygen

;IM

�in

tram

uscu

lar;

IV�

intr

aven

ous;

NS

�no

tsi

gnifi

cant

;PPC

�po

stop

erat

ive

pulm

onar

yco

mpl

icat

ion;

SaO

2�

arte

rial

oxyg

ensa

tura

tion

;VA

TPN

�V

eter

ans

Aff

airs

Tot

alPa

rent

eral

Nut

riti

on.



App

endi

xT

able

5.A

bstr

acte

dD

ata

for

Elig

ible

Ran

dom

ized

Tria

ls,

Con

tinu

ed*

Aut

hor,

Yea

r(R

efer

ence

)A

dver

seEf

fect

:In

terv

enti

onA

dver

seEf

fect

:C

ontr

olP

Val

ueC

oncl

usio

nSt

udy

Qua

lity

Com

men

t

Møl

ler

etal

.,20

02(1

2)N

oda

taN

oda

taTh

esm

okin

gce

ssat

ion

prog

ram

redu

ced

over

all

post

oper

ativ

eco

mpl

icat

ions

,pr

imar

ilydu

eto

asi

gnifi

cant

redu

ctio

nin

wou

ndco

mpl

icat

ions

,an

dno

nort

hope

dic

hosp

itald

ays

into

talh

ipan

dkn

eere

plac

emen

t.Th

era

teof

PPC

was

too

low

tosh

owan

effe

ct.

Goo

d

Berg

etal

.,19

97(1

3)N

oda

taN

oda

taIn

cide

nce

and

dura

tion

ofre

sidu

albl

ock

occu

rssi

gnifi

cant

lym

ore

ofte

nw

ithpa

ncur

oniu

m.

Res

idua

lblo

ckw

ithlo

ng-a

ctin

gpa

ncur

oniu

mis

asso

ciat

edw

ithm

ore

PPC

s;re

sidu

albl

ock

with

inte

rmed

iate

-act

ing

vecu

roni

umor

atra

curiu

mis

not

asso

ciat

edw

ithhi

gher

risk

for

PPC

s.

Goo

d

Nor

riset

al.,

2001

(14)

No

data

No

data

No

adva

ntag

eto

epid

ural

anal

gesi

aor

com

bine

dge

nera

l�re

gion

alan

esth

esia

;ve

ryfe

wPP

Cs

over

allo

ccur

red.

Goo

d

Rig

get

al.,

2002

(15)

No

data

No

data

Com

bine

din

trao

pera

tive

gene

rala

nest

hesi

aan

dep

idur

allo

cala

nest

hetic

�po

stop

erat

ive

epid

ural

loca

lane

sthe

ticw

asas

soci

ated

with

asi

gnifi

cant

lylo

wer

rate

ofre

spira

tory

failu

rebu

tno

diff

eren

cein

30-d

mor

talit

y,ca

rdia

cco

mpl

icat

ions

,or

othe

rpo

stop

erat

ive

mor

bidi

ty.

Fair

Onl

y22

5of

447

patie

nts

assi

gned

toep

idur

alw

ere

fully

adhe

rent

toth

eep

idur

alpr

otoc

ol(2

22pr

otoc

olvi

olat

ions

:no

epid

ural

cath

eter

,29

;ca

thet

erre

mov

ed�

72h

afte

rsu

rger

y,19

0;ca

thet

erre

mov

ed�

72h

afte

rsu

rger

y,3)

.Pa

rket

al.,

2001

(16)

No

data

No

data

Ove

rall,

epid

ural

anes

thes

iaan

dan

alge

sia

was

asso

ciat

edw

itha

tren

dto

war

dle

ssre

spira

tory

failu

re(P

�0.

06),

pneu

mon

ia(P

�0.

15),

and

maj

orca

rdio

vasc

ular

com

plic

atio

ns(P

�0.

18).

Inth

esu

bgro

upha

ving

abdo

min

alao

rtic

surg

ery,

epid

ural

was

asso

ciat

edw

ithsi

gnifi

cant

lyle

ssre

spira

tory

failu

re(P

�0.

01)

and

maj

orca

rdio

vasc

ular

com

plic

atio

ns(P

�0.

03)

and

atr

end

tow

ard

less

pneu

mon

ia(P

�0.

06).

