Skip to main content
Download PDF

Postoperative pulmonary complications after major abdominal surgery in elderly patients and its association with patient-controlled analgesia

BMC Geriatrics volume 24, Article number: 751 (2024) Cite this article

Abstract

Objectives

This study aims to identify the risk factors for postoperative pulmonary complications (PPCs) in elderly patients undergoing major abdominal surgery and to investigate the relationship between patient-controlled analgesia (PCA) and PPCs.

Design

A retrospective study.

Method

Clinical data and demographic information of elderly patients (aged ≥ 60 years) who underwent upper abdominal surgery at the First Affiliated Hospital of Sun Yat-sen University from 2017 to 2019 were retrospectively collected. Patients with PPCs were identified using the Melbourne Group Scale Version 2 scoring system. A directed acyclic graph was used to identify the potential confounders, and multivariable logistic regression analyses were conducted to identify independent risk factors for PPCs. Propensity score matching was utilized to compare PPC rates between patients with and without PCA, as well as between intravenous PCA (PCIA) and epidural PCA (PCEA) groups.

Results

A total of 1,467 patients were included, with a PPC rate of 8.7%. Multivariable analysis revealed that PCA was an independent protective factor for PPCs in elderly patients undergoing major abdominal surgery (odds ratio = 0.208, 95% confidence interval = 0.121 to 0.358; P < 0.001). After matching, patients receiving PCA demonstrated a significantly lower overall incidence of PPCs (8.6% vs. 26.3%, P < 0.001), unplanned transfer to the intensive care unit (1.1% vs. 8.4%, P = 0.001), and in-hospital mortality (0.7% vs. 5.3%, P = 0.021) compared to those not receiving PCA. No significant difference in outcomes was observed between patients receiving PCIA or PCEA after matching.

Conclusion

Patient-controlled analgesia, whether administered intravenously or epidurally, is associated with a reduced risk of PPCs in elderly patients undergoing major upper abdominal surgery.

Peer Review reports

Introduction

With the global trend of aging, the proportion of elderly individuals is steadily increasing due to improved healthcare, declining fertility rates, and extended life expectancies [1]. This trend is leading to a significant rise in the number of elderly patients requiring surgical interventions, posing new challenges for healthcare systems worldwide [2]. In China, this trend is particularly pronounced. As of 2020, the elderly population over 60 years old accounted for 18.7% of the total population in China and exceeded the population of children for the first time [3]. The physiological changes brought about by aging may increase the risk of patients undergoing anesthesia and surgery, particularly for complex and lengthy surgeries [4, 5]. Upper abdominal surgery involves the diaphragm and abdominal wall muscles, impacting breathing and potentially leading to a prolonged postoperative recovery time [6, 7]. Effective perioperative planning and interventions during the period can improve the prognosis of elderly patients undergoing upper abdominal surgery [8].

Postoperative pulmonary complications (PPCs) are common after major abdominal surgery, directly related to delayed postoperative recovery, economic burden, and mortality rates. It was reported that PPCs occurred in 3–39.5% of adult patients [4, 9]. Identified risk factors of PPCs included older age [10, 11], high American Society of Anesthesiologists (ASA) classification [12, 13], and prolonged surgery [10, 13]. While intraoperative protective pulmonary ventilation and refraining from residual muscle relaxation were acknowledged to shorten the length of the hospital stay, their preventive value for PPCs was still under debate [14, 15]. Therefore, exploring and validating more controllable factors for preventing PPCs, especially in elderly patients undergoing upper abdominal surgery, is essential.

Postoperative pain in upper abdominal surgery patients has a significant impact on the recovery of effective spontaneous respiration [8]. However, there are limited studies directly analyzing the suitability and effectiveness of analgesic strategies on PPCs in elderly patients. Patient-controlled analgesia (PCA) based on opioids is a widely used technique for the management of postoperative pain in China [16], allowing patients to press the analgesic button to achieve effective analgesia while reducing adverse reactions, such as excessive sedation, respiratory depression, and difficulty in clearing sputum [17, 18]. Nevertheless, PCA relies on adequate analgesic education, personalized analgesia formulas, and timely adjustment of analgesic parameters. It was reported that PCA might not ensure proper analgesia [19], even delayed physical function recovery and increased the length of hospital stay in older patients undergoing orthopedic procedures [20]. Only moderate to low-quality evidence supports opioid-based intravenous PCA as an efficacious alternative to non-patient-controlled systemic analgesia for postoperative pain [21]. Therefore, while PCA stands out as an optimal choice for postoperative pain control, there is a need for further elucidation on the relationship between PCA and PPCs. This clarification is essential for enhancing the quality of analgesia and effectively preventing PPCs.

This study is designed to: (1) investigate whether the application of PCA was associated with reduced PPCs in elderly patients undergoing upper abdominal surgery; and (2) investigate the relationship between different analgesic methods and opioid drug doses and PPC incidence, thereby improving our ability to prevent PPCs.

Materials and methods

Study design

This single-center retrospective observational study was conducted at the First Affiliated Hospital of Sun Yat-sen University (FASU) in Guangzhou, China. The study’s design and the waiver of informed consent were approved by the Ethics Committee of FASU (protocol# 2021 − 395).

Setting and participants

The study included all elderly patients (age ≥ 60) who received their initial upper abdominal surgery with general anesthesia at an academic medical center and teaching hospital in China between January 2017 and December 2019.

