Nithiuthai et al.

Perioperative Medicine (2021) 10:43

https://doi.org/10.1186/s13741-021-00214-3

RESEARCH Open Access

Do ARISCAT scores help to predict the

incidence of postoperative pulmonary
complications in elderly patients after
upper abdominal surgery? An observational
study at a single university hospital
Jitsupa Nithiuthai1, Arunotai Siriussawakul1,2, Rangsinee Junkai1, Nutthakorn Horugsa1, Sunit Jarungjitaree2 and
Namtip Triyasunant1*

Abstract
Background: The incidence of postoperative pulmonary complications (PPCs) is increasing in line with the rise in
the number of surgical procedures performed on geriatric patients. In this study, we determined the incidence and
risk factors of PPCs in elderly Thai patients who underwent upper abdominal procedures, and we investigated
whether the Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score helps to predict PPCs in Thais.
Methods: A retrospective study was conducted on upper abdominal surgical patients aged over 65 years who had
been admitted to the surgical ward of Siriraj Hospital, Mahidol University, Thailand, between January 2016 and
December 2019. Data were collected on significant PPCs using the European Perioperative Clinical Outcome
definitions. To identify risk factors, evaluations were made of the relationships between the PPCs and various
preoperative, intraoperative, and postoperative factors, including ARISCAT scores.
Results: In all, 1100 elderly postoperative patients were analyzed. Their mean age was 73.6 years, and 48.5% were
male. Nearly half of their operations were laparoscopic cholecystectomies. The incidence of PPCs was 7.7%, with the
most common being pleural effusion, atelectasis, and pneumonia. The factors associated with PPCs were
preoperative oxygen saturation less than 96% (OR = 2.6, 1.2–5.5), albumin level below 3.5 g/dL (OR = 1.7, 1.0–2.8),
duration of surgery exceeding 3 h (OR = 2.0, 1.0–4.2), and emergency surgery (OR = 2.8, 1.4–5.8). There was a
relationship between ARISCAT score and PPC incidence, with a correlation coefficient of 0.226 (P < 0.001). The area
under the curve was 0.72 (95% CI, 0.665–0.774; P < 0.001).
Conclusions: PPCs are common in elderly patients. They are associated with increased levels of postoperative
morbidities and extended ICU and hospital stays. Using the ARISCAT score as an assessment tool facilitates the
classification of Thai patients into PPC risk groups. The ARISCAT scoring system might be able to be similarly
applied in other Southeast Asian countries.
Keywords: Abdominal surgery, Ageing, ARISCAT, Elderly, Postoperative, Pulmonary complications, Thai

* Correspondence: namtip229@gmail.com
1
Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol
University, Bangkok, Thailand
Full list of author information is available at the end of the article

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Nithiuthai et al. Perioperative Medicine (2021) 10:43 Page 2 of 12

Introduction population. ARISCAT scores are derived from several var-

According to the World Population Prospects 2019, the iables: age, oxygen saturation, respiratory tract infection in
proportion of individuals aged 65 years or over in the preceding month, anemia, abdominal or thoracic sur-
South-Eastern Asia will increase from 11% in 2019 to al- gery, operative time, and emergency surgery (Canet et al.
most a quarter in 2050 (Desa 2019). Elderly people ex- 2010). The scoring system was developed to predict the
perience progressive degenerative changes in all of their risk of PPCs, and it demonstrated good performance in a
physiological systems, and they frequently have many Western European subsample (Mazo et al. 2014).
diseases (Colloca et al. 2010). Elderly patients might not
tolerate surgery well, which can result in perioperative Methods
complications. Objectives
Postoperative pulmonary complications (PPCs) happen The primary outcome was the incidence of PPCs in eld-
in every age group, with an incidence ranging from less erly patients who underwent upper abdominal surgery.
than 1 to 23% (Miskovic and Lumb 2017). PPCs affect The secondary outcomes were the relationships between
the elderly easily because of the many changes that the PPCs and various perioperative factors, including
occur in an aging respiratory system, including the pul- ARISCAT scores, as well as the effects those PPCs had
monary structure, function, and neural controls. Advan- on hospital stays, ICU stays, postoperative ventilator
cing age can also cause an increase in lung compliance support, and mortality.
and a decline in chest wall compliance. In addition, the
cough reflexes of the elderly might become depressed, Study design and participants
and their ventilatory responses to hypoxia and hypercap- Prior approval for this retrospective study was obtained
nia impaired (Lalley 2013). In a 2006 study of PPCs, from the Siriraj Institutional Review Board (Si 006/
Smetana et al. found that old age is a risk factor; this 2019). Using ICD-10-CM procedure codes, the authors
finding was later supported by many studies (Miskovic searched electronic medical records to identify upper ab-
and Lumb 2017; Smetana et al. 2006; Canet et al. 2010). dominal surgeries performed at Siriraj Hospital, Mahidol
PPCs are mostly temporary and tend to resolve spon- University, Bangkok, Thailand. The inclusion criteria
taneously; however, their sequelae can affect patients for were patients aged over 65 years who had undergone
a prolonged period. PPCs in the elderly are not only as- open or laparoscopic upper abdominal surgery. The opera-
sociated with delayed recovery, extended durations of tions included Whipple procedures, liver resections, liver
hospital stay, and hospital readmissions, but they also transplantations, open and laparoscopic cholecystectomies,
contribute negatively to overall healthcare costs, quality bile duct resections, pancreatectomies, adrenalectomies,
of life, and mortality rate (Lawson et al. 2013; Shander splenectomies, gastrectomies, and hyperthermic intraperito-
et al. 2011). neal chemotherapies. (Fig. 1) The exclusion criteria were in-
To date, the incidences of PPCs and their sequelae at ter- complete medical records, patients who were intubated or
tiary hospitals in Thailand have not been reported. The pri- required a noninvasive or invasive ventilator before the sur-
mary aim of our study was to determine the prevalence of gery, thoracic surgery, and a blunt chest injury. The study
PPCs in elderly patients, using the European Perioperative period was from January 2016 to December 2019.
Clinical Outcome definitions of 2015 (respiratory infection, The sample size was calculated using the average inci-
respiratory failure, pleural effusion, atelectasis, pneumo- dence of PPCs (7.49%) obtained from a literature review
thorax, bronchospasm, aspiration pneumonitis, pneumonia, (Yang et al. 2015; Jeong et al. 2014; Smith et al. 2010);
and bronchitis) (Jammer et al. 2015). Scholes et al. found the allowable error was 1.87% at a 95% level of confi-
that patients were 50% more likely to develop PPCs with dence. After adding 15% to the calculated population,
upper gastrointestinal surgery than other surgical proce- the study size was determined to be 900 patients. We
dures (Scholes et al. 2009). As gastrectomy, pancreatic re- then performed a calculation using the multiple logistic
section, and esophagectomy have been found to have regression “rule of thumb” with 7 independent variables:
higher mortality rates than colectomy in Australia and the smoking, oxygen saturation, recent upper respiratory in-
USA, we decided to investigate PPCs in patients undergo- fection, abnormal chest X-ray, hemoglobin, surgical dur-
ing upper abdominal surgery (Warrillow et al. 2008). ation, and urgency of surgery. With that method, the
Our secondary outcomes were to ascertain the risk minimum number of patients required was 1100; that
factors associated with PPCs, and the effects of PPCs on figure became the final sample size target.
hospital stay, ICU stay, postoperative ventilator support,
and mortality. Assessment of postoperative pulmonary risks
Finally, we set out to establish whether the Assess Re- Details of the cohorts’ demographic data and the factors
spiratory Risk in Surgical Patients in Catalonia (ARIS- that might be related to PPCs were retrieved from the
CAT) score can be applied to predict PPCs in the Thai medical records. The PPCs complied with the European
Nithiuthai et al. Perioperative Medicine (2021) 10:43 Page 3 of 12