Ther

ew

asno

diff

eren

cein

mor

talit

y.

Fair

Fler

onet

al.,

2003

(17)

No

data

No

data

Intr

aope

rativ

eep

idur

alop

ioid

s,co

mpa

red

with

intr

aope

rativ

eIV

opio

ids,

wer

eno

tas

soci

ated

with

redu

ced

PPC

s.Fa

ir

Man

net

al.,

2000

(18)

Post

oper

ativ

ehy

pote

nsio

n:5

patie

nts

Post

oper

ativ

ehy

pote

nsio

n:no

patie

nts

0.01

Com

bine

din

trao

pera

tive

gene

rala

ndep

idur

alan

esth

esia

and

anal

gesi

aw

ithpo

stop

erat

ive

PCEA

was

not

asso

ciat

edw

ithfe

wer

PPC

sco

mpa

red

with

gene

ral

anes

thes

iaal

one

and

post

oper

ativ

eIV

PCA

.

Poor

Low

stat

istic

alpo

wer

Seve

rehy

pote

nsio

n,sy

stol

icBP

�78

mm

Hg:

nopa

tient

sSe

vere

hypo

tens

ion,

syst

olic

BP�

78m

mH

g:no

patie

nts

NS

Mot

orbl

ocka

de:

nopa

tient

sM

otor

bloc

kade

:no

patie

nts

NS

Abs

cess

orne

urol

ogic

com

plic

atio

ndu

eto

epid

ural

:no

patie

nts

Cus

chie

riet

al.,

1985

(19)

Hyp

oten

sion

:9

patie

nts;

urin

ary

trac

tin

fect

ion:

4pa

tient

sN

oda

taIn

trao

pera

tive

and

post

oper

ativ

eep

idur

alan

esth

etic

may

redu

cePP

Cs

com

pare

dw

ithan

alge

sia

with

IMm

orph

ine.

Poor

Smal

lsam

ple

size

,no

the

lpfu

ltha

tep

idur

alse

emed

bett

erth

anIM

mor

phin

ebe

caus

eIM

mor

phin

eis

rare

lyus

edno

w.

Pva

lues

wer

eno

tre

port

edfo

rIV

vs.

epid

ural

com

paris

ons;

we

calc

ulat

edth

emfr

omth

era

wda

ta.

Kar

ayia

nnak

iset

al.,

1996

(20)

3LC

patie

nts

conv

erte

dto

OC

but

wer

eex

clud

edfr

oman

alys

isLC

was

asso

ciat

edw

itha

sign

ifica

ntly

low

erin

cide

nce

and

seve

rity

ofat

elec

tasi

sco

mpa

red

with

OC

.Po

orA

naly

sis

was

not

inte

ntio

n-to

-tre

at;

nopn

eum

onia

occu

rred

inei

ther

grou

p.V

igna

liet

al.,

2004

(21)

10LC

Rpa

tient

sco

nver

ted

toO

CR

but

wer

ein

clud

edin

inte

ntio

n-to

-tre

atan

alys

es

LCR

was

asso

ciat

edw

itha

nons

igni

fican

ttr

end

tow

ard

few

erre

spira

tory

trac

tin

fect

ions

.G

ood

Chu

mill

aset

al.,

1998

(22)

Apr

ogra

mof

perio

pera

tive

brea

thin

gex

erci

ses

that

incl

uded

forc

edex

pira

tion,

coug

h,ch

est

expa

nsio

nex

erci

ses

and

diap

hrag

mm

obili

zatio

n,m

axim

umin

spira

tion

for

3–5

s,an

dea

rlyam

bula

tion

afte

rsu

rger

yw

asas

soci

ated

with

few

erPP

Cs.

Poor

Low

stat

istic

alpo

wer

Fage

vik

Ols

enet

al.,

1997

(23)

Inte

nsiv

ech

est

phys

ioth

erap

y,co

mpa

red

with

none

,w

asas

soci

ated

with

few

erPP

Cs.

Poor

Ver

yw

eak

defin

ition

ofpu

lmon

ary

com

plic

atio

ns;

appa

rent

lyno

unifo

rmsu

rvei

llanc

epr

otoc

ol.