The exclusion criteria were: (1) patients receiving in-hospital pain treatment before the surgery or taking pain medication for an extended period before and after the onset of the illness; (2) unplanned PCA termination after surgery due to severe side effects (such as severe pruritus or nausea/vomit); (3) difficulty in determining the development of PPCs in patients.

Anesthesia management

The anesthesia care followed our institute’s management protocol. Typically, patients underwent general anesthesia through tracheal intubation using a combination of inhaled and intravenous anesthetics. During the surgery, volume-controlled mechanical ventilation was applied, with a tidal volume of 7-8 ml/kg of the ideal body weight and a fraction of inspired oxygen between 40% and 60%. Intermittent recruitment maneuvers were performed during the surgery and before extubation. All patients received local anesthesia with ropivacaine at the wound site at the end of surgery. Flurbiprofen axetil and tramadol were the most commonly used analgesic drugs after surgery in our hospital, prescribed by the surgeon.

Data collection

The perioperative surgical and anesthesia records were reviewed for confirmation by two experienced clinicians via the Medicalsystem Health Electronic Database (Suzhou, China) and REHN analgesia database (Nantong, China). Data was then collected into a secure database, de-identified, and analyzed. General information (age, sex, weight, body mass index (BMI), ASA physical status classification, smoking history), preoperative comorbidities (GOLD [22] staging of pulmonary ventilation dysfunction, history of pulmonary diseases, history of chronic diseases) and surgical information (surgical site, surgical approach, length of surgery, conversion to open surgery, unplanned second surgery) were included as patient baseline variables.

As for missing data, general case information (such as age and sex) and surgery-related items (such as surgery duration and whether the surgery was open or not) are mandatory items in the registration system, and thus have no missing. For some numerical data (such as height and weight), there is less than 5% missing data, which we have imputed using the median value of the cohort. For important data related to exposure and outcome variables, such as analgesia plans, analgesic drugs, and their types, cases with missing data have been excluded from the study.

Exposures

The major exposure in this study was the use of postoperative PCA. In general, PCA is typically used for patients experiencing moderate to severe postoperative pain. In our study, we included patients who underwent abdominal surgeries, which are known to cause significant pain in most cases. However, PCA would not be applied in the following conditions: (1) a patient has significant preoperative cognitive impairment or a related history, and cannot understand how to use the PCA device; (2) patients with a history of substance abuse or certain psychiatric conditions that were not suitable for opioids, such as severe renal or hepatic function damage, respiratory depression, or severe nausea and vomiting; and (3) patients refused to use PCA. More details about the PCA protocol of our hospital could refer to our previous publications [23, 24].

Patients were divided into two groups: those who received PCA and those who did not. For patients receiving PCA, the analgesia was initiated upon returning to the ward from the operating rooms. The PCA could be administered either intravenously (PCIA) or epidurally (PCEA). Predefined PCA parameters, including background dosage, bolus dosage, limited interval time, and hourly limits, were set by the attending anesthesiologists. Early education and postoperative adjustment of PCA parameters were provided to patients and their families, ensuring effective utilization of PCA for alleviating pain in elderly patients at rest or during activities (no or mild postoperative pain). For patients who did not receive PCA, pain relief was provided by surgeons/intensive care unit (ICU) doctors, such as non-steroidal anti-inflammatory drugs, tramadol, continuous intravenous opioid analgesia, etc., to ensure no or mild postoperative pain. Regardless of PCA or non-PCA management, the goal was to keep the Numeric Rating Scale (NRS) score under 4 for all patients.

Endpoints

The primary endpoint of this study was the prevalence of PPCs. PPCs were diagnosed using the Melbourne Group Scale Version 2 (MGS-2) criteria [25, 26]. The MGS-2 is an assessment tool designed to detect PPCs and has been validated across various surgical populations, including post-upper abdominal surgery [26]. Information collected for PPC diagnosis included respiratory symptoms, pulmonary imaging, and functional examination (See Supplementary Table 1 for the criteria for diagnosing PPCs using MGS-2). If participants were discharged from the hospital within one week after surgery, it was assumed that they did not develop a PPC. This judgement is based on the discharge criteria at our hospital, which include: (1) infection indicators (PCT, WBC, N%) being either normal or showing a significant improvement trend on the day of discharge; (2) recovery of gastrointestinal function and dietary tolerance; (3) adequate pain control with oral analgesia to maintain a pain visual analog score below 5; (4) ability to perform self-care as before or having adequate post-discharge support; (5) no evidence of complications or untreated medical problems; and (6) patient willingness to leave. Therefore, if patients are able to be discharged within one week, we assume that they have no evidence of complications or untreated medical problems, including PPCs.

Secondary endpoints included other clinical outcomes, such as postoperative length of hospital stay (LHS), rate of unplanned postoperative ICU admissions, and in-hospital mortality. Additionally, postoperative pain management data (PCA routes, morphine milligram equivalents (MMEs) of opioid analgesics hours after surgery, total number of PCA pump presses, and effective press percentage) were reported.

Quantitative variables

The total amount of opioids used for postoperative analgesia was converted to a daily intravenous morphine milligram equivalent dose according to the previous study [27].

Statistical analysis

We did not perform a power analysis as we included all elderly patients undergoing upper abdominal surgeries in our hospital from 2017 to 2019. Continuous variables are expressed as the mean ± standard deviation or the median (interquartile range, IQR), while categorical variables are expressed as numbers and percentages. The t-tests or nonparametric tests were used to compare continuous variables, and χ2 tests were used to compare categorical variables.

