Title: Perioperative Pulmonary Complications
1Perioperative Pulmonary Complications
- Dr. Behrooz Yaghchi,
- PGY 3 Anesthesiology
2Objectives
- Preoperative Risk Stratification
- Arouzalah respiratory failure index
- Strategies to reduce perioperative pulmonary
complications
3Postoperative pulmonary complications are as
common as cardiac complications for patients
undergoing non-cardiothoracic surgery.
4Postoperative 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
6Pulmonary 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
7The most important and morbid postoperative
pulmonary complications1. Atelectasis2.
Pneumonia3. Respiratory failure4.
Exacerbation of underlying chronic lung
disease
8Postoperative 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
9Postoperative 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.
10Preoperative Pulmonary Risk Stratification for
Noncardiothoracic Surgery Systematic Review for
the American College of Physicians
Gerald W. Smetana et al. Ann Inten
Med. 2006144575-580.
11Patient-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
12Patient-Related Risk Factors
- Chronic Lung Disease
- COPD the most commonly identified risk factor
- odds ratio 1.79
13Patient-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
14Patient-Related Risk Factors
- CHF
- significant risk factor
- odds ratio 2.93
15Patient-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
16Patient-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
17Patient-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
18Procedure-Related Risk Factors
- Surgical Site
- Increased risk
- AAA repair and vascular surgery
- Thoracic
- Abdominal
- Neurosurgery
- Head and neck surgery
19Procedure-Related Risk Factors
- Duration of Surgery
- Prolonged surgery 3-4 hours - independent
predictor of postoperative pulm. complications - odds ratio 2.14
20Procedure-Related Risk Factors
- Anesthetic Technique
- increased risk after GA (4 studies)
- odds ratio 1.83
21Procedure-Related Risk Factors
- Emergency Surgery
- significant predictor of postoper. pulm.
complications (6 studies) - odds ratio 2.21
22Laboratory 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)
23Laboratory Testing To Estimate Risk
- serum BUN gt21 mg /dl - risk factor
24Preoperative 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
25Table 5
26Table 6
27Table 7
Arozullah AM et al,Multifactorial risk factor
for predicting postoper.respiratory failure in
men after major noncardiac surgery Ann
Surg.2000232242-53.
28Strategies 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
29Strategies 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
30Strategies 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
31Strategies 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
32Reference
- 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.
33Strategies 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
34Strategies of Proven Benefit
- Good evidence suggests that lung expansion
therapy like - Incentive spirometry
- Deep breathing exercises
- CPAP
- reduces postoperative pulmonary risk after
abdominal surgery.
35Strategies 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
36Strategies of Possible Benefit
- Laparascopic vs. open abdominal operations
37Strategies 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)