Hal

let

al.,

1991

(24)

No

diff

eren

cebe

twee

nIS

and

ches

tph

ysio

ther

apy

inra

teof

post

oper

ativ

epn

eum

onia

.Po

orN

oro

utin

esu

rvei

llanc

epr

otoc

olfo

ral

lpat

ient

s;ch

est

radi

ogra

phy

done

only

onpa

tient

ssu

spec

ted

ofa

pulm

onar

yco

mpl

icat

ion

(IS,

44%

;ch

est

phys

ioth

erap

y,43

%).

No

info

rmat

ion

abou

tam

ount

and

inte

nsity

ofth

erap

yac

tual

lyre

ceiv

ed.

Con

tinue

don

follo

win

gpa

ge



App

endi

xT

able

5—C

onti

nued

Aut

hor,

Yea

r(R

efer

ence

)A

dver

seEf

fect

:In

terv

enti

onA

dver

seEf

fect

:C

ontr

olP

Val

ueC

oncl

usio

nSt

udy

Qua

lity

Com

men

t

Hal

let

al.,

1996

(25)

Inlo

w-r

isk

patie

nts,

ther

ew

asno

diff

eren

cein

rate

ofPP

Cs

betw

een

ISan

dD

BEs.

Inhi

gh-r

isk

patie

nts,

ther

ew

asno

diff

eren

cebe

twee

nIS

and

ISco

mbi

ned

with

ches

tph

ysio

ther

apy.

Poor

Both

stud

ies

byH

alla

ndco

lleag

ues

seem

toha

veid

entic

alm

etho

ds;

som

eof

the

met

hods

lang

uage

isid

entic

al,

som

eno

t.�P

rese

nce

ofcl

inic

alsi

gns

was

dete

rmin

edea

chda

yby

the

atte

ndin

gph

ysic

ian.

�C

hest

radi

ogra

phy

was

done

only

for

susp

ecte

dco

mpl

icat

ions

.Sp

utum

was

sent

for

test

ing

�whe

nth

epa

tient

prod

uced

disc

olou

red

sput

um.�

Som

esu

rvei

llanc

efo

rPP

Cs

was

rout

ine

(clin

ical

sign

s),

som

eno

t(c

hest

radi

ogra

phy,

sput

umte

stin

g).

Ther

eis

now

ayto

tell

how

man

ypa

tient

sfr

omth

epr

evio

uspu

blic

atio

nw

ere

incl

uded

inth

ere

port

.Bo

hner

etal

.,20

02(2

6)Su

perf

icia

lnos

eul

cer:

4(4

%)

Non

e(0

%)

Nas

alC

PAP

for

12h

afte

rhi

gh-r

isk

abdo

min

alva

scul

arsu

rger

yw

asas

soci

ated

with

few

erep

isod

esof

seve

rehy

poxe

mia

(Fi O

2�

70m

mH

gw

ithFi

O2

�0.

7)an

dtr

ends

tow

ard

few

erep

isod

esof

pneu

mon

iaan

dre

spira

tory

failu

re.

Goo

d

VA

TPN

Coo

pera

tive

Stud

yG

roup

,19

91(2

7)

Maj

orin

fect

ious

com

plic

atio

ns:

27/1

92(1

4%)

Maj

orin

fect

ious

com

plic

atio

ns:

13/2

03(6

%)

0.01

Ove

rall,

ther

ew

asno

bene

fitof

TPN

for

prev

entin

gpu

lmon

ary

com

plic

atio

ns.

Ove

rall,

TPN

was

asso

ciat

edw

ithm

ore

maj

orin

fect

ious

com

plic

atio

nsan

dm

ore

cath

eter

-rel

ated

com

plic

atio

ns.

Goo

dSu

bgro

upan

alys

essu

gges

ted

mild

mal

nutr

ition

,no

bene

fit;

TPN

asso

ciat

edw

ithm

ore

infe

ctio

ns,

espe

cial

lypn

eum

onia

and

wou

ndin

fect

ion;

seve

rem

alnu

triti

on,

noin

crea

sed

infe

ctio

n,bu

tsi

gnifi

cant

lyfe

wer

noni

nfec

tious

com

plic

atio

ns.