Fig. 1 Participant recruitment

Perioperative Clinical Outcome definitions of 2015 The most frequent surgical operation was cholecystec-
(Jammer et al. 2015). tomy (630 cases; 57%), with over 80% done laparoscopic-
ally. This was followed by liver resection (183 cases;
Statistical analysis 17%) and gastrectomy (65 cases; 6%).
Comparisons were made of the characteristics of a non- The overall PPC incidence was 7.7% (85/1100 pa-
PPC group and a PPC group. An analysis-of-variance tients). Of those cases, pleural effusion had the highest
model, the independent t test, or the Mann–Whitney U incidence (31/85 cases; 36%), followed by atelectasis at
test was used for continuous variables; and the chi- 28% and pneumonia at 24%. The procedure with the
squared or Fisher’s exact test was employed for categor- highest prevalence of PPCs was cholecystectomy (27/85
ical variables. Missing data were treated as missing and cases; 31.8%), followed by liver resection (22/85 cases;
not imputed. Significant variables in the preliminary uni- 25.9%) and gastrectomy (9/85 cases; 10.6%). Excluding
variable analyses, at a predetermined alpha level of 0.2, the cholecystectomies, the PPC incidence was 11.4% (61/
were included in a multivariable logistic regression 535 patients).
model. Due to the exploratory nature of our study, The median hospital and intensive-care-unit stays of
model building was done by analyzing the factors related the PPC patients were significantly higher than of those
to the occurrence of PPCs after surgery using stepwise without PPCs at 16 (9, 37.5) versus 5 (3, 9) days, with P
backward logistic regression. Results of the multivariable < 0.001; and 4 (3, 10) versus 1 (1, 4) days, with P =
logistic regression analysis were reported as adjusted 0.032, respectively.
odds ratio (OR) and 95% confidence interval (CI). We The non-PPC and PPC groups had median ARISCAT
deemed probability (P) values of < 0.05 to be statistically scores of 32 (18–41; 95% CI, 31.1–32.7) and 41 (34–52;
significant. P values were two-sided for all statistical 95% CI, 40.2–46.1), respectively, with P < 0.001. Each
tests, when applicable. The data analyses were per- score indicated an intermediate risk in the ARISCAT
formed using IBM SPSS Statistics for Windows (version system. Relative to the patients with a low ARISCAT
21.0; IBM Corp., Armonk, NY, USA). score, those with an intermediate score range had a
threefold higher risk (95% CI, 1.528–6.034) of develop-
Results ing PPCs. By contrast, those with a high ARISCAT score
In all, 1100 elderly postoperative patients were recruited range had a 7.8-fold higher probability (95% CI, 3.89–
and analyzed. Their mean age was 73.6 years, and 48.5% 15.69). The perioperative risk factors and outcomes are
were male. The detailed patient demographic data are listed in Tables 2, 3, and 4. Our multivariable regression
listed in Table 1. There were no preoperative statistical analysis revealed that 4 risk factors were associated with
differences in the ages, genders, body mass indexes, re- PPCs: preoperative SpO2 ≤ 95% (OR 2.60; 95% CI, 1.23–
spiratory comorbidities, chest X-ray findings, or creatin- 5.51), preoperative albumin less than 3.5 g/dL (OR 1.70;
ine levels of the patients with and without PPCs. 95% CI, 1.02–2.83), surgery duration exceeding 3 h (OR
Nithiuthai et al. Perioperative Medicine (2021) 10:43 Page 4 of 12