We used a directed acyclic graph to identify the potential confounders, and guide the modeling strategy [28, 29]. For the primary analysis, the minimally sufficient adjustment variables were determined based on the directed acyclic graph (Fig. 1) using the “dagitty” package in R software. Multivariable logistic regression analysis with the minimally sufficient adjustment variables were used to investigate the risk factors of PPCs in elderly patients undergoing upper abdominal surgery and the association between the application of PCA and PPCs. A sensitivity multivariable analysis was also performed by including variables with a P-value less than 0.25 in univariate logistic regression analyses. If two continuous variables had an absolute Pearson’s or Spearman’s rank correlation coefficient greater than 0.5, we included only one variable to avoid collinearity [30]. In addition, we performed another sensitivity analysis using propensity score matching to verify the result of multivariable regression analysis.

Fig. 1
figure 1

A directed acyclic graph represents associations between covariates and primary exposure and outcome. The adjusted arrows represent paths that are being adjusted for in the analysis, indicating confounding variables or backdoor paths that need to be controlled for to estimate the causal effect of interest. The unadjusted arrows represent paths that are not being adjusted for in the analysis, indicating direct effects or other relationships that do not require adjustment. PPCs, postoperative pulmonary complications; PCA, patient-controlled analgesia, BMI, body mass index; ASA, American Society of Anesthesiologists

Full size image

Subgroup analysis was conducted by the following variables: age (60 to 70, 70 to 80, and 80 years or older), sex, body mass index (less than 25 vs. 25 or more), surgery site (stomach, liver/biliary tract, and pancreas), type of surgery (open vs. not open), preoperative pulmonary function, and length of surgery (less than 3 vs. 3 h or more). The heterogeneity of effects across subgroups was evaluated by testing the significance of the exposure-by-group interaction in the multivariable logistic regression models.

In addition, we used propensity score matching to investigate the relationship between different analgesic methods (PCIA vs. PCEA) and opioid drugs (sufentanil vs. hydromorphone) in relation to PPC incidence. The same variables from the multivariable regression were included in the propensity score matching model. The balance between matched pairs was assessed using standardized differences, with a standardized difference < 10% regarded as indicative of balance. In cases where achieving a standardized difference below 10% for all variables was unfeasible, it was also deemed acceptable if only several variables exhibited a standardized difference below 20%.

P values less than 0.05 were considered statistically significant. All statistical analyses were conducted using R (version 4.3.1, R Foundation for Statistical Computing, Austria) and SPSS 26.0 (IBM, Armonk, NY, USA).

Results

Baseline data and PPCs

The final analysis included 1,467 patients, as depicted in the flowchart (Fig. 2). The median age of the patients was 66 years, with 70.4% being male. Among them, 127 patients (8.7%) were diagnosed with PPCs. The incidence and distribution of MGS-2 diagnostic items among patients with and without PPCs are illustrated in Supplementary Fig. 1. Detailed baseline characteristics of patients with or without PPCs are summarized in Table 1. Notably, patients diagnosed with PPCs exhibited an extended LHS and higher 90-day mortality rates (Table 1). Analysis of the thirteen deceased patients revealed that 31% (4 out of 13) had PPCs (Supplementary Table 1).

Fig. 2
figure 2

Patients enrolling flowchart. PPCs, postoperative pulmonary complications; MGS-2, Melbourne group scale Version 2

Full size image
Table 1 Baseline characteristics and clinical outcomes of all patients (n = 1,467)
Full size table

The association between PCA and PPCs

PCA and other 18 variables were incorporated into the directed acyclic graph (Fig. 2). The minimally sufficient adjustment sets consisted of 10 confounders, including age, sex, ASA grade, BMI, surgical site, length of surgery, conversion to open surgery, open surgery, emergency surgery, and residency. These were included in the multivariable logistic regression model. The results showed that PCA was a significant beneficial factor for preventing PPCs (odds ratio [95% confidence interval], 0.208 [0.121 ~ 0.358], P < 0.001; Table 2).

Table 2 Results of multivariable logistic regression based on variables selected using the directed acyclic graph (n = 1,467)
Full size table

Sensitivity analysis

The first sensitivity analysis was the multivariable logistic regression based on selected variables with P-value less than 0.25 in the univariate analyses (Supplementary Table 3). Consistent with the primary analysis, the sensitivity analysis also demonstrated that PCA was a significant beneficial factor for preventing PPCs (odds ratio [95% confidence interval], 0.187 [0.106 ~ 0.329], P < 0.001; Supplementary Table 4). The second sensitivity analysis with propensity score generated two well balanced cohorts: one comprising 267 patients who received PCA and the other comprising 95 patients who did not receive PCA (Table 3). This analysis revealed a reduced incidence of PPCs in patients who received PCA (PCA vs. non-PCA, 23/267 [8.6%] vs. 25/95 [26.3%], P < 0.001; Table 3).

Table 3 Sensitivity analysis: the impact of PCA on clinical outcomes before and after propensity-score matching
Full size table

Subgroup analysis

The results of subgroup analysis are presented in Fig. 3. PCA was associated with a reduced risk of PPCs across age groups (60 ~ 70, 70 ~ 80, or over 80 years old; Fig. 3), but the effectiveness did not show significant difference across these groups (P for interaction = 0.729). The characteristics of patients in different age groups are detailed in Supplementary Table 5. The subgroup analysis also suggested that PCA was associated with significantly lower rate of PPCs in patients with a body mass index ≤ 24 (P for interaction = 0.033), receiving open surgery (P for interaction = 0.020), and without preoperative pulmonary decline (P for interaction = 0.045). In addition, patients who received PCA exhibited a lower rate of PPCs across different genders and surgical sites.

