Title: Intra-operative steroid use during pneumonectomy is not associated with increased bronchopleural fistulae or infectious complications
Authors: Kidane B, Kaaki S, Shen Y, Jacob N, Gupta V, Keshavjee S, , De Perrot M, Pierre A, Yasufuku K, Cypel M, Waddell T, Darling GE
  
Despite evidence suggesting that intra-operative steroid use may reduce the incidence of post-pneumonectomy ARDS, surgeons are reluctant to use intra-operative steroids because of concern about potential increased risk of bronchopleural fistula (BPF) and infectious complications. Our objective was to assess the safety of intra-operative steroid use during pneumonectomy with respect to BPF and infectious complications.
We performed a retrospective cohort study using prospectively collected data on consecutive pneumonectomies between 2005 and 2015. Anesthetic records were reviewed for type and dose of steroid administered intra-operatively. Univariable and multivariable analyses were performed.
Of the 251 pneumonectomies performed during the study period, 8 (3.2%) were performed for non-cancer indications and 121 (48.2%) were extrapleural pneumonectomies for mesothelioma or thymoma. Fifty-three patients (21.1%) were exposed to intra-operative steroids at the following doses: 92.4% (n= 49) dexamethasone (4-8mg IV), 7.5% (n=4) hydrocortisone (100mg IV) and 3.8% (n=2) methylprednisolone (1g IV).  BPFs were uncommon and occurred in 3.8% (n=2) of patients receiving intra-operative steroids versus in 3.0% (n=6) of those who did not (p=0.68). There was no difference in infectious complications between those who did (17.0%, n=9) and did not receive intra-operative steroids (11.6%, n=23) (p=0.35).  Non-cancer indication for resection was the only factor significantly associated with infectious complications on univariable (p=0.0001) and multivariable analyses (adjusted odds ratio [aOR]=13.83, 95%CI:3.01-63.57, p=0.001). Intra-operative steroid use was not significantly associated with infectious complications on multivariable analysis (aOR=0.96, 95%CI:0.31-2.97, p=0.95). There were no significant differences in 90-day mortality (p=0.51) and respiratory failure (p=0.19) rates between the 2 groups.
The use of intraoperative steroids during pneumonectomy appears reasonably safe, recognizing the limitation of sample size and a single center experience. Multicenter studies are required to evaluate the trade-offs between reducing respiratory/nausea complications and the potential for wound healing impairment.

Intra-Operative Steroid Use During Pneumonectomy is not Associated with Increased Bronchopleural Fistulae or Infectious Complications