Preoperative PulmonaryCardiac Criteria

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Pre-operative Pulmonary/Cardiac Criteria

• Josh Adams
• Nathan DeWitt

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Definition of Post-Op Pulmonary Complications

• Pulmonary abnormality that produces identifiable
  disease or dysfunction that is clinically
  significant and adversely affects the clinical
  course

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Categories of Clinically Significant Complications

• Atelectasis
• Infection, including bronchitis and pneumonia
• Prolonged mechanical ventilation and respiratory
  failure
• Exacerbation of underlying chronic lung disease
• Bronchospasm

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Peri-operative lung physiology Thoracic and
Abdominal Surgery

• Vital capacity (VC) is reduced by 50 to 60
  percent and may remain decreased for up to one
  week
• Functional residual capacity (FRC) is reduced by
  about 30 percent
• Diaphragmatic dysfunction appears to play the
  most important role in these changes
• Reduction of the FRC below closing volumes
  contributes to the risk of atelectasis,
  pneumonia, and ventilation/perfusion (V/Q)
  mismatching
• Residual effects of anesthesia itself and
  postoperative opioids both depress the
  respiratory drive
• Inhibition of cough and impairment of mucociliary
  clearance- Increased risk of infection

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Patient Related Risk Factors

• Definite Risk Factors
• Upper abdominal and thoracic surgery lasting
  greater than three hours
• Chronic obstructive lung disease
• Smoking hx within past 8 weeks
• Use of pancuronium as a neuromuscular blocker
• Probable Risk Factors
• General Anesthesia (when compared to spinal or
  epidural anesthesia)
• Emergency surgery
• PaCO2 gt 45 mm Hg
• Possible Risk Factors
• Current upper respiratory tract infection
• Abnormal chest x-ray
• Age gt65
• Peri-operative NG tube placement

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Pre-operative Risk Assessment

• Complete HP is most important tool for
  evaluation risk assesement
• Significant risk factors should be identified
• Physical examination should be directed toward
  evidence for obstructive lung disease
• Laboratory tests serve as adjuncts to the
  clinical evaluation and should be obtained only
  in selected patients
• Pulmonary function tests (PFTs)
• Arterial blood gas analysis
• Chest radiographs
• Exercise testing

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Recommended Strategies

• Preoperative Strategies
• Smoking cessation for 8 weeks
• Inhaled ipratropium for all patients with
  clinically significant COPD
• Inhaled beta-agonists for patients with COPD or
  asthma who have wheezes or dyspnea
• Preoperative corticosteriods for patients with
  COPD or asthma who are not optimized to best
  baseline and whose airway obstruction has not
  been maximally reduced
• Delay elective surgery if respiratory infection
  present
• Antibiotics for patients with infected sputum

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Recommended Strategies Cont.

• Intraoperative Strategies
• Choose alternative procedure lasting less than 3
  to 4 hours when possible
• Minimize duration of anesthesia
• Surgery other than upper abdominal or thoracic
  when possible
• Choose laparoscopic rather than open abdominal
  surgery when possible
• Regional anesthesia (nerve block) in very
  high-risk patients
• Epidural or spinal anesthesia in lieu of general
  anesthesia in high risk patients
• Avoid use of pancuronium as a muscle relaxant in
  high risk patients

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Recommended Strategies Cont.

• Postoperative Strategies
• Deep breathing exercises or incentive spirometry
  in high risk patients
• Epidural analgesia in lieu of parenteral opioids
• Continuous positive airway pressure (CPAP)

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Perioperative Cardiac Risk

• Each year approximately 50,000 patients have
  perioperative MIs, and about 40 of them will
  die
• Most perioperative MIs occur without the typical
  chest pain, due to analgesics after surgery,
  residual effects from the anesthesia, and other
  perioperative painful stimuli

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Periop Cardiac Risk

• In studies evaluating incidence of MI after
  general anesthesia for patients who previously
  had an MI within 3 months, there was a
  reinfarction rate of 27-37. Reinfarction was
  11-16 for those who had an MI 3-6 months
  previously.
• Reinfarction rate remained stable at 5 for those
  who had an MI gt6 months previous to surgery.

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• In 1977 Goldman and colleagues developed a preop
  cardiac risk index for patients undergoing
  non-cardiac surgery. They reported nine
  variables associated with an increased risk for
  perioperative cardiac complications.
• Each risk factor was assigned a point score, and
  patients were stratified into four risk
  categories based on their total points.

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Goldman Preop Cardiac Risk Index

• 9 Individual risk factors and their scores are as
  follows

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Goldman Criteria Results

• Patients with scores gt25 had a 56 incidence of
  death, with a 22 incidence of severe
  cardiovascular complications
• Patients with scores lt26 had a 4 incidence of
  death, with a 17 incidence of severe
  cardiovascular complications.
• Patients with scores lt6 had a 0.2 incidence of
  death, with a 0.7 incidence of severe
  cardiovascular complications.

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Detskys Modified Cardiac Risk Index

• In 1986 Detsky and colleagues modified the
  original multifactorial index by adding variables
  such as angina and pulmonary edema.
• Patients are stratified into three risk
  categories based on their total points

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ACP guidelines