Table 1 Patient demographic data

Demographic data PPCs (n = 85) No PPCs (n = 1015) P value
Age (years) 75.0 ± 7.7 73.5 ± 6.5 0.052
Male sex 46 (54.1%) 488 (48.1%) 0.285
ASA classification > 2 50 (58.8%) 452 (44.5%) 0.011
BMI (kg/m2) 23.7 ± 4.2 24.1 ± 4.2 0.389
Previous pulmonary disease 4 (4.7%) 31 (3.1%) 0.340
Respiratory infection in preceding month 0 7 (0.7%) 1.000
History of smoking 27 (31.8%) 229 (22.6%) 0.054
Current smoker 7 (8.2%) 38 (3.7%) 0.077
Chronic obstructive pulmonary disease 3 (3.5%) 22 (2.2%) 0.434
Asthma 2 (2.4%) 23 (2.3%) 1.000
Obstructive sleep apnea 2 (2.4%) 14 (1.4%) 0.354
Congestive heart failure 1 (1.2%) 2 (0.2%) 0.215
Preoperative SpO2 (%) 97.8 ± 1.5 98.3 ± 1.7 0.012
Preoperative albumin (g/dL) 3.4 ± 1.0 3.80 ± 1.2 0.002
Preoperative Hb (g/dL) 11.0 ± 2.3 11.9 ± 2.0 < 0.001
Preoperative HCO3 25.0 ± 3.5 25.8 ± 2.8 0.053
Preoperative creatinine 1.3 ± 1.5 1.1 ± 0.8 0.224
Abnormal CXR 24 (28.2%) 252 (24.8%) 0.486
Spirometer usage 5 (5.9%) 51 (5.0%) 0.598
Deep-breathing exercises 2 (2.4%) 23 (2.3%) 0.707
Data presented as n (%) or mean ± SD
Abbreviations: ASA American Society for Anesthesiologists physical status, BMI body mass index, CXR chest X-ray, Hb hemoglobin, HCO3 bicarbonate, SpO2
peripheral capillary oxygen saturation/pulse oximetry

2.05; 95% CI, 1.00–4.22), and emergency surgery (OR The average age of the participants in our study was
2.84; 95% CI, 1.39–5.83). In contrast, a high incidence of 73.6 years, and nearly half of the cases required minor
PPCs was not associated with gender; body mass index; upper abdominal surgery. Laparoscopic cholecystecto-
or a history of asthma, chronic obstructive pulmonary mies represented 47% of all operations, and the overall
disease, or obstructive sleep apnea. On the other hand, a incidence of PPCs was 7.7%. Excluding the cholecystec-
low PPC incidence was not related to respiratory preha- tomies, the PPC incidence was 11.4%. That level was
bilitation therapy, such as spirometer usage or deep- comparable with the PPC incidence of 5.8% found after
breathing exercises implemented before surgery. abdominal surgery in an analysis of the National Surgi-
Using Pearson’s correlations analysis, a relationship cal Quality Improvement Program by (Yang et al. 2015).
was identified between the ARISCAT score and the PPC Although that research team focused on major abdom-
incidence, with a correlation coefficient of 0.226 (P < inal surgery, 71% of the operations were colectomies,
0.001). The area under the curve was 0.72 (95% CI, which had the lowest rate of PPCs (4.4%) of all the op-
0.665–0.774; P < 0.001). erations. Moreover, the mean ages of the patients in
that study were lower than in ours: 66.9 years for the
PPC patients and 60.4 years for the patients without
Discussion PPCs. Looking at the “Prospective Evaluation of a Risk
In Thailand, the incidences of PPCs and their sequelae Score for Postoperative Pulmonary Complications in
at tertiary hospitals have not previously been reported. Europe; PERISCOPE” data, 7.9% of patients experi-
Identifying their incidences and the associated, modifi- enced PPCs. Their median ARISCAT score was 15 (9–
able risk factors in high-risk patients might increase the 26), which indicated that the PPCs were low risk. Fur-
quality of perioperative care and decrease overall mor- thermore, the median age of the population was 59.1
bidity. To this end, we collected data relating to 1100 (44.9–70.9) years. Most of the operations involved a
patients aged over 65 years who had either open or lap- peripheral incision (72.5%), followed by upper abdom-
aroscopic upper abdominal surgery between January inal surgery (21.4%) and intrathoracic or cardiac sur-
2016 and December 2019. gery (6.1%) (Mazo et al. 2014).
Nithiuthai et al. Perioperative Medicine (2021) 10:43 Page 5 of 12