Maj

orno

ninf

ectio

usco

mpl

icat

ions

:32

/192

(17%

)M

ajor

noni

nfec

tious

com

plic

atio

ns:

45/2

03(2

2%)

0.20

Non

infe

ctio

usca

thet

er-r

elat

edco

mpl

icat

ions

:11

/192

(6%

)N

onin

fect

ious

cath

eter

-rel

ated

com

plic

atio

ns:

2/20

3(1

%)

0.01

Pace

lliet

al.,

2001

(28)

3bl

oatin

g;4

diar

rhea

;4

tube

prob

lem

s;2

chyl

ous

fistu

la;

1bl

eed

from

jeju

nost

omy

5tr

ansi

ent

hypo

glyc

emia

;2

cath

eter

seps

is0.

11Th

ere

was

nodi

ffer

ence

betw

een

post

oper

ativ

eTE

Nan

dTP

Nin

rate

sof

over

allc

ompl

icat

ions

,pn

eum

onia

,re

spira

tory

failu

re,

com

bine

dpu

lmon

ary

com

plic

atio

ns,

orad

vers

eev

ents

ofth

e2

inte

rven

tions

.

Goo

d

Bozz

etti

etal

.,20

01(2

9)D

iste

nsio

n:23

(14%

)10

(6%

)0.

018

TEN

,co

mpa

red

with

TPN

,w

asas

soci

ated

with

few

erov

eral

l,m

inor

,an

din

fect

ious

com

plic

atio

nsan

dm

argi

nally

sign

ifica

ntly

few

erno

ninf

ectio

usco

mpl

icat

ions

but

nobe

nefit

rega

rdin

gpu

lmon

ary

com

plic

atio

ns.

TEN

,co

mpa

red

with

TPN

,w

asas

soci

ated

with

sign

ifica

ntly

mor

eab

dom

inal

dist

ensi

onan

dcr

amps

but

not

mor

edi

arrh

eaan

dvo

miti

ng.

Goo

d

Cra

mps

:21

(13%

)8

(5%

)0.

012

Dia

rrhe

a:13

(8%

)9

(6%

)0.

385

Vom

iting

:4

(3%

)3

(2%

)0.

709

Tota

l:56

(35%

)22

(14%

)�

0.00

01G

iano

ttie

tal

.,20

02(3

0)C

ram

ping

orbl

oatin

g:1)

16,

2)42

;di

arrh

ea:

1)3,

2)7;

vom

iting

:1)

1,2)

2

Cra

mpi

ngor

bloa

ting:

14;

diar

rhea

:3)

3;vo

miti

ng:

3)2

All

NS,

exce

ptP

�0.

001

for

2(p

erio

pera

tive)

vs.

1(p

reop

erat

ive)

and

3(c

ontr

ol)

Preo

pera

tive

and

perio

pera

tive

ente

rali

mm

unon

utrit

ion,

com

pare

dw

ithno

ente

raln

utrit

ion

was

asso

ciat

edw

ithfe

wer

infe

ctio

usco

mpl

icat

ions

but

nobe

nefit

inno

ninf

ectio

usco

mpl

icat

ions

,re

spira

tory

trac

tin

fect

ion,

orre

spira

tory

failu

re.

Goo

d

Sand

ham

etal

.,20

03(3

1)O

vera

ll:17

Ove

rall:

50.

016

Perio

pera

tive

pulm

onar

yar

tery

cath

eter

sin

high

-ris

ksu

rgic

alpa

tient

sdi

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tim

prov

ein

patie

ntm

orta

lity

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duce

the

rate

ofth

ese

cond

ary

outc

ome

ofpn

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onia

and

was

asso

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itha

stat

istic

ally

sign

ifica

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high

erra

teof

adve

rse

cath

eter

-rel

ated

even

ts.

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uncl

ear

reas

ons,

the

rate

ofth

ese

cond

ary

outc

ome

ofpu

lmon

ary

embo

lism

was

also

sign

ifica

ntly

high

erin

patie

nts

rece

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vs.

