• Luca J Wachtendorf, Elena Ahrens, Aiman Suleiman, Dario von Wedel, Tim M Tartler, Maíra I Rudolph, Simone Redaelli, Peter Santer, Ricardo Munoz-Acuna, Abeer Santarisi, Harold N Calderon, Michael E Kiyatkin, Lena Novack, Daniel Talmor, Matthias Eikermann, and Maximilian S Schaefer.
• Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, United States of America; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, 375 Longwood Avenue, Boston, MA 02215, United States of America. Electronic address: lwachte1@bidmc.harvard.edu.
• J Clin Anesth. 2024 Nov 1; 98: 111567111567.

Study ObjectiveA low dynamic driving pressure during mechanical ventilation for general anesthesia has been associated with a lower risk of postoperative respiratory complications (PRC), a key driver of healthcare costs. It is, however, unclear whether maintaining low driving pressure is clinically relevant to measure and contain costs. We hypothesized that a lower dynamic driving pressure is associated with lower costs.DesignMulticenter retrospective cohort study.SettingTwo academic healthcare networks in New York and Massachusetts, USA.Patients46,715 adult surgical patients undergoing general anesthesia for non-ambulatory (inpatient and same-day admission) surgery between 2016 and 2021.InterventionsThe primary exposure was the median intraoperative dynamic driving pressure.MeasurementsThe primary outcome was direct perioperative healthcare-associated costs, which were matched with data from the Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP-NIS) to report absolute differences in total costs in United States Dollars (US$). We assessed effect modification by patients' baseline risk of PRC (score for prediction of postoperative respiratory complications [SPORC] ≥ 7) and effect mediation by rates of PRC (including post-extubation saturation < 90%, re-intubation or non-invasive ventilation within 7 days) and other major complications.Main ResultsThe median intraoperative dynamic driving pressure was 17.2cmH2O (IQR 14.0-21.3cmH2O). In adjusted analyses, every 5cmH2O reduction in dynamic driving pressure was associated with a decrease of -0.7% in direct perioperative healthcare-associated costs (95%CI -1.3 to -0.1%; p = 0.020). When a dynamic driving pressure below 15cmH2O was maintained, -US$340 lower total perioperative healthcare-associated costs were observed (95%CI -US$546 to -US$132; p = 0.001). This association was limited to patients at high baseline risk of PRC (n = 4059; -US$1755;97.5%CI -US$2495 to -US$986; p < 0.001), where lower risks of PRC and other major complications mediated 10.7% and 7.2% of this association (p < 0.001 and p = 0.015, respectively).ConclusionsIntraoperative mechanical ventilation targeting low dynamic driving pressures could be a relevant measure to reduce perioperative healthcare-associated costs in high-risk patients.Copyright © 2024. Published by Elsevier Inc.

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