Table 2 Intraoperative parameters

Intraoperative parameters PPCs (n = 85) No PPCs (n = 1015) P value
Open surgery 60 (70.6%) 450 (44.3%) < 0.001
Emergency surgery 14 (16.5%) 52 (5.1%) < 0.001
Duration of surgery 3.1 (1.8, 5.0) 1.8 (1.2, 3.2) < 0.001
Anesthesia technique 0.012
GA 51 (60%) 739 (72.8%)
Combined GA & epidural 34 (40%) 276 (27.2%)
Crystalloid IV (mL) 1550 (1000, 2800) 700 (400, 1700) < 0.001
Blood loss (mL) 350 (150, 1000) 50 (10. 300) < 0.001
Inhalation 0.147
Isoflurane 4 (4.70%) 70 (6.9%)
Sevoflurane 21 (24.7%) 335 (33%)
Desflurane 60 (70.6%) 603 (59.4%)
Midazolam used 20 (23.5%) 162 (16.0%) 0.071
Neuromuscular blocking 0.005
Cisatracurium 49 (57.6%) 605(59.6%) 0.724
Atracurium 22 (25.9%) 348(34.3%) 0.115
Rocuronium 14 (16.5%) 59(5.8%) < 0.001
Ventilator setting 0.608
VCV mode 63 (74.1% 643 (63.3%)
PCV mode 18 (21.2%) 159 (15.7%)
TV (cc/kg) 8.9 ± 1.2 9.0 ± 1.4 0.459
PAP (cmH2O) 20.7 ± 5.3 21.2 ± 4.5 0.346
RR (min) 12.2 ± 2.2 12.4 ± 2.7 0.400
PEEP (cm·H2O) 4.8 ± 0.83 4.8 ± 0.9 0.994
ARISCAT score 41 (34–52) 32 (18–41) < 0.001
Data presented as n (%), mean ± SD, or median (IQR)
Abbreviations: ARISCAT Assess Respiratory Risk in Surgical Patients in Catalonia, GA general anesthesia, IV intravenous, PAP peak airway pressure, PCV pressure-
controlled ventilation, PEEP positive end-expiratory pressure, RR respiratory rate, TV tidal volume, VCV volume-controlled ventilation

Our investigation revealed that the PPC with the high- (70.3%). Most of their cases were asymptomatic and self-
est incidence was pleural effusion (36%), which was diag- limiting (Rossi and Bromberg 2005). Pleural effusions
nosed from postoperative chest X-ray reports. Rossi and might result from sodium and water retention, and they
Bromberg also reported finding a high rate of pleural ef- may be aggravated by the relative cardiac decompensa-
fusion through ultrasound examinations during the post- tion typically found in the elderly (Nielsen et al. 1989).
operative period following elective abdominal surgery Subsequent to the performance of hepatectomies for the

Table 3 Postoperative parameters

Postoperative parameters PPCs (n = 85) No PPCs (n = 1015) P value
Postoperative ventilator (h) 73 (32.5, 270) 20 (16, 81.25) 0.029
Numerical pain rating score 5.9 ± 3.2 5.3 ± 3.2 0.074
Morphine dose (mg) 6.4 ± 5.6 5.4 ± 3.2 0.647
Pethidine dose (mg) 45.0 ± 7.1 42.6 ± 12.2 0.823
Fentanyl dose (mcg) 103.3 ± 52.5 91.8 ± 41.1 0.145
Length of hospital stay (days) 16 (9, 37.5) 5 (3, 9) < 0.001
Length of ICU stay (days) 4 (3, 10) 1 (1, 4) 0.032
Data presented as mean ± SD
Abbreviation: ICU intensive care unit
Nithiuthai et al. Perioperative Medicine (2021) 10:43 Page 6 of 12

Table 4 Results of multivariate regression analysis

Protective/risk factors Adjusted OR 95% CI P value
ASA classification > 2 1.30 0.80–2.09 0.290
Preoperative SpO2 ≤ 95% 2.60 1.23–5.51 0.012
Preop. Hb < 10 mg/dL 1.24 0.69–2.21 0.479
Preoperative albumin < 3.5 g/dL 1.70 1.02–2.83 0.040
Duration of surgery (reference < 2 h) 1
2–3 h 1.05 0.50–2.21 0.900
>3h 2.05 1.00–4.22 0.050
Open surgery 1.49 0.83–2.67 0.187
Emergency surgery 2.84 1.39–5.83 0.004
Crystalloid IV > 1000 mL 1.88 0.89–4.00 0.100
Abbreviations: 95% CI 95% confidence interval, ASA American Society for Anesthesiologists physical status, Hb hemoglobin, IV intravenous, OR odds ratio, SpO2
peripheral capillary oxygen saturation/pulse oximetry

