Incidence, patterns, and factors associated with postoperative pulmonary complications in an ERAS cardiac surgery program: a 500-patient cohort study.

BACKGROUND

Postoperative pulmonary complications (PPCs) remain the most frequent adverse events after cardiac surgery. Enhanced Recovery After Surgery (ERAS) programs aim to reduce postoperative morbidity, and data describing the incidence, patterns, and protective factors associated with PPCs within cardiac ERAS pathways remain limited.

METHODS

We analyzed 500 consecutive adult patients undergoing cardiac surgery within a standardized ERAS program at a tertiary center. PPCs included respiratory infection, respiratory failure, pleural effusion, atelectasis, pneumothorax, bronchospasm, or aspiration pneumonitis.

RESULTS

PPCs occurred in 130 of 500 patients (26%). The most frequent events were atelectasis (28.5%), respiratory failure (23.8%), and pneumonia (20%). Independent preoperative and intraoperative factors included age ≥ 70 years (OR 1.86, 95% CI 1.14-3.03), BMI ≥ 35 kg/m2 (OR 2.37, 95% CI 1.18-4.76), active smoking (OR 1.95, 95% CI 1.13-3.37), frailty (OR 2.21, 95% CI 1.12-4.33), and redo surgery (OR 3.09, 95% CI 1.52-6.26). Patients with PPCs had longer ICU and hospital length of stay, higher ICU readmission rates, and increased postoperative complications, without a significant difference in 30-day mortality. Exploratory analyses identified early extubation and shorter chest drain duration as variables associated with a lower incidence of PPCs, whereas postoperative delirium and transfusion were associated with an increased risk of PPCs.

CONCLUSION

PPCs affected one in four patients in this ERAS cardiac surgery cohort and were associated with significant morbidity. Preoperative factors including age, obesity, frailty, and redo surgery were the main associated factors. Among these, frailty and active smoking emerged as key modifiable associated factors that remain incompletely addressed and represent important targets for optimization. Several postoperative factors, including early extubation, delirium, transfusion, and chest drain management, were potential targets for optimization. Further studies are needed to better clarify their causal role and to guide targeted interventions.