Purpose The idiopathic interstitial pneumonias (IIP) constitute a large cohort of the over 200 subtypes of interstitial lung disease (ILD). Idiopathic pulmonary fibrosis (IPF) is the most widely studied, arguably the most severe etiology of ILD and the most common IIP diagnosis. The objective of this narrative review is to outline the current evidence on optimal perioperative management of IPF. PubMed, Embase and Web of Science were analyzed for appropriate peer-reviewed references by utilizing key word search (“interstitial lung disease” OR “idiopathic pulmonary fibrosis” OR “idiopathic interstitial pneumonitis” OR “ILD” OR “IPF” AND “surgery” OR “anesthesia” OR “perioperative”) within the past thirty years (1990-current). Non-English language references were excluded. A total of 205 references were curated by the authors. Eighty-seven consensus statements, clinical trials, retrospective cohort studies or case series met criteria and were incorporated into the findings of this narrative review. Conclusion After review, we conclude that complications, dominated by postoperative pulmonary complications, pose a significant barrier to safe perioperative care of patients with IPF. Ensuring that the preoperative IPF patient has been medically optimized is important for minimizing this risk. Initial assessment of the ARISCAT score, pulmonary function studies and cardiopulmonary exercise testing may identify IPF patients at particularly high perioperative pulmonary risk. Identifying IPF patients with 6–12-month declines in D LCO of >15%, V 02max <8.3 mL/kg/min, <80% predicted value FVC, a 50-meter reduction in the 6MWT or preoperative home oxygen use may be helpful in preoperative risk stratification. Medically optimizing treatable co-morbidities should be a priority in preoperative assessment. Regional or neuraxial anesthesia should be considered an optimal technique for the avoidance of general anesthesia related complications when indicated. Acute exacerbation and postoperative pneumonia have been identified as important postsurgical complications in both thoracic and nonthoracic surgical populations.

Objectives This study sought to assess feasibility of a randomized trial of blood pressure intervention (home blood pressure monitoring vs. counseling) in the preoperative clinic and the baseline rates of primary care follow-up after such interventions. Methods A prospective randomized feasibility study was performed at Yale New Haven Hospital Preadmission Testing Clinic. A sample of 100 adults, with elevated blood pressure, were recruited during their preadmission visit, and randomized 1:1 to receive brief BP counseling and an educational brochure versus additionally receiving a home BP monitor (HBPM) with a mailed report of their home readings. At 60-day post-surgery telephone follow-up, investigators asked whether participants had primary-care follow-up; had new/adjusted hypertension treatment; and felt satisfied with the study. Results There were 51 patients in the counseling group and 49 in the HBPM group. Of 46 patients in the HBPM group who returned their monitors, 36 (78%) were hypertensive at home. At 60 days post-surgery, 31 (61%) patients in the counseling group and 30 (61%) in the HBPM group were reached by telephone with the remaining followed by EHR. Thirty-six (71%) patients in the counseling group and 36 (73%) in the HBPM group had seen their primary care provider. Seventeen of 36 (47%) in the counseling group and 18 of 31 (58%) in the HBPM group received new or adjusted hypertension medications. Sixty-one participants answered questions regarding their satisfaction with the study with 52 (85%) reporting that they felt moderately to very satisfied. Conclusions This feasibility study suggests that interventional blood pressure trials in the preoperative clinic are feasible, but telephone follow-up leads to significant gaps in outcome ascertainment. Trial registration Clinicaltrials.gov, NCT03634813. Registered 16 of August 2018.

No abstract

Background There are significant knowledge gaps regarding perioperative outcomes for patients with systemic sclerosis (SSc), a rare immune-mediated disease characterized by cutaneous and organ-based fibrosis. The primary aim of this study was to describe the incidence of various perioperative complications in a single-center population of SSc. Methods 278 SSc patients with 605 unique surgical encounters were identified over a ten-year period (Jan 1, 2010, through Jan 1, 2020). Data collection included airway management, intraoperative adverse events (pulmonary aspiration, cardiac arrest, difficult airway designation), and 30-day postoperative complications (pneumonia, myocardial infarction, atrial fibrillation, congestive heart failure). Results Hypertension (57.9%), pulmonary hypertension (PH) or pulmonary arterial hypertension (PAH) (52.5%), interstitial lung disease (ILD) (32.4%), and gastroesophageal reflux disease (82.4%) were common in our study population. Difficult direct laryngoscopy occurred in 10.9% of cases, but the first attempt success rate was high at 93.2%. Video laryngoscopy was used in 24.1% of cases. The most common intraoperative complications were hypotension and bradycardia within 15 minutes of induction (24.3% and 17.5%, respectively), and vasopressor use (34.0%). The in-hospital complication rate was 14.7% while the 30-day postoperative complication rate was 27.6%, with ileus > 3 days (5.6%) and postoperative pneumonia (POP) (5.5%) occurring most often. Microstomia was an independent predictor of difficult airway designation [Adjusted Odds Ratio (ORadj): 3.42, 95% Confidence Interval (CI) = 1.13, 10.31, p = 0.029]. ILD was not associated with 30-day POP (ORadj: 1.41, 95% CI = 0.54, 3.71, p = 0.482). A composite of PH/PAH was an independent predictor for 30-day POP (ORadj: 2.61, 95% CI = 1.08, 6.29, p = 0.033), 30-day CHF diagnosis (ORadj: 4.15, 95% CI = 1.33, 12.94, p = 0.014), and 30-day mortality (ORadj: 3.57, 95% CI = 1.24, 10.28, p = 0.018). Conclusions This study identified perioperative characteristics of patients with SSc. Current knowledge on perioperative outcomes in SSc in the surgical population is predominately based on reports of single case reports or small case series. Our findings suggest that intraoperative and airway complications are similar but postoperative complications are high when compared to known incidences in surgical populations. Secondly, this study demonstrates that composite PAH/PH but not ILD was a strong predictor of POP, CHF and 30-day mortality in this patient population.

We describe a case of unusually persistent vasoplegia in the postoperative course of a patient recovering after elective right robotic nephroureterectomy with intravesical salvage gemcitabine. In the treatment of patients with intravesical adjuvant therapy, gemcitabine may precipitate persistent vasoplegia requiring further fluid resuscitative efforts, vasopressor support, and other supportive management. This potential adverse event should be considered when all common causes of persistent vasoplegia are ruled out, such as shock related to bleeding, infection, allergic reaction, or pulmonary embolic phenomenon.