treatment of primary liver cancer, postoperative pleural surgeries. Although past and current cigarette smoking
effusions were found in a quarter of such cases. Sub- were not statistically associated with PPCs in our study,
phrenic collection and operative injuries to the liver Lugg et al. revealed that the current smokers had a
were found to be statistically related to those pleural ef- greater incidence of PPCs and a higher rate of ICU ad-
fusions (Chu et al. 2007). mission following non-small cell lung cancer surgery. In
addition, the PPC risk was reduced following smoking
Preoperative parameters cessation (Lugg et al. 2017). For various surgeries, such
Like other studies, older age was determined to be an in- as spine surgery, plastic surgery, and renal transplant
dependent risk factor for PPCs. They were found in 7.2% surgery, quitting smoking improved a wide range of out-
of patients aged 65 to 80 years (63/881 patients) and in comes. Therefore, smoking cessation should be incorpo-
10% over 80 years of age (22/219 patients). Qaseem rated in the pathway before surgery for better care
et al. reported that, compared with younger patients, the (Grocott et al. 2017). A retrospective review conducted
ORs of developing PPCs were 2.09 (95% CI, 1.70–2.58) at Pusan National University Yangsan Hospital, South
for patients aged 60–69 years, and 3.04 (95% CI, 2.11– Korea, found that the incidence of PPCs after non-
4.39) for those aged 70–79 years. Although age cannot cardiothoracic surgery with adult asthma patients was as
be modified, careful perioperative management might high as 29.1%, with the most common PPCs being pneu-
decrease the incidence or severity of complications in monia (32.4%) and bronchospasm (24.3%). The signifi-
older patients (Qaseem et al. 2006). cant risk factors were age, the presence of preoperative
We also found that the incidence of PPCs rose in pa- respiratory symptoms, and a low forced expiratory vol-
tients having an American Society of Anesthesiologists ume in 1 s (Lee et al. 2014).
physical status > II (crude OR 1.78; 95% CI 1.14–2.79), The mean hemoglobin levels of the 2 groups in our
but it declined in those with a preoperative peripheral study being similar at around 11 g/dL, the values could
capillary oxygen saturation value exceeding 95% in room not demonstrate clinical importance, with an adjusted
air (crude OR 0.30; 95%CI 0.15–0.59). Our study showed OR of 1.24 (95% CI, 0.69–2.21). In our study, patients
that the PPC incidence was not associated with gender, who had a serum hemoglobin level of < 10 g/dL had a
body mass index, preoperative spirometer usage, or pre- threefold greater chance of experiencing at least 1 PPC
operative deep-breathing exercises. than those with higher hemoglobin levels. Even at a mild
Unlike the findings of Yoder et al., we found no correl- degree (hemoglobin < 13 g/dL in males and < 12 g/dL in
ation between PPCs and respiratory comorbidities females), preoperative anemia was reported to be inde-
(asthma, chronic obstructive pulmonary disease, and pendently related to a heightened risk of 30-day mortal-
smoking history) (Yoder et al. 2011). This may be be- ity and morbidities (cardiac, respiratory, CNS, urinary
cause there were only 50 cases of respiratory-related pa- tract, wound, sepsis, and venous thromboembolism out-
tients, all of which were medically well controlled. comes) in patients undergoing major non-cardiac sur-
Moreover, some of those 50 cases had been screened gery (Musallam et al. 2011).
and treated by specialist staff at our Siriraj Pre- Preoperative albumin was reported to correlate in-
Anesthetic Clinic—with several achieving optimized versely with complications such as reintubation, pneu-
medical conditions—at least 2 weeks prior to their monia, and failure to wean from a mechanical ventilator,
Nithiuthai et al. Perioperative Medicine (2021) 10:43 Page 7 of 12

especially after upper abdominal surgery (Barisione et al. over half of those occurrences being caused by aspir-
1997). Compared with colonic surgery, patients under- ation. Furthermore, another 4.3% of the study cohort
going esophageal or pancreatic procedures were also died from pneumonia (Fukuda et al. 2012; Ferreyra et al.
found to have significantly higher complication rates at 2009). By comparison, our study revealed the incidence
any level of serum albumin < 3.25 g/dL (Kudsk et al. of patients with PPCs after emergency abdominal sur-
2003). The relationship between serum albumin levels gery as 21.2% (14/66 cases) with adjusted OR 2.84 (95%
and mortality was demonstrated to be continuous when CI, 1.39–5.83). The most common PPCs were atelectasis
the levels were < 3.5 g/dL (Gibbs et al. 1999). Although (6 cases), followed by pneumonia (4 cases). There was
there was a statistical difference in the mean serum albu- no mortality.
min levels of the non-PPC and PPC groups in our study, In patients undergoing abdominal surgery, epidural
neither mean was < 3.0 g/dL, which Smetana et al. iden- analgesia reduces the risk of postoperative pneumonia
tified as a PPC predictor (Smetana et al. 2006; Lawrence while improving pulmonary function and arterial oxy-
et al. 2006). Patients with serum albumin levels less than genation (Pöpping et al. 2008). However, in our study,
3.5 g/dL had a greater risk of PPCs, with an adjusted OR the PPC incidence was not affected by the choice of
of 1.7 (95% CI, 1.02–2.83). anesthesia (general, versus a combination of general and
Preoperative spirometry usage and deep-breathing ex- regional anesthesia).
ercises showed no benefits in reducing the incidence of Looking at the major surgery subgroups in Table 5,
PPCs in our study. However, we cannot comment on there were no significant differences in the PPC preva-
the impact of this finding, given that less than 5% of our lences of the patients who received general anesthesia
population used spirometry preoperatively, and less than (GA) combined with epidural anesthesia, and the other
2% performed deep-breathing exercises. The preopera- anesthetic methods. Therefore, performing combined
tive physiotherapist consultations also varied, depending GA-epidural anesthesia neither increased nor reduced
on the judgements of the attending surgeons, the oper- the incidence of PPCs in our population. In addition,
ation type, and patient comorbidities. Furthermore, the there were no statistical differences in the postoperative
outcomes of the prehabilitation depended on the degree pain-rating scores or 72-h opioid consumption levels of
of patient cooperation and compliance. In a prospective the non-PPC and PPC groups.
multicenter randomized controlled trial conducted in Compared with conventional ventilation, a protective
Australia and New Zealand by Boden et al., a 30-min ventilation strategy reduces inflammation and improves
preoperative physiotherapy education and exercise train- oxygenation in patients undergoing esophagectomies. In
ing session halved the incidence of PPCs, especially a protective ventilation group, the incidence of pneumo-
hospital-acquired pneumonia after upper abdominal sur- nia was demonstrated by one study to be lower than that
gery. The absolute risk reduction was 15% (95% CI, 7– for a conventional ventilation group, although the differ-
22%), with a number needed to treat of 7 (95% CI, 5–14) ence was nonsignificant (Michelet et al. 2006). In our in-
(Boden et al. 2018). vestigation, most of the ventilation parameters followed
the lung-protective strategy; the mean tidal volumes of
Intraoperative and postoperative parameters the PPC and non-PPC groups were almost 9 mL/kg, and
In the present work, strong relationships were demon- the parameters of the groups were not statistically differ-
strated between PPCs and surgical duration (especially if ent. As to the anesthetic risk factors, no relationship was
longer than 3 h), with a twofold increase in the inci- apparent between the PPCs and airway equipment, in-
dence of complications (95% CI, 1.0–4.2). Patel et al. re- halation agent, or anesthetic technique.
ported that the risk of PPCs increased with every We found an association between rocuronium and
additional minute of operating time (Patel et al. 2016). postoperative complications. The PPC-inducing action
Despite finding that laparoscopic and open cholecyst- of rocuronium still remained even when used in con-
ectomies had similar PPC risk profiles in terms of their junction with neostigmine or sugammadex. In a com-
operative durations, Owen et al. demonstrated that open parison of the major and minor operations, a significant
surgery had at least double the risk of PPCs compared difference in their PPC incidences was only demon-
with laparoscopic surgery (Owen et al. 2013). A separate strated with the use of rocuronium with the major oper-
study comparing open and minimally invasive esopha- ations. In other words, the type of surgery influenced the
gectomies reported that there was a significant reduction usage of rocuronium, which then affected the occur-
in postoperative pneumonia when the minimal approach rence of PPCs. The observational study entitled “Post-
was employed (Biere et al. 2012). Anaesthesia Pulmonary Complications After Use of
According to a study of the factors predicting mortal- Muscle Relaxants” showed that the administration of
ity in emergency abdominal surgery of the elderly, the neuromuscular blocking drugs during GA was associated
incidence of postoperative pneumonia was 12.8%, with with an elevated risk of PPCs (OR 1.86; 95% CI, 1.53–
Nithiuthai et al. Perioperative Medicine (2021) 10:43 Page 8 of 12