Fig. 3
figure 3

Results of subgroup analysis. PPCs, postoperative pulmonary complications; PCA, patient-controlled analgesia; OR, odds ratio; BMI, body mass index

Full size image

The association between different analgesic methods and opioid drugs of PCA with PPCs

Further categorization of patients receiving PCA into distinct groups facilitated an exploration of the relationship between analgesic methods/opioid drugs and PPCs. Following propensity-score matching, patients receiving PCIA or PCEA exhibited balanced baseline characteristics (Supplementary Table 6). Results indicated no significant differences in PPCs, unplanned ICU transfers, postoperative LHS, or in-hospital mortality, irrespective of whether the patients received PCIA or PCEA (Table 4). Similarly, patients receiving hydromorphone or sufentanil demonstrated balanced baseline characteristics after propensity score matching (Supplementary Table 7). There were no differences in the aforementioned outcomes between patients who received hydromorphone or sufentanil postoperatively (Table 5).

Table 4 The impact of type of PCA on clinical outcomes before and after propensity-score matching
Full size table
Table 5 The impact of type of analgesics on clinical outcomes before and after propensity-score matching
Full size table

Discussion

Key results

In this study, we observed a PPC incidence of 8.7% among elderly patients undergoing upper abdominal surgery. One in every five patients with PPCs required transfer to the ICU and reintubation. Based on multivariable analysis, we observed that PCA was associated with a reduced incidence of PPCs in elderly patients following upper abdominal surgery. The result was further validated by a sensitivity analysis using propensity score matching. Additionally, after categorizing patients receiving PCA into different groups, we observed no significant differences in PPCs, unplanned ICU transfers, postoperative LHS, or in-hospital mortality, regardless of the analgesic methods (PCIA vs. PCEA) and opioid drugs (hydromorphone vs. sufentanil).

Interpretation

Risk and beneficial factors for PPCs

The study identified several factors influencing the occurrence of PPCs in elderly patients undergoing upper abdominal surgery. Consistent with previous findings [31], a history of preoperative pulmonary disease was an independent risk factor for PPCs [32]. At the medical center where this study was conducted, elderly patients undergoing upper abdominal surgery are required to undergo routine respiratory mechanics and pulmonary imaging (X-ray or CT) exams. We speculate that in the post-COVID era, the prevalence and detection rate of preoperative pulmonary disease screening will improve, aiding in the accurate preoperative diagnosis of pulmonary diseases, thereby enabling clinicians to take preventive measures against PPCs more promptly. In addition, age has consistently been a risk factor for PPCs [10, 12], with 80 years being a noteworthy threshold where the incidence of PPCs rapidly increases from 7.9 to 27.3% (≤ 80 vs. >80 years old), emphasizing the imperative to address controllable factors in order to mitigate PPC risk in elderly patients. Some of these factors are indeed controllable and adjustable, such as postoperative analgesia method, surgical duration, surgical approach, and secondary surgery.

Interventions for PPC reduction

Several established interventions may contribute to lowering the incidence of PPCs, including promoting enhanced recovery [33], epidural analgesia [34], prophylactic respiratory physiotherapy [35], goal-directed hemodynamic therapy [36], prophylactic sputum clearance, intraoperative lung-protective ventilation, and postoperative continuous positive airway pressure [37]. The combined use of the first four interventions has been shown to reduce the relative risk of PPCs by 25% [37]. In this study, we focused on the relationship between perioperative pain management strategies and the risk of PPCs.

Previous studies have demonstrated the role of PCA in alleviating postoperative pain and facilitating postoperative mobility [38, 39]. PCA may also reduce respiratory muscle dysfunction and enhance ventilatory efficiency [40], potentially preventing PPCs. However, the effectiveness of PCA depends on adequate analgesic education and timely adjustment of analgesic parameters. Improperly use of PCA may cause respiratory depression and decrease minute ventilation, contributing to PPCs [19]. Although prior studies indicated that PCA may reduce PPCs, these studies were limited by sample sizes and specific types of surgery (such as cardiac or thoracic surgery) [41,42,43]. The role of PCA in reducing PPCs in elderly patients has not been fully explored.

Elderly patients are inherently frail and more sensitive to opioids compared to younger people, making them more susceptible to opioid-related side effects such as respiratory depression, dizziness, drowsiness, and hypotension. Our study emphasizes the role of PCA in elderly patients undergoing abdominal surgery, and observed the effectiveness of PCA in reducing PPCs in different age groups of elderly patients. Given the severity and humanitarian concerns of pain in upper abdominal surgery, 92.6% of elderly patients received PCA. Although there was a significant imbalance in the number of patients between the PCA and non-PCA groups in the entire population, this discrepancy does not imply frailty or more comorbidities in the non-PCA group. In fact, non-PCA patients often declined PCA due to economic reasons (postoperative analgesia not fully covered by medical insurance in China) and fear of side effects of analgesics [44,45,46]. To minimize the bias from this imbalance, we matched baseline data for patients in both PCA and non-PCA groups and found that postoperative PCA was still associated with a lower risk of PPCs in elderly patients undergoing major upper abdominal surgery.

