Objectives: In ESTS survey about management of malignant pleural effusions (MPE), 56% of respondents were not informed of any relevant clinical guidelines, 52% declared the need of updating or revision of guidelines. The ESTS Pleural Diseases Working Group developed a project quality analysis of previous guidelines on MPE management. Methods: Appraisal-of-Guidelines-for-Research-and-Evaluation (AGREE-II) instrument was used to assess each guideline. The purpose of the AGREE II is to provide a

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... amework to evaluate quality of guidelines, methodological strategy for development of guidelines, guidance on content and best reporting strategy. Each item was scored on a 7-point scale. Results: Five out of 6 guidelines (83%) were produced by multinational collaborations (29 countries). A governmental organisation was involved in 2 (33%) guidelines and a scientific society in 5 (83%). Two areas that received best score were clarity of presentation and scope and purpose. Applicability of guideline had lowest score. Involvement of stakeholders was strongly correlated with the rigour of development (rho=0.92) and clarity of presentation (rho=0.96). Rigour of development was strongly correlated with clarity of presentation (rho=0.93). The scores for 2 domains, rigour of development and clarity of presentation, were influenced by 2 factors: international guidelines for the rigour of development and international guidelines for clarity of presentation. International guidelines also had a positive influence on scope and purpose. Multivariate analysis showed that for the clarity of presentation, the international guidelines and the publication hrough scientific journal were related to improved scores. Conclusions: Quality of guidelines assessed by AGREE-II was extremely variable with relatively low average scores. Guidelines achieving higher AGREE II scores were from European Union with direct involvement of scientific societies in development. It was recognised that fundamental unanswered questions remain about MPE management. Disclosure: No significant relationships. Objectives: Failure to rescue (FtR) measures the ability of treating postoperative complications to prevent death and is an important indicator of patient safety. While variability in postoperative mortality is well documented in patients undergoing VATS anatomic lung resection, FtR is poorly researched. This analysis aims to evaluate FtR and its risk factors in a single centre experience. Methods: All patients undergoing VATS anatomic lung resection between 2009 and 2016 were included. FtR was analysed for different groups of complications: (i) any complication, (ii) pulmonary complications (airleak >5 days, pneumonia, atelectasis requiring bronchoscopy, reintubation, ARDS, pneumothorax, respiratory failure), (iii) major complications (reintubation, ARDS, pulmonary embolism, myocardial infarction, pneumonia, bronchopleural fistula), (iv) pneumonia and (v) atrial arrhythmia. Results: In total, 508 consecutive patients were included. 30.9% (157 patients) developed postoperative complications: pneumonia in 5.1% (26/508), pulmonary complications in 18.3% (93/508), major complications in 5.3% (27/508), atrial arrhythmia in 3.3% (17/508). Six patients (1.2%) died postoperatively, accounting for a FtR rate of 3.8%. Complications occurring in these patients were pneumonia in 4, pulmonary complications in 5 (ARDS in 4), major complications in 5 and atrial fibrillation in 2, with correlating FtR rates of 15.4%, 5.3%, 18.5% and 5.9%, respectively. Of note, 3/6 (50%) patients who died were patients after solid organ transplantation. Conclusions: Perioperative complications do occur irrespective of the extent of surgery. When compared to the scarce literature available, our complication rate seems acceptable, but even with low mortality rates, FtR rates appear to be increased. Therefore, FtR has to be interpreted with care when matched with other institutions. However, analyzing the ability of a hospital to treat complications is important to align efforts to improve patient safety. As a direct effect of this study, we are currently restructuring treatment algorithms for NSCLC patients after solid organ transplantations and patients with early signs of respiratory failure. Disclosure: No significant relationships. P-170 Objectives: Transfusion of blood products has been associated with increased risk of post-pneumonectomy respiratory failure. It is unclear whether intra-or postoperative transfusions confer higher risk of respiratory failure. Our objective was to assess the role of transfusions in developing post-pneumonectomy respiratory failure. Methods: We performed a retrospective cohort study using prospectivelycollected data on consecutive pneumonectomies (2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015). Patient records were reviewed for intra-/postoperative exposures. Univariable and multivariable analyses were performed. Results: Of the 251 pneumonectomies performed during the study period, 24 (9.6%) patients suffered respiratory failure. Ninety-day mortality was 5.6% (n = 14) and was more likely in patients with respiratory failure (7/24 vs 7/227, P < 0.001). Intraoperative and postoperative transfusions occurred in 42.2% (n = 106) and 44.6% (n = 112) of patients respectively and were predominantly red blood cells. On univariable analysis, both intraoperative (P=0.03) and postoperative transfusion (P=0.004) were associated with higher risk for respiratory failure. The multivariable model significantly predicted respiratory failure with an AUC=0.88 (P=0.001). On multivariable analysis, the only independent predictors of respiratory failure were postoperative transfusions (adjusted odds ratio [aOR]=6.54, 95% CI 1.74-24.59, P=0.005) and lower preoperative FEV1 (aOR=0.96, 95% CI 0.93-0.99, P=0.03). Estimated blood loss (EBL) was not significantly different (P=0.91) between those with (median=800 ml, interquartile range 300-2000 ml) and without respiratory failure (median=800 ml, nterquartile range 300-2000 ml). Conclusions: Respiratory failure occurred in 9.6% of patients postpneumonectomy and confers higher risk of 90-day mortality. Postoperative (but not intraoperative) transfusion was the strongest independent predictor of respiratory failure. EBL is not significantly different between those with and without respiratory failure, thus our findings are not likely due to confounding relationships between increased intraoperative bleeding complications, reactionary transfusions and respiratory failure. Intraoperative transfusion may be in reaction to active/unpredictable blood loss and may not be easily modifiable. However, postoperative transfusion may be modifiable and potentially avoidable. Transfusion thresholds should be assessed in light of potential costbenefit trade-offs.