Table 5 Major and minor surgery subgroup analysis

Factors Major surgery (n = 535) Minor surgery (n = 565)
PPCs (n = 61, No PPCs (n = 474, P value PPCs (n = 24, No PPCs (n = 541, P value
11.4%) 88.6 %) 4.2%) 95.8%)
Duration of surgery 0.034 0.018
<2h 10 (7.9%) 116 (92.1%) 14 (3.1%) 432 (96.9%)
2–3 h 9 (7.3%) 115 (92.7%) 7 (7.4%) 88 (92.6%)
>3h 42 (14.7%) 243 (85.3%) 3 (12.5%) 21 (87.5%)
Neuromuscular blocking 0.005 0.059
Rocuronium 10 (27.0%) 27 (73.0%) 4 (11.1%) 32 (88.9%)
Others 51 (10.2%) 447 (89.8%) 20 (3.8%) 509 (96.2%)
Combined GA with epidural anesthesia 0.838 0.459
Yes 33 (11.1%) 263 (88.9%) 1 (7.1%) 13 (92.9 %)
No 28 (11.7%) 211 (88.3%) 23 (4.2%) 528 (95.8%)
Maximal numerical pain score in 72 h 6.0 ± 3.2 5.4 ± 3.2 0.205 5.8 ± 3.2 5.1 ± 3.2 0.331
ARISCAT scores 0.003 < 0.001
< 26 4 (4.3%) 89 (95.7%) 3 (1.1%) 282 (98.9%)
26–44 29 (10.2%) 256 (89.8%) 12 (5.3%) 216 (94.7%)
≥ 45 28 (17.8%) 129 (82.2%) 9 (17.3%) 43 (82.7%)
Total crystalloid received (mL) 2200 (1300, 3875) 1750 (1100, 2600) 0.009 950 (525, 1300) 450 (300, 650) < 0.001
Estimated blood loss (mL) 500 (200, 1300) 300 (100, 600) < 0.001 150 (40, 275) 10 (5, 30) < 0.001
Data presented as mean ± SD, median (IQR)
Abbreviation: ARISCAT Assess Respiratory Risk in Surgical Patients in Catalonia