Continuous thoracic epidural analgesia (TEA) was once considered the best analgesic method after abdominal surgery [34, 47], achieving effective analgesia by blocking visceral and somatic pain signals to the spinal cord. However, recent high-quality studies have shown that TEA increases the risk of hypotension and arrhythmias after thoracic surgery [48, 49]. TEA may also impair postoperative lung function by paralyzing respiratory muscles such as intercostal or abdominal muscles [50]. At the center where this dataset was collected, thoracic segment PCEA is mainly used for patients undergoing upper abdominal surgery via laparotomy. However, with the increased adoption of laparoscopic minimally invasive techniques over the years, the proportion of patients experiencing moderate to severe pain after upper abdominal surgery has significantly decreased. Additionally, with the development of multimodal analgesia, auxiliary analgesic measures including local infiltration anesthesia at the wound site, early initiation of oral NSAIDs, traditional Chinese acupuncture, and family-like accompaniment, the demand for traditional opioid analgesics in elderly patients has gradually decreased. Therefore, even low-dose opioid-based patient-controlled intravenous analgesia can achieve effective analgesic effects while reducing interference with respiration and effective coughing [51]. This may explain why there was no difference in the incidence of PPCs between the PCEA and PCIA groups in this dataset whether confounding factors were matched or not, as well as the choice between the water-soluble opioid (hydromorphone) and the lipophilic opioid (sufentanil) in PCIA did not show a significant association with the occurrence of PPCs. From another perspective, compared to the operational difficulty of epidural puncture in elderly patients, PCIA may serve as a more achievable alternative to PCEA for anesthesiologist.

Generalizability

One of the strengths of our study was the focus on a high-risk population. Preventing PPCs in elderly patients posed greater challenges and clinical significance compared to younger patients. Reducing the delayed discharge rates and mortality associated with PPCs significantly impacted the acceleration of recovery of life quality in elderly patients and alleviated societal burdens. Additionally, pain following upper abdominal surgery is typically more severe [52], with movement pain notably impacting respiratory function [53, 54]. This study concentrated on the effects of PCA on PPCs in elderly patients.

However, it is essential to consider the limitations in generalizing our findings. Our sample primarily consists of elderly patients who underwent upper abdominal surgery, which may not represent all elderly patients or those undergoing different types of surgeries because the severity of postoperative pain and PCA’s side effect can vary significantly depending on the surgical procedure and patient demographics. Although an increasing number of surgeons and pain specialists have recognized the importance of PCA in controlling excessive stress in patients undergoing major surgery and in protecting organ functions, few studies have directly correlated postoperative analgesia with adverse outcomes, possibly due to the heterogeneity of analgesic regimens across different studies. Therefore, caution should be exercised when extrapolating these results to other populations or surgical contexts. Further studies with diverse cohorts and standardized analgesic protocols are needed to validate our results and enhance the generalizability of our conclusions.

Limitations

The results of this study should be interpreted in light of its limitations. One limitation is the sourcing of patient data from a single center, which limits the extrapolation and scalability of our findings over time and impedes the external validation of the discovered results. Secondly, several factors may influence the application of PCA but the information could not be collected in this retrospective study, such as the income of patients, pre- and postoperative cognitive decline assessments, or anxiety. Third, unobserved or latent variables associated with PPCs might have been missing, such as prophylactic respiratory physiotherapy, goal-directed hemodynamic therapy, the specific days required to start standing and walking postoperatively, and postoperative pain intensity. Although strategies were employed to minimize the impacts of these limitations, the inherent limitations of this retrospective study could not be completely eliminated. Fourth, we judged a patient who was discharged from the hospital within one week after surgery, as not having PPC. Although this judgement is based on the discharge criteria at our hospital, we cannot entirely rule out the possibility that some patients may develop PPCs after discharge. Hence, the existing results should be carefully interpreted in further research with longer follow-up.

Conclusion

Elderly patients undergoing upper abdominal surgery should take measures to prevent the PPCs. PCA may be beneficial, whether through intravenous or epidural. However, the specific mechanisms and effects of PCA required further prospective research.

Data availability

Data are available upon reasonable request, provided by the corresponding author of the manuscript (Z.X. Wang; E-mail: wzhxing@mail.sysu.edu.cn).

References

  1. Bloom DE, Luca DL. The global demography of aging: facts, explanations, future. Handbook of the economics of population aging. Volume 1. edn.: Elsevier; 2016. pp. 3–56.

  2. Ueda Y, Shiraishi N, Kawasaki T, Akagi T, Ninomiya S, Shiroshita H, Etoh T, Inomata M. Short-and long-term outcomes of laparoscopic surgery for colorectal cancer in the elderly aged over 80 years old versus non-elderly: a retrospective cohort study. BMC Geriatr. 2020;20:1–9.

    Article  Google Scholar 

  3. Xia CF, Chen WQ. [Fractions and trends of cancer burden attributable to population ageing in China]. Zhonghua Zhong Liu Za Zhi. 2022;44(1):79–85.

    PubMed  CAS  Google Scholar 

  4. Miskovic A, Lumb AB. Postoperative pulmonary complications. Br J Anaesth. 2017;118(3):317–34.

    Article  PubMed  CAS  Google Scholar 

  5. Shander A, Fleisher LA, Barie PS, Bigatello LM, Sladen RN, Watson CB. Clinical and economic burden of postoperative pulmonary complications: patient safety summit on definition, risk-reducing interventions, and preventive strategies. Crit Care Med. 2011;39(9):2163–72.