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TE

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ans

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airs

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eral

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App

endi

xT

able

6.A

bstr

acte

dD

ata

for

Elig

ible

Syst

emat

icR

evie

ws

and

Met

a-A

naly

ses*

Aut

hor,

Yea

r(R

efer

ence

)Ty

peof

Surg

ery

Inte

rven

tion

Lite

ratu

reSe

arch

Dat

esEl

ectr

onic

Dat

abas

esG

ray

Lite

ratu

reU

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lishe

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glis

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ngua

geLi

tera

ture

Onl

y

Tria

lsId

enti

fied

,n

Elig

ible

Tria

ls,

n

Rod

gers

etal

.,20

00(3

2)N

ore

stric

tion

Reg

iona

lan

esth

esia

(epi

dura

lor

spin

al)

1966

–199

8C

urre

ntC

onte

nts,

EMBA

SE,

MED

LIN

E,C

ochr

ane

Libr

ary

No

data

Yes

No

158

141

Urw

inet

al.,

2000

(33)

Hip

frac

ture

repa

irR

egio

nal

anes

thes

ia(e

pidu

ralo

rsp

inal

)

Not

stat

edC

urre

ntC

onte

nts,

EMBA

SE,

MED

LIN

E,C

ochr

ane

Libr

ary

Clin

ical

Tria

lsR

egis

try,

CIN

AH

L

No

data

No

No

Not

stat

ed15

Balla

ntyn

eet

al.,

1998

(34)

No

rest

rictio

nPo

stop

erat

ive

anal

gesi

cth

erap

y

1966

–199

5M

EDLI

NE

No

data

No

No

data

195

48

Wal

der

etal

.,20

01(3

5)N

ore

stric

tion

IVPC

A19

66–2

000

EMBA

SE,

MED

LIN

E,C

ochr

ane

Libr

ary

Clin

ical

Tria

lsR

egis

try

No

data

No

No

9532

Dow

nset

al.,

1996

(36)

Cho

lecy

stec

tom

yLC

1987

–199

6EM

BASE

,M

EDLI

NE

Yes

Yes

No

Unc

lear

15to

tal;

only

1as

sess

eda

clin

ical

lyre

leva

ntpu

lmon

ary

com

plic

atio

n(a

tele

ctas

is)

Abr

aham

etal

.,20

04(3

7)R

esec

tion

ofco

lore

ctal

canc

er

Lapa

rosc

opic

rese

ctio

n19

66–2

002

EMBA

SE,

MED

LIN

E,C

ochr

ane

Libr

ary

Clin

ical

Tria

lsR

egis

try

No

data

No

Yes

6212

;un

clea

rnu

mbe

ras

sess

ing

pulm

onar

yco

mpl

icat

ions

Che

atha

met

al.,

1995

(38)

Elec

tive

lapa

roto

my

Sele

ctiv

epo

stop

erat

ive

naso

gast

ricde

com

pres

sion

No

data

,pu

blis

hed

1995

Cur

rent

Con

tent

s,M

EDLI

NE

No

data

No

Yes

1715

Nel

son

etal

.,20

05(3

9)La

paro

tom

ySe

lect

ive

post

oper

ativ

ena

soga

stric

deco

mpr

essi

on

No

data

,pu

blis

hed

2005

EMBA

SE,

MED

LIN

E,C

ochr

ane

Libr

ary

Clin

ical

Tria

lsR

egis

try

No

data

No

Unc

lear

3328

tota

l;19

repo

rtpu

lmon

ary

com

plic

atio

ns

Thom

asan

dM

cInt

osh,

1994

(40)

Upp

erab

dom

inal

surg

ery

Post

oper

ativ

elu

ngex

pans

ion

ther

apie

s

1966

–199

2M

EDLI

NE,

CIN

AH

LN

oda

taN

oY

esU

ncle

ar14

Ove

rend

etal

.,20

01(4

1)A

bdom

inal

surg

ery

Post

oper

ativ

elu

ngex

pans

ion

ther

apie

s

1966

–200

0C

urre

ntC

onte

nts,

MED

LIN

E,C

INA

HL,

Hea

lthST

AR

No

data

No

Yes

Unc

lear

26

Moo

reet

al.,

1992

(42)

Hig

h-ris

ksu

rger

y,no

rest

rictio

nsEa

rlyen

tera

lvs.

TPN

No

data

No

data

Yes

Yes

No

data

Unc

lear

8to

tal;

alla

ppea

rto

bein

dust

ry-s

pons

ored

by1

com

pany

*IV

�in

trav

enou

s;LC

�la

paro

scop

icch

olec

yste

ctom

y;PC

A�

pati

ent-

cont

rolle

dan

alge

sia;

TPN

�to

tal

pare

nter

alnu

trit

ion.



