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Ann Thorac Surg 2008;86:1060. doi:10.1016/j.athoracsur.2008.05.030
© 2008 The Society of Thoracic Surgeons
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Correspondence

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Dana M. Radu, MDa, Françoise Jauréguy, Pharm Db, Emmanuel Martinod, MD, PhDa

a Department of Thoracic and Vascular Surgery, Avicenne Hospital, Assistance Publique des Hôpitaux de Paris, Paris XIII University, Bobigny, 93009 France
b Department of Microbiology and Hygiene, Avicenne Hospital, Assistance Publique des Hôpitaux de Paris, Paris XIII University, Bobigny, 93009 France

(Email: danabudescu{at}gmail.com).

To the Editor:

We would like to thank Dr Terzi and coworkers [1] for their valuable comments, which bring into discussion the role of tracheobronchial aspiration of gastric content in the development of postoperative pulmonary injury.

In our practice, gastrointestinal management of patients is in accordance to the prophylactic measures for aspiration [2] (ie, fasting from midnight for morning surgery, light breakfast for afternoon-scheduled operations, nothing by mouth the day of the operation, and diet advanced as tolerated starting from the first postoperative day). Certain measures are not standardized but are particularly applied to patients at high risk for aspiration, as the intraoperative placement of a nasogastric tube, which are usually removed at the end of the operation, and as the prophylactic use of H2-inhibitors or proton-pump inhibitors. Special attention is given to prolonged or inappropriate use of some of these measures, as they may actually promote gastric colonization with micro-organisms, as is the case of antacids [3], and thus, by aspiration, increase the risk of postoperative respiratory tract infections.

Despite these measures, in our study [4], aspiration could have been the initial event in the development of a number of microbiologically documented cases of postoperative pneumonia. Moreover, the possibility that some of the microbiologically nondocumented cases of pneumonia might actually be acid-associated aspiration pneumonitis can not be excluded. This might have led to an overestimation of the total incidence of pneumonia. Unfortunately, this information is difficult to acquire with certainty in a retrospective study.

Regardless of the pathogenic mechanism involved, our study showed that the antibiotic prophylaxis by first generation cephalosporins was not adapted to microorganisms recovered from patients with postoperative pneumonia.

We are well aware that in the effort to reduce the incidence of postoperative pneumonia it is essential to counterbalance all pathogenic factors involved. Therefore, every element has its rightful place in the battle (ie, pre-emptive gastrointestinal tract management, pain control, chest physical therapy, and early ambulation, as well as adapted antibiotic prophylaxis).


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 References
 

  1. Terzi A, Luzzi L, Campione A, Gorla A. Postoperative pneumonia after major pulmonary resections: the importance of gastrointestinal tract management (letter) Ann Thorac Surg 2008;86:1059-1060.[Free Full Text]
  2. Kalinowski CP, Kirsch JR. Strategies for prophylaxis and treatment for aspiration Best Pract Res Clin Anaesthesiol 2004;18:719-737.[Medline]
  3. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing health-care-associated pneumonia, 2003. CDC, Healthcare Infection Control Practices Advisory Committeehttp://www.cdc.gov/ncidod/dhqp/pdf/guidelines/CDCpneumo_guidelines.pdf 2008Accessed March 29.
  4. Radu DM, Jauréguy F, Seguin A, et al. Postoperative pneumonia after major pulmonary resections: an unsolved problem in thoracic surgery Ann Thorac Surg 2007;84:1669-1674.[Abstract/Free Full Text]

Related Article

Postoperative Pneumonia After Major Pulmonary Resections: The Importance of Gastrointestinal Tract Management
Alberto Terzi, Luca Luzzi, Andrea Campione, and Alberto Gorla
Ann. Thorac. Surg. 2008 86: 1059-1060. [Extract] [Full Text] [PDF]




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