Risks for and Prevention of Pulmonary Complications in Non-Cardiac - PowerPoint by djd18436

VIEWS: 69 PAGES: 15

									Risks for and Prevention
     of Pulmonary
 Complications in Non-
Cardiac Surgery Patients
           Robert Folzenlogen MD
   Assistant Professor of Clinical Medicine
     Hospitalist, University of Missouri
             Columbia, Missouri
    Pulmonary Complications in Non-
       Cardiac Surgery Patients

 Overall incidence: 6.8%
 Prolong hospitalization 2x cardiac compli-
  cations; LOS increase up to 6x expected
 Primary complications
    –   Atelectasis
    –   Pulmonary Infection
    –   Respiratory Failure/Prolonged Ventilation
    –   Bronchospasm
      Independent Risk Factors
    for Pulmonary Complications

 Age over 60
 History of COPD

 History of CHF

 Functional Dependence

 Tobacco cessation within past 8 weeks?

 ASA Class II or greater

 Serum Albumin < 3.5
   Serum Albumin and Surgical
       Complication Risk
 Gibbs et al., 1999 VA, n=54,000+
 Looked at age, functional status,
  emergency surgery, lab values
 Serum albumin was best predictor of
  morbidity/mortality in postop month
 Serum albumin also best predictor of
  postop infection/sepsis
 Low albumin: 5x fail to wean, 4x
  postop pneumonia, 3x reintubation
Surgical Risk in COPD Patients

 Definition: FEV1< 50% Predicted
 Pulmonary Complication risk increase
  of 2-6x
 Overall surgical complication rate of
  56% in major abdominal procedures
 Overall surgical complication rate of
  38% for procedures > 2 hrs (73% if
  > 4 hrs)
     Factors associated with a
     Moderate Increase in Risk

 Chronic Tobacco or Alcohol Use
 Altered Mental Status

 Weight Loss (>10% in last 6 months)

 History of CVA

 Clinical Chest Findings/Abnormal CXR

 BUN > 21

 Perioperative Transfusion
      No independent Risk of
     Pulmonary Complications

 Obesity              HIV Infection
 Controlled Asthma    History of Cardiac

 Diabetes Mellitus     Arrythmias
 Obstructive Sleep    Poor Exercise

  Apnea                 Tolerance
 Chronic Steroid      Abnormal Pre-Op

  Use                   Spirometry
     Procedure-related Risk
 Procedures  lasting > 3 hours
 Emergency Surgery
 Aortic/Vascular Surgery
 Thoracic or Upper Abdominal Surgery
 Neurosurgery
 Neck Surgery
 General Anesthesia
 Use of Long-acting NM blockade
  Procedures not associated with
         increased risk

 Esophageal  Surgery
 Gynecologic Surgery

 Urologic Surgery

 Hip Fracture Repair

 Open vs. Laparascopic Procedures
  Respiratory Failure Index
Arozullah et al., VA, 2000, n=81,719
men
Prospective of Major Non-Cardiac
Surgery
Excluded: DNR, Comatose, Ventilator
Dependent
Postop Resp Failure (3.4%) – need
for vent >48hrs or reintubation
Arozullah Respiratory Failure Index
   AAA Surgery (27)         Dependency (7)
   Thoracic Surg (21)       Hx COPD (6)
   Neurosurg (14)           Age 70 or over (6)
   Upper Abd Surg (14)      Age 60-69 (4)
   Vascular Surg (14)
   Neck Surg (11)           >40 pts: 26.6% risk
   Emergency Surg (11)      28-40 pts: 10.1%
   Serum Alb <3.0 (9)       20-27 pts: 4.2%
   BUN >30 (8)              11-19 pts: 1.8%
                             <10 pts: 0.5%
        Recommended Pre-Op
      Assessment and Intervention
   PFTs only:
    – Before lung resection to estimate postop lung
      volumes
    – To maximize preop control of COPD/asthma
    – To investigate cause of dyspnea/exercise
      intolerance
 Tobacco cessation – only if >8weeks
  before surgery
 Optimize medication regimen for COPD or
  asthma
PreOp testing/interventions with no
proven value to assess/reduce risk

 Routine spirometry
 Routine ABGs

 Routine CXR (controversial for age >50)

 Right Heart Catheterization

 Routine TPN or Enteral Supplementation

 Pulmonary Artery Catheter
   Post-Op recommendations to
 reduce Pulmonary Complications

 Deep   Breathing Exercises/Incentive
  Spirometry
 CPAP – if patient cannot cooperate
  for I.S.
 Avoid routine use of NG tubes

 Adequate Pain Control
                         References
   Qaseen, Amir et al., Risk Assessment for and Strategies to Reduce
    Perioperative Complications for Patients Undergoing Noncardiothoracic
    Surgery: A Guideline from the ACP; Annals of IM 144, No.8, 575-580,
    4/18/06
   Smetana MD, Gerald W. et al., Preoperative Pulmonary Risk Stratification
    for Noncardiothoracic Surgery: Systemic Review for the ACP; Annals of IM
    144, No.8, 581-595, 4/18/06
   Arozullah, Ahsan M. et al., Multifactorial Risk Index for Predicting
    Postoperative Respiratory Failure in Men after Major Non-Cardiac Surgery,
    Annals Surgery, 2000:232, pgs 242-253
   Smetana, Gerald, Preoperative Pulmonary Evaluation: Identifying and
    Reducing Risks for Pulmonary Complications, Cleveland Clinic J. Medicine,
    Supplement 73, pages 36-41, 3/06
   Gibbs J. et al., Preoperative Serum Albumin Level as a Predictor of
    Operative Morbidity and Mortality: Results from the National VA Surgical
    Risk Study, Archives of Surgery, 1999, 134:36-42
   McAlister, F.A. et al. Incidence of and Risk Factors for Pulmonary
    Complications after Non-Thoracic Surgery, Am J Resp Critical Care Med,
    171:514-517, 3/05
   Kroenke, LTC Kurt et al., Operative Risk in Patients with Severe COPD,
    Archives of IM, 152:967-971, 5/92

								
To top