Appendix Table 7. Abstracted Data for Eligible Systematic Reviews and Meta-Analyses, Continued*


Analysis Results

Fixed- orRandom-EffectsModels

HeterogeneityAssessed

SensitivityAnalysis

SubgroupAnalysis

PublicationBiasAssessed

StudyQuality

Rodgers et al.,2000 (32)

Fixed Yes Yes Yes Yes Good Regional anesthesia, with or without generalanesthesia, was associated with lower mortalityoverall (OR, 0.70 [95% CI, 0.51–0.97]) andorthopedic surgery (results depicted in Forestplot; OR and CI not stated) but not for othersurgical subgroups. Regional anesthesia vs.general anesthesia alone was also associated withreduced mortality (OR, 0.64 [CI, 0.47–0.87]; n �5202). Regional anesthesia was associated withless pneumonia (OR, 0.61 [CI, 0.48–0.76]),respiratory depression (OR, 0.41 [CI, 0.23–0.73]),deep venous thrombosis (OR, 0.56 [CI,0.43–0.72]), and less need for transfusion (OR,0.50 [CI, 0.39–0.66]).

Urwin et al.,2000 (33)

Fixed orrandom perheterogeneity(P � 0.1)

Yes No Yes No data Good Regional, compared with general, anesthesia wasassociated with lower 30-d mortality (OR, 0.66[CI, 0.47–0.96]) and deep venous thrombosis(OR, 0.41 [CI, 0.23–0.72]) but not lower 3-, 6-,or 12-mo mortality, risk for pneumonia (OR, 0.92[CI, 0.53–1.59]), or several other medicalcomplications, including all pulmonary embolisms.Regional anesthesia was associated withsignificantly fewer fatal pulmonary embolisms(OR and CI not stated).

Ballantyne et al.,1998 (34)

Random Yes Yes Yes No data Fair Epidural opioid, compared with systemic opioid, wasassociated with less atelectasis (OR, 0.53 [CI,0.33–0.85]) but not �pulmonary infection� (OR,0.53 [CI, 0.18–1.53]) or overall PPCs (OR, 0.51[CI, 0.20–1.33]). Epidural local anesthetic,compared with systemic opioid, was associatedwith less �pulmonary infection� (OR, 0.36 [CI,0.21–0.65]) and overall PPCs (OR, 0.58 [CI,0.42–0.80]) but not atelectasis (OR, 0.74 [CI,0.50–1.11]). There were nonsignificant trendstoward fewer PPCs with epidural opioid �anesthetic compared with systemic opioid andwith intercostal nerve block compared withsystemic opioid.

Walder et al.,2001 (35)

Fixed orrandom perheterogeneity(P � 0.1)

Yes No Yes No data Good In a subgroup analysis of 2 morphine trialsreporting PPCs (n � 147), IV PCA was associatedwith lower risk (OR, 0.93 [CI, 0.86–0.99]). In aseparate trial of 60 patients, there was no benefitregarding �chest infection� (no data given).Among 689 patients, respiratory depression wasnot more frequent with PCA (OR, 1.08 [CI,0.44–2.68]).

Downs et al.,1996 (36)

Quantitativepooling notdone

No data Good LC, compared with OC, was associated with lesscompromise and faster recovery of postoperativepulmonary function. In 1 trial of 40 patients withblinded assessment of postoperative chestradiography, LC was associated with lessatelectasis (frequency, 29% vs. 63%; P � 0.05;severity, chi-square for trend, P � 0.05).

Abraham et al.,2004 (37)

Fixed orrandom perheterogeneityassessment

Yes No No No data Good LCR, compared with OCR, for cancer wasassociated with no mortality benefit, a trendtoward fewer respiratory complications (OR, 0.65[CI, 0.28–1.49]), fewer overall complications (OR,0.62 [CI, 0.38–1.03])—primarily due to fewerwound complications, primarily wound infection(OR, 0.47 [CI, 0.28–0.80])—faster recovery ofrespiratory function (PEF, 44% faster [CI,32%–67%]; FEV1, 36% faster [CI, –33% to50%]; FVC, 40% faster [CI, 0%–50%]) andshorter hospital stay (21% shorter [CI,14%–38%]).

