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

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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

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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
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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

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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.
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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

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Patient-Related Risk Factors

• Chronic Lung Disease
• COPD the most commonly identified risk factor
• odds ratio 1.79

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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

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Patient-Related Risk Factors

• CHF
• significant risk factor
• odds ratio 2.93

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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

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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

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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

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Procedure-Related Risk Factors

• Surgical Site
• Increased risk
• AAA repair and vascular surgery
• Thoracic
• Abdominal
• Neurosurgery
• Head and neck surgery

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Procedure-Related Risk Factors

• Duration of Surgery
• Prolonged surgery 3-4 hours - independent
  predictor of postoperative pulm. complications
• odds ratio 2.14

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Procedure-Related Risk Factors

• Anesthetic Technique
• increased risk after GA (4 studies)
• odds ratio 1.83

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Procedure-Related Risk Factors

• Emergency Surgery
• significant predictor of postoper. pulm.
  complications (6 studies)
• odds ratio 2.21

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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)

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Laboratory Testing To Estimate Risk

• serum BUN gt21 mg /dl - risk factor

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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

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Table 5
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Table 6
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Table 7
Arozullah AM et al,Multifactorial risk factor
for predicting postoper.respiratory failure in
men after major noncardiac surgery Ann
Surg.2000232242-53.
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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

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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

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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

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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

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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.

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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

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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.

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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

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Strategies of Possible Benefit

• Laparascopic vs. open abdominal operations

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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)