    Article  PubMed  Google Scholar 

  6. Li C, Yang WH, Zhou J, Wu Y, Li YS, Wen SH, Huang WQ, Liu KX. Risk factors for predicting postoperative complications after open infrarenal abdominal aortic aneurysm repair: results from a single vascular center in China. J Clin Anesth. 2013;25(5):371–8.

    Article  PubMed  Google Scholar 

  7. McAlister FA, Bertsch K, Man J, Bradley J, Jacka M. Incidence of and risk factors for pulmonary complications after nonthoracic surgery. Am J Respir Crit Care Med. 2005;171(5):514–7.

    Article  PubMed  Google Scholar 

  8. Marshall K, McLaughlin K. Pain Management in thoracic surgery. Thorac Surg Clin. 2020;30(3):339–46.

    Article  PubMed  Google Scholar 

  9. Chandler D, Mosieri C, Kallurkar A, Pham AD, Okada LK, Kaye RJ, Cornett EM, Fox CJ, Urman RD, Kaye AD. Perioperative strategies for the reduction of postoperative pulmonary complications. Best Pract Res Clin Anaesthesiol. 2020;34(2):153–66.

    Article  PubMed  Google Scholar 

  10. Canet J, Gallart L, Gomar C, Paluzie G, Vallès J, Castillo J, Sabaté S, Mazo V, Briones Z, Sanchis J. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology. 2010;113(6):1338–50.

    Article  PubMed  Google Scholar 

  11. Tran D, Rajwani K, Berlin DA. Pulmonary effects of aging. Curr Opin Anaesthesiol. 2018;31(1):19–23.

    Article  PubMed  Google Scholar 

  12. Neto AS, da Costa LGV, Hemmes SNT, Canet J, Hedenstierna G, Jaber S, Hiesmayr M, Hollmann MW, Mills GH, Vidal Melo MF, et al. The LAS VEGAS risk score for prediction of postoperative pulmonary complications: an observational study. Eur J Anaesthesiol. 2018;35(9):691–701.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Wang B, Chen Z, Zhao R, Zhang L, Zhang Y. Development and validation of a nomogram to predict postoperative pulmonary complications following thoracoscopic surgery. PeerJ. 2021;9:e12366.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Futier E, Constantin JM, Paugam-Burtz C, Pascal J, Eurin M, Neuschwander A, Marret E, Beaussier M, Gutton C, Lefrant JY, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med. 2013;369(5):428–37.

    Article  PubMed  CAS  Google Scholar 

  15. Cammu G. Residual neuromuscular blockade and postoperative pulmonary complications: what does the recent evidence demonstrate? Curr Anesthesiol Rep. 2020;10(2):131–6.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Liu Y, Xiao S, Yang H, Lv X, Hou A, Ma Y, Jiang Y, Duan C, Mi W. Postoperative pain-related outcomes and perioperative pain management in China: a population-based study. Lancet Reg Health Western Pac. 2023;39:100822.

    Article  Google Scholar 

  17. Oswald N, Halle-Smith J, Kerr A, Webb J, Agostini P, Bishay E, Kalkat M, Steyn R, Naidu B. Perioperative immune function and pain control may underlie early hospital readmission and 90 day mortality following lung cancer resection: a prospective cohort study of 932 patients. Eur J Surg Oncol. 2019;45(5):863–9.

    Article  PubMed  Google Scholar 

  18. van Boekel RL, Vissers KC, van de Vossenberg G, de Baat-Ananta M, van der Sande R, Scheffer GJ, Steegers MA. Comparison of Epidural or Regional Analgesia and patient-controlled Analgesia: a critical analysis of Patient Data by the Acute Pain Service in a University Hospital. Clin J Pain. 2016;32(8):681–8.

    Article  PubMed  Google Scholar 

  19. Roozekrans M, van der Schrier R, Aarts L, Sarton E, van Velzen M, Niesters M, Dahan A, Olofsen E. Benefit versus severe side effects of Opioid Analgesia: Novel Utility functions of Probability of Analgesia and Respiratory Depression. Anesthesiology. 2018;128(5):932–42.

    Article  PubMed  CAS  Google Scholar 

  20. Iddagoda MT, Nienaber A, Pretorius C, Flicker L. Patient controlled Analgesia and its effect on postoperative outcomes in an older cohort of patients undergoing orthopaedic procedures: a retrospective observational study. J Perioper Pract. 2023;33(6):190–6.

    PubMed  Google Scholar 

  21. Morlion B, Schäfer M, Betteridge N, Kalso E. Non-invasive patient-controlled analgesia in the management of acute postoperative pain in the hospital setting. Curr Med Res Opin. 2018;34(7):1179–86.

    Article  PubMed  Google Scholar 

  22. Pauwels RA, Buist AS, Calverley PM, Jenkins CR, Hurd SS. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) workshop summary. Am J Respir Crit Care Med. 2001;163(5):1256–76.

    Article  PubMed  CAS  Google Scholar 

  23. He Q, Liu Q, Liang B, Zhao X, Huang W, Gao S, Chen C, Zhou F, Wang Z. Esketamine use for primary intelligent analgesia in adults with severe burns: A double-blind randomized trial with effects on analgesic efficacy, gastrointestinal function and mental state. Burns 2024.