Continued on following page



Appendix Table 7—Continued


Analysis Results

Fixed- orRandom-EffectsModels

HeterogeneityAssessed

SensitivityAnalysis

SubgroupAnalysis

PublicationBiasAssessed

StudyQuality

Cheatham et al.,1995 (38)


No Poor The meta-analysis was good quality up toquantitative pooling, which pooled RCTs,uncontrolled studies, and case–control studies,thus rendering the results unusable. For theoverall group of 26 studies (which appears tocomprise 15 RCTs, 3 nonrandomized trials, and 8case–control studies [n � 3964]), selectivedecompression was associated with lesspneumonia (RR, 0.49; P � 0.0001) andatelectasis (RR, 0.46; P � 0.001) and shorter timeto oral intake (3.5 d vs. 4.6 d; P � 0.04). Therewas no difference in aspiration rates (RR, 0.61; P� 0.88), nausea (RR, 0.98; P � 0.31), vomiting(RR, 1.19; P � 0.11), or abdominal distension(RR, 0.98; P � 0.36). For 20 higher-qualitystudies (15 RCTs plus 5 case–control studies [n �2915]), selective nasogastric decompression wasalso associated with less pneumonia (RR, 0.59;P � 0.01) and atelectasis (RR, 0.52; P � 0.002),a trend toward shorter time to oral intake (3.5 dvs. 4.5 d; P � 0.07), no difference in aspiration(RR, 0.94; P � 0.91) but more vomiting (RR,1.45; P � 0.005) and abdominal distension (RR,1.34; P � 0.02). Insufficient data were reportedfor calculating pooled effects for RCTs only andCIs.

Nelson et al.,2005 (39)

Fixed orrandom perheterogeneityassessment

Yes Yes Yes No Good Selective, compared with routine, nasogastricdecompression was associated with a trendtoward fewer PPCs (reported as relative benefitincrease of 1.35 [CI, 0.98–1.86] converted to RRreduction of 0.74 [CI, 0.54–1.02]; P � 0.07).Data were insufficient or too heterogeneous topool for nausea, vomiting, aspiration, orabdominal distension, and 15 of the 28 includedtrials were also included in the Cheatham et al.review (38).

Thomas andMcIntosh,1994 (40)

No data Yes No Yes No Poor Across all lung expansion modalities, there was atrend toward fewer PPCs compared with controls(OR, 0.85 [CI, 0.59–1.2]), but there wasunexplained significant heterogeneity. IS,compared with control (2 studies [n � 212]) wasassociated with fewer PPCs (OR, 0.44 [CI,0.18–0.99]) with no significant heterogeneity.DBEs, compared with control (4 studies [n �564]), were also associated with fewer PPCs (OR,0.43 [CI, 0.27–0.63]), but the heterogeneity testwas significant. Among studies comparingdifferent modalities, none (IS, DBEs, IPPB) wasclearly superior.

Overend et al.,2001 (41)


No Poor The authors reported no raw data on rates of PPCs.In the only trial in the review that met oursample size inclusion criteria, DBEs and IPPBreportedly equally prevented PPCs compared withno lung expansion intervention.

Moore et al.,1992 (42)

Fixed Yes No Yes No Poor Infections were twice as frequent among patientsreceiving TPN compared with those receivingearly enteral nutrition (35% vs. 16%; P � 0.01),even after excluding patients with catheter sepsisfrom analysis (29% vs. 16%; P � 0.03). Overallinfections and pneumonia were significantlyreduced in trauma patients, but power was verylow for �nontrauma� (? elective surgery) patientsfor overall infections (4/28 vs. 3/32; P � 0.70)and pneumonia (3/28 vs. 1/32; P � 0.33).

* DBE � deep breathing exercise; IPPB � intermittent positive-pressure breathing; IS � incentive spirometry; IV � intravenous; LC � laparoscopic cholecystectomy;LCR � laparoscopic colorectal resection; OC � open cholecystectomy; OCR � open colorectal resection; OR � odds ratio; PCA � patient-controlled analgesia; PEF �peak expiratory flow; PPC � postoperative pulmonary complication; RCT � randomized, controlled trial; RR � relative risk; TPN � total parenteral nutrition.



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