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Perioperative Pulmonary Complications

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Title: Perioperative Pulmonary Complications


1
Perioperative Pulmonary Complications
  • Dr. Behrooz Yaghchi,
  • PGY 3 Anesthesiology

2
Objectives
  • Preoperative Risk Stratification
  • Arouzalah respiratory failure index
  • Strategies to reduce perioperative pulmonary
    complications

3
Postoperative pulmonary complications are as
common as cardiac complications for patients
undergoing non-cardiothoracic surgery.
4
Postoperative pulmonary complications
  • 5- 10 all surgical patients
  • 9- 40 after abdominal surgery Wong et
    al.Factors associated with postoper. pulmonary
    complications in patients with severe COPD.
    Anesthesia Analgesia 199580276-284.

5
  • Postoperative pulmonary complications are
    equally prevalent and contribute similarly to
    morbidity, mortality and length of stay as
    cardiac complications

6
Pulmonary complications may even be more likely
than
cardiac
complications to predict long-term mortality
after surgery, particularly among older
patients.Qassem A et al. Guideline from the
American College of Physicians. Ann Intern Med.
2006
7
The most important and morbid postoperative
pulmonary complications1. Atelectasis2.
Pneumonia3. Respiratory failure4.
Exacerbation of underlying chronic lung
disease
8
Postoperative respiratory failure (PRF)
  • the most serious postoperative complication
  • inability to be extubated 48 hours or (some
    experts) up to 5 days postoperatively
  • Unplanned intubation after surgery

9
Postoperative respiratory failure (PRF)
  • After AAA , the rate of PRF is 5-21 , depending
    on the type of aneurysm
  • the in-hospital death rate is 40-42 vs. 6 for
    those without PRF

Money SR et al.Risk of respiratory failure after
repair of thoracoabdominal aortic aneurysms.Am J
Surg 1994168152-155.
10
Preoperative Pulmonary Risk Stratification for
Noncardiothoracic Surgery Systematic Review for
the American College of Physicians
Gerald W. Smetana et al. Ann Inten
Med. 2006144575-580.
11
Patient-Related Risk Factors
  • Age
  • Studies showed
  • age was a significant risk predictor
  • the second most commonly identified risk factor
  • 60-69 years of age- odds ratio 2.09
  • 70-79 years of age-odds ratio 3.04

12
Patient-Related Risk Factors
  • Chronic Lung Disease
  • COPD the most commonly identified risk factor
  • odds ratio 1.79

13
Patient-Related Risk Factors
  • Cigarette Use
  • increase in risk for postoperative pulmonary
    complications among current smokers
  • odds ratio 1.26
  • No paradoxical increase in pulm. complications
    among smokers who have recently quit smoking (1w-
    2 mo)
  • Barrera R et al, Chest 2005

14
Patient-Related Risk Factors
  • CHF
  • significant risk factor
  • odds ratio 2.93

15
Patient-Related Risk Factors
  • Functional Dependence
  • Total dependence (inability to perform any
    activities of daily living)odds ratio 2.51
  • Partial dependence (need for equipment or devices
    and assistance from another person for some
    activities of daily living)
  • odds ratio 1.65

16
Patient-Related Risk Factors
  • ASA Classification and postoperative pulmonary
    complication rates
  • Class I 1.2 Class
    II 5.4 Class III 11.4 Class
    IV 10.9

17
Patient-Related Risk Factors
  • Obesity - no increased risk, even for patients
    with morbid obesity
  • Asthma - not a risk factor for postoperative
    pulmonary complications
  • OSA - complication rates may be higher, but this
    needs to be confirmed by more studies

18
Procedure-Related Risk Factors
  • Surgical Site
  • Increased risk
  • AAA repair and vascular surgery
  • Thoracic
  • Abdominal
  • Neurosurgery
  • Head and neck surgery

19
Procedure-Related Risk Factors
  • Duration of Surgery
  • Prolonged surgery 3-4 hours - independent
    predictor of postoperative pulm. complications
  • odds ratio 2.14