2.26). Furthermore, the usage of neuromuscular moni- as guidance (for example, calculated oxygen delivery,
toring and reversal agents (sugammadex or neostigmine) pulmonary capillary wedge pressure, or cardiac stroke
was not associated with a decreased PPC risk (Kirmeier volume variation). Over recent years, our institution has
et al. 2019). However, in a multicenter, matched cohort progressively revised the perioperative management
analysis (STRONGER), sugammadex administration was protocol for enhanced recovery (the Siriraj ERAS Proto-
associated with a reduction in PPC risk (adjusted OR col). In the current work, even though we could retro-
0.70; 95% CI, 0.63–0.77) as well as a 55% reduced risk of spectively collect and analyze the intraoperative fluid
respiratory failure, compared with the administration of administration for each case, we were unable to identify
neostigmine (Kheterpal et al. 2020). In addition, a ran- which fluid strategy was used. Our results showed that
domized controlled trial by Togioka et al. explored the the median intraoperative crystalloid infusions of the
effects of reversal agents on the PPC incidence of older PPC and non-PPC groups were 1550 mL (1000, 2800)
adults undergoing prolonged surgery. Their work con- and 700 mL (400, 1700), respectively. In the case of the
firmed that sugammadex is superior to neostigmine in major operation subgroup, the median intravenous fluid
reducing the incidence of residual neuromuscular par- volume was 2200 mL (1300, 3875) for the PPC group,
alysis. Moreover, there was a threefold increase in the and 1750 mL (1100, 2600) for the non-PPC group (P =
30-day hospital readmission rate of the neostigmine 0.009). A large intraoperative crystalloid administration
group (15%) relative to that of the sugammadex group was associated with a high PPC risk (adjusted OR 1.88;
(5%) (Togioka et al. 2020). 95% CI, 0.89–4.00), but this might not represent statis-
A 2020 systematic review and meta-analysis focusing tical significance. A fluid volume cutoff point affecting
on the prevention of PPCs identified some perioperative PPCs could not be determined. Many factors were in-
interventions that probably reduce the occurrence of volved in fluid administration, like blood loss, the pres-
PPCs. For example, the use of enhanced recovery after ence of patient comorbidities, and preoperative volume
surgery pathways and goal-directed hemodynamic ther- status.
apy demonstrated benefits, whereas restrictive fluid ad- An increased fluid volume administration was associ-
ministration strategies might not (Odor et al. 2020). ated with an elevated risk of pulmonary complications,
Goal-directed hemodynamic therapy was a type of peri- whereas goal-directed fluid administration was reported
operative fluid administration that used biological targets to offer a 30% reduction in pulmonary complications
Nithiuthai et al. Perioperative Medicine (2021) 10:43 Page 9 of 12

following upper abdominal and major vascular surgery triggering PPCs. However, the average postoperative
(OR 0.7; 95% CI, 0.6–0.9) (Casado et al. 2010; Corcoran pain rating scores for the PPC and non-PPC groups did
et al. 2012). During major abdominal surgery, periopera- not differ significantly. In our analysis of the maximum
tive fluid therapy recommendations aim for a moderately postoperative pain rating scores during the first 72 post-
liberal intravenous (IV) fluid regimen, with an average surgery hours, the PPC patients scored a mean of 5.9
crystalloid fluid infusion rate of 10–12 mL/kg/h. In versus 5.3 for those without PPCs. Furthermore, the
addition, for higher-risk patients undergoing major sur- total opioid usage (morphine, pethidine, and fentanyl) of
gery, employing an advanced hemodynamic monitor to the 2 groups were not statistically different. However,
assess fluid responsiveness was recommended (Miller our findings contrast with those of Roberta et al., who
and Myles 2019). investigated PPCs experienced by the elderly after ab-
In our study, the median blood loss for the PPC group dominal surgery. Those researchers concluded that pain
(350 mL [150, 1000]) was significantly higher than that contributes to the development of PPCs. This dissimilar-
for the non-PPC group (50 mL [10, 300]). This result ity might result from the different assessment durations
corresponds with the finding of Sah et al. for gastric can- that were utilized. Specifically, the current investigation
cer treatments: blood loss volumes exceeding 500 mL assessed the pain levels of both groups within 3 days
were associated with early postoperative complications postoperatively. By comparison, Roberta et al. assessed
(OR 2.86; 95% CI, 1.67–4.92) (Sah et al. 2009). Table 5 pain daily between postoperative Days 1 and 6, inclusive,
lists the results after defining all cholecystectomies as and they found that their PPC patients experienced sig-
minor surgeries. Patients who developed PPCs had con- nificant pain at rest on postoperative Day 4 (Shea et al.
siderably higher volumes of fluid administered and 2002).
greater estimated blood losses. Total intravenous fluid There are many predictive tools for PPCs, for example,
and estimated blood loss had a linear correlation of the ARISCAT scoring system, the LAS VEGAS risk
around 82%. However, the adjusted OR of blood loss in score, the Melbourne Risk Prediction Tool, and the Sur-
our study was weak and nonsignificant. gical Lung Injury Prediction model. However, only the
Although the presence of a nasogastric (NG) tube was ARISCAT system has demonstrated sufficient predictive
reported by some studies to be a PPC risk factor (Gupta power in external validations (Nijbroek et al. 2019). In
et al. 2020), there were no significant differences be- Thailand, only 1 risk scoring system has been validated
tween its use and nonuse in terms of the PPC incidences for the prediction of respiratory complications after
in our study. One explanation is that NG decompression thoracic surgery in the Thai population (Pipanmekaporn
was not a routine procedure at our hospital during the et al. 2019). For our elderly patients undergoing upper
study period. A systematic review of prophylactic NG abdominal surgery, we used the ARISCAT scoring sys-
decompression after abdominal operations by Nelson tem as a tool to predict PPCs. The median ARISCAT
et al. reported that patients with selective NG tube usage scores for the non-PPC and PPC groups were 32 (18–
after laparotomies developed pneumonia and atelectasis 41) and 41 (34–52), respectively (P < 0.001). The pro-
less often than patients using NG tubes until gastrointes- portions of PPCs with low, intermediate, and high ARIS-
tinal motility returned (Nelson et al. 2005). With the CAT scores were 1.9%, 8.0%, and 17.7%, respectively.
presence of an NG tube, patients might not cough ef- Patients whose scores ranked in the intermediate-risk
fectively, resulting in secretion retention and atelectasis. level had an OR for pulmonary complications of 3.04
Furthermore, the tube can trigger silent aspiration and (95% CI, 1.53–6.03), while for those with scores in the
pneumonia as the lower esophageal sphincter cannot high-risk level, the OR was as high as 7.82 (95% CI,
work as it should (Mitchell et al. 1998). 3.90–15.70).
The lengths of hospital and ICU stays were longer for Table 5 showed that having an intermediate-scoring
PPC patients (Table 3). This would inevitably lead to ARISCAT in the major surgery subgroup was associated
higher costs for the patients, their families, and the with PPCs occurring twice as frequently as in the minor
healthcare system. A multicenter study concluded that surgery subgroup (10.2% vs. 5.3%). In the high-scoring
even mild PPC cases—such as atelectasis and the need ARISCAT, however, there was no significant difference
for prolonged oxygen therapy—were related to increases in the prevalence of PPCs (17.8% versus 17.3%).
in early postoperative mortality and extended ICU and A Pearson’s correlations analysis established a relation-
hospital stays. The researchers opined that all such cases ship between the ARISCAT scores and PPC incidence,
deserve attention and intervention (Fernandez-Busta- with a correlation coefficient of 0.226 (P < 0.001). Over-
mante et al. 2017). In our study, no deaths during the all, test accuracy was fair, with a value for the area under
perioperative period were directly attributable to PPCs. the curve of 0.72 (95% CI, 0.665–0.774; P < 0.001). Using
Patients might avoid moving or breathing deeply when a cutoff point at score 26 or analyzing the low-risk ver-
they feel pain or are uncomfortable, thereby possibly sus the intermediate-to-high-risk group, the ARISCAT
Nithiuthai et al. Perioperative Medicine (2021) 10:43 Page 10 of 12