  24. Song Y, He Q, Huang W, Yang L, Zhou S, Xiao X, Wang Z, Huang W. New insight into the analgesic recipe: a cohort study based on smart patient-controlled analgesia pumps records. Front Pharmacol. 2022;13:988070.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  25. Reeve JC, Nicol K, Stiller K, McPherson KM, Birch P, Gordon IR, Denehy L. Does physiotherapy reduce the incidence of postoperative pulmonary complications following pulmonary resection via open thoracotomy? A preliminary randomised single-blind clinical trial. Eur J Cardiothorac Surg. 2010;37(5):1158–66.

    Article  PubMed  Google Scholar 

  26. Parry S, Denehy L, Berney S, Browning L, Team AHP-OS. Clinical application of the Melbourne risk prediction tool in a high-risk upper abdominal surgical population: an observational cohort study. Physiotherapy. 2014;100(1):47–53.

    Article  PubMed  CAS  Google Scholar 

  27. Santa Cruz Mercado LA, Liu R, Bharadwaj KM, Johnson JJ, Gutierrez R, Das P, Balanza G, Deng H, Pandit A, Stone TAD, et al. Association of Intraoperative Opioid Administration with Postoperative Pain and Opioid Use. JAMA Surg. 2023;158(8):854–64.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Mansournia MA, Nazemipour M. Recommendations for accurate reporting in medical research statistics. Lancet. 2024;403(10427):611–2.

    Article  PubMed  Google Scholar 

  29. Lipsky AM, Greenland S. Causal Directed Acyclic Graphs. JAMA. 2022;327(11):1083–4.

    Article  PubMed  Google Scholar 

  30. Zhao X, Gao C, Dai F, Treggiari MM, Deshpande R, Meng L. Treatments Associated with Lower Mortality among critically ill COVID-19 patients: a retrospective cohort study. Anesthesiology. 2021;135(6):1076–90.

    Article  PubMed  CAS  Google Scholar 

  31. Lu S, Yan M, Li C, Yan C, Yao X, Chen M, Feng R, Bi R, Liu W, Zhu Z, et al. [Analysis of clinicopathological features and risk factors for postoperative complications in the elderly gastric cancer patients]. Zhonghua Wei Chang Wai Ke Za Zhi. 2016;19(5):514–21.

    PubMed  Google Scholar 

  32. Cavayas YA, Eljaiek R, Rodrigue É, Lamarche Y, Girard M, Wang HT, Levesque S, Denault AY. Preoperative diaphragm function is Associated with postoperative pulmonary complications after cardiac surgery. Crit Care Med. 2019;47(12):e966–74.

    Article  PubMed  Google Scholar 

  33. Kuang X, She G, Shi Y, Liu S, Nie L, Tang H. Enhanced recovery after surgery promotes the postoperative recovery of lung and gastrointestinal function of pseudomyxoma peritonei. Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2021;46(8):838–42.

    PubMed  Google Scholar 

  34. Pöpping DM, Elia N, Van Aken HK, Marret E, Schug SA, Kranke P, Wenk M, Tramèr MR. Impact of epidural analgesia on mortality and morbidity after surgery: systematic review and meta-analysis of randomized controlled trials. Ann Surg. 2014;259(6):1056–67.

    Article  PubMed  Google Scholar 

  35. Tao W, Huang J, Jin Y, Peng K, Zhou J. Effect of Pulmonary Rehabilitation Exercise on Lung volume and respiratory muscle recovery in Lung Cancer patients undergoing lobectomy. Altern Ther Health Med 2023.

  36. Licker M, Hagerman A, Bedat B, Ellenberger C, Triponez F, Schorer R, Karenovics W. Restricted, optimized or liberal fluid strategy in thoracic surgery: a narrative review. Saudi J Anaesth. 2021;15(3):324–34.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Odor PM, Bampoe S, Gilhooly D, Creagh-Brown B, Moonesinghe SR. Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis. BMJ. 2020;368:m540.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Wang D, Guo Y, Yin Q, Cao H, Chen X, Qian H, Ji M, Zhang J. Analgesia quality index improves the quality of postoperative pain management: a retrospective observational study of 14,747 patients between 2014 and 2021. BMC Anesthesiol. 2023;23(1):281.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  39. McNicol ED, Ferguson MC, Hudcova J. Patient controlled opioid analgesia versus non-patient controlled opioid analgesia for postoperative pain. Cochrane Database Syst Rev. 2015;2015(6):Cd003348.

    PubMed  PubMed Central  Google Scholar 

  40. Asada M, Nobukuni K, Yoshino J, Fujimura N. Comparison of changes in chest wall mechanics and respiratory timing between patient-controlled epidural analgesia and intravenous patient-controlled Analgesia after laparoscopic gastrectomy: a Randomized Controlled Trial. Cureus. 2023;15(4):e37276.

    PubMed  PubMed Central  Google Scholar 

  41. Pöpping DM, Elia N, Marret E, Remy C, Tramèr MR. Protective effects of Epidural Analgesia on Pulmonary complications after Abdominal and thoracic surgery: a Meta-analysis. Arch Surg. 2008;143(10):990–9.

    Article  PubMed  Google Scholar 

  42. Yan G, Chen J, Yang G, Duan G, Du Z, Yu Z, Peng J, Liao W, Li H. Effects of patient-controlled analgesia with hydromorphone or sufentanil on postoperative pulmonary complications in patients undergoing thoracic surgery: a quasi-experimental study. BMC Anesthesiol. 2018;18(1):192.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  43. Gust R, Pecher S, Gust A, Hoffmann V, Böhrer H, Martin E. Effect of patient-controlled analgesia on pulmonary complications after coronary artery bypass grafting. Crit Care Med. 1999;27(10):2218–23.