20
Procedure-Related Risk Factors
  • Anesthetic Technique
  • increased risk after GA (4 studies)
  • odds ratio 1.83

21
Procedure-Related Risk Factors
  • Emergency Surgery
  • significant predictor of postoper. pulm.
    complications (6 studies)
  • odds ratio 2.21

22
Laboratory Testing To Estimate Risk
  • Albumin level lt 35 g/L - powerful marker of
    increased risk for postoper. pulmonary
    complications
  • odds ratio 2.53
  • Albumin should be measured in all patients, who
    are clinically suspected of having
    hypoalbuminemia and having 1 or more another risk
    factors
  • The most important predictor of 30-day perioper.
    Morbidity and mortality (National VA Surgical
    Risk Study)

23
Laboratory Testing To Estimate Risk
  • serum BUN gt21 mg /dl - risk factor

24
Preoperative testing
  • Rarely provided unexpected information that
    influences preop. Management
  • Most abnormalities can be predicted by history
    and PE
  • Joo HS et al. Can J Anesth. 2005
  • Chest X-ray
  • should not be used routinely
  • helpful for patients with cardiopulm. disease or
    gt 50 years of age undergoing upper abdominal,
    thoracic, or AAA repair
  • Spirometry
  • should be reserved for undiagnosed COPD patients

25
Table 5
26
Table 6
27
Table 7
Arozullah AM et al,Multifactorial risk factor
for predicting postoper.respiratory failure in
men after major noncardiac surgery Ann
Surg.2000232242-53.
28
Strategies to reduce postoperative pulmonary
complications
  • Smoking cessation for 8 weeks
  • Inhaled ipratropium or tiotropium in clinically
    significant COPD
  • Inhaled beta-agonists in COPD or asthma who have
    wheezes or dyspnea

29
Strategies to reduce postoperative pulmonary
complications
  • Preop. Corticosteroids in non-optimized COPD or
    asthma
  • Delay elective surgery if resp. infection present
  • Antibiotics for patients with infected sputum
  • Patient education regarding lung expansion
    maneuvers

30
Strategies to reduce postoperative pulmonary
complications
  • Choose alternative procedure lt 3-4 hours duration
    if possible
  • Minimize duration of anesthesia
  • Surgery other than upper abdominal or thoracic
    when possible ?
  • Regional anesthesia in high-risk patients

31
Strategies to reduce postoperative pulmonary
complications
  • Avoid use of pancuronium in high-risk patient
    (residual blockage)
  • Postoperative epidural pain management seems
    superior to other routes of delivering opioids
  • Choosing laparascopic vs. open abdominal may be
    beneficial (futher studies need)
  • Periop. pulmonary artery catheterization is not
    beneficial

32
Reference
  • Lawrence,VA , Cornell, JE, Smetana, GW.
    Strategies to Reduce Postoperative Pulmonary
    Complications after noncardiothoracic surgery
    systematic review for the American College of
    Physicians. Ann Intern Med 2006144596.

33
Strategies of No Benefit
  • Good evidence indicates
  • Routine TPN or enteral hyperalimentation
    nutrition (except for patients with severe
    malnutrition)
  • Pulmonary artery catheter
  • doesnt reduce risk of pulmonary complications

34
Strategies of Proven Benefit
  • Good evidence suggests that lung expansion
    therapy like
  • Incentive spirometry
  • Deep breathing exercises
  • CPAP
  • reduces postoperative pulmonary risk after
    abdominal surgery.

35
Strategies of Probable Benefit
  • Fair evidence suggests
  • selective nasogastric tube decompression after
    abdominal surgery
  • Use of short-acting neuromuscular blocking
    agents
  • reduce risk for pulmonary complications

36
Strategies of Possible Benefit
  • Laparascopic vs. open abdominal operations

37
Strategies of Unclear Benefit
  • Smoking cessation within 2 months of surgery
  • Intraoperative epidural anesthesia and
    postoperative epidural analgesia
  • (more good-quality efficacy trials of sufficient
    size are needed)
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