score had a sensitivity of 91.8% (95% CI, 83.8–96.6%) Acknowledgements

and specificity of 36.6% (95% CI, 33.6–39.6%). The nega- This paper and the research behind it would not have been possible without
the generous support of the Siriraj Integrated Perioperative Geriatric
tive predictive value was as high as 98.2% (95% CI, 96.3– Excellent Research Center, Faculty of Medicine Siriraj Hospital, Mahidol
99.1%). At the cutoff score of 40, the sensitivity was University. We appreciate that Khanita Kasikan and Supaphn Noipitak, our
68.2%, while the specificity was 64.3%. colleagues at Mahidol University, collected the data enthusiastically and kept
our work on track. Dr. Orawan Supapueng’s exacting attention to detail and
As only 85 cases out of the 1100 patients in our study deep knowledge of statistical analysis greatly helped. We also gratefully
cohort developed PPCs, we could not establish a predict- acknowledge the professional language editing by Mr. David Park. Finally,
ive score that would demonstrate an effective power as Ms. Chusana Rungjindamai, a research coordinator, efficiently executed the
research tasks related to the preparation of this paper.
well as the ARISCAT scores presently do. The ARIS-
CAT scores did well as a screening tool for PPCs in our Authors’ contributions
patients. Those scores could therefore be applied to the AS initiated the project and supervised it throughout. RJ, SJ, and NH
collected and analyzed the patient data. JN and NT interpreted the data and
general Thai population and might be used in other
were major contributors to the writing of the manuscript. All authors read
Southeast Asian countries. and approved the final manuscript.

Funding
Limitations This research project was supported by the Siriraj Research Fund ([IO]
As this study involved a retrospective data collection, R016232015), Faculty of Medicine Siriraj Hospital, Mahidol University. This
funding source had no role in the design of the study; the collection,
some factors that might have affected the results could
analysis, and interpretation of the data; nor the writing of this manuscript.
not be controlled. In addition, we used the 2015 Euro-
pean Perioperative Clinical Outcome PPC definitions ra- Availability of data and materials
ther than those of the 2018 Standardized Endpoints for The data supporting the findings of this study are available from the Faculty
of Medicine Siriraj Hospital, Mahidol University. However, restrictions apply to
Perioperative Medicine: Core Outcome Measures in their availability: they were used under license for the current study and are
Perioperative and Anaesthetic Care. This is because the not publicly available. Data are available from the authors upon reasonable
former set of definitions covers all complications pre- request and with the permission of the Faculty of Medicine Siriraj Hospital,
Mahidol University.
dicted by the ARISCAT scoring system, whereas the lat-
ter definitions only consider four main complications Declarations
(Abbott et al. 2018).
Ethics approval and consent to participate
The ethics approval for this retrospective study was obtained from the Siriraj
Conclusions Institutional Review Board (Si 006/2019). The need for patient consent was
waived.
PPCs are common in elderly Thai patients, being found
in 7.7% of the study cohort. The factors affecting PPC Consent for publication
incidence that have acceptable adjusted ORs are pre- Not applicable.
operative oxygen saturation, albumin level, duration of
surgery, and emergency surgery. PPCs elevate the inci- Competing interests
The authors declare that they have no competing interests.
dence of postoperative morbidity of patients and extend
their lengths of ICU and hospital stays. It is appropriate Author details
1
to use the ARISCAT scoring system as a screening tool Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol
University, Bangkok, Thailand. 2Siriraj Integrated Perioperative Geriatric
to classify geriatric Thai patients into PPC risk groups. Excellent Research Center, Faculty of Medicine Siriraj Hospital, Mahidol
The system might be able to be similarly applied in University, Bangkok, Thailand.
other Southeast Asian countries.
Received: 25 February 2021 Accepted: 22 August 2021

Further research
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