    Article  PubMed  CAS  Google Scholar 

  44. QJ Z, JH L. KJ J: The Recognition of and demands for patients-controlled Analgesia in Surgical patients and the related factors. J Nurs Sci 2014, 12(23).

  45. Barrie U, Montgomery EY, Ogwumike E, Pernik MN, Luu IY, Adeyemo EA, Christian ZK, Edukugho D, Johnson ZD, Hoes K, et al. Household Income as a Predictor for Surgical outcomes and Opioid Use after spine surgery in the United States. Global Spine J. 2023;13(8):2124–34.

    Article  PubMed  Google Scholar 

  46. Qiaoyun L, Dujuan Z, Feihong A. Factors influencing the level of knowledge and belief in patient -controlled epidural labor analgesia for primipara. Nurs Clin 2021, 25(24).

  47. Guay J, Choi P, Suresh S, Albert N, Kopp S, Pace NL. Neuraxial blockade for the prevention of postoperative mortality and major morbidity: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev. 2014;2014(1):Cd010108.

    PubMed  PubMed Central  Google Scholar 

  48. D’Ercole F, Arora H, Kumar PA. Paravertebral block for thoracic surgery. J Cardiothorac Vasc Anesth. 2018;32(2):915–27.

    Article  PubMed  Google Scholar 

  49. Xu ZZ, Li HJ, Li MH, Huang SM, Li X, Liu QH, Li J, Li XY, Wang DX, Sessler DI. Epidural anesthesia-analgesia and recurrence-free survival after Lung Cancer surgery: a Randomized Trial. Anesthesiology. 2021;135(3):419–32.

    Article  PubMed  CAS  Google Scholar 

  50. Clemente A, Carli F. The physiological effects of thoracic epidural anesthesia and analgesia on the cardiovascular, respiratory and gastrointestinal systems. Minerva Anestesiol. 2008;74(10):549–63.

    PubMed  CAS  Google Scholar 

  51. White I, Ghinea R, Avital S, Chazan S, Dolkart O, Weinbroum AA. Morphine at sub-analgesic background infusion rate plus low-dose PCA bolus control pain better and is as safe as twice a bolus-only PCA regimen: a randomized, double blind study. Pharmacol Res. 2012;66(2):185–91.

    Article  PubMed  CAS  Google Scholar 

  52. Humble SR, Dalton AJ, Li L. A systematic review of therapeutic interventions to reduce acute and chronic post-surgical pain after amputation, thoracotomy or mastectomy. Eur J Pain. 2015;19(4):451–65.

    Article  PubMed  CAS  Google Scholar 

  53. Yang CK, Teng A, Lee DY, Rose K. Pulmonary complications after major abdominal surgery: National Surgical Quality Improvement Program analysis. J Surg Res. 2015;198(2):441–9.

    Article  PubMed  Google Scholar 

  54. Ding X, Zhang H, Liu H. Early ambulation and postoperative recovery of patients with lung cancer under thoracoscopic surgery-an observational study. J Cardiothorac Surg. 2023;18(1):136.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

We thank Q. Liu, Y.F. Deng and S.Q. Hong for their work in the data collection.

Funding

This research was supported by the National Key Research and Development Program of China (2020YFC2008405).

Author information

Author notes

  1. Qiulan He, Zhenyi Lai and Senyi Peng contributed equally to this work.

Authors and Affiliations

  1. Department of Anesthesiology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, 510080, China

    Qiulan He, Senyi Peng, Shiqing Lin, Guohui Mo, Xu Zhao & Zhongxing Wang

  2. Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Guangzhou, China

    Zhenyi Lai

Authors
  1. Qiulan He
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Zhenyi Lai
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Senyi Peng
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Shiqing Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Guohui Mo
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Xu Zhao
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Zhongxing Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Z.X. Wang and Q.L. He designed the study. Z.Y. Lai, S.Y. Peng and G.H Mo. collected and collated the data. Q.L. He, S.Y. Peng and X. Zhao performed statistical analysis and data interpretation. Q.L. H, Z.Y. Lai and Xu Zhao wrote the main manuscript text and prepared the figures and Tables 1, 2, 3, 4 and 5. S.Y. Peng and X. Zhao prepared all the supplemental tables. S.Q. Lin and Z.X. Wang provided guidance for data analysis and the discussion section of the main text. All authors reviewed the manuscript.

Corresponding authors

Correspondence to Xu Zhao or Zhongxing Wang.

Ethics declarations

Ethical approval

This retrospective study was approved by the ethics committees of the First Affiliated Hospitals of Sun Yat-sen University according to the China Good Clinical Practice (GCP) guidelines and the tenets of the Declaration of Helsinki. The requirement for written consent was waived by the Institutional Review Board of the First Affiliated Hospitals of Sun Yat-sen University (No. 2021 − 395, approval date: Jun 3rd, 2021).

Consent for publication

Not applicable.

Patient and public involvement

Patients or the public were not involved in setting the research agenda.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Supplementary Material 2

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

He, Q., Lai, Z., Peng, S. et al. Postoperative pulmonary complications after major abdominal surgery in elderly patients and its association with patient-controlled analgesia. BMC Geriatr 24, 751 (2024). https://doi.org/10.1186/s12877-024-05337-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12877-024-05337-y

Keywords

BMC Geriatrics

ISSN: 1471-2318

Contact us