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Risks for and Prevention of Pulmonary Complications in Non-Cardiac Surgery Patients

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%

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Risks for and Prevention of Pulmonary Complications in Non-Cardiac Surgery Patients

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  1. 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

  2. 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

  3. Independent Risk Factorsfor 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

  4. 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

  5. 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)

  6. Factors associated with aModerate 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

  7. Obesity Controlled Asthma Diabetes Mellitus Obstructive Sleep Apnea Chronic Steroid Use HIV Infection History of Cardiac Arrythmias Poor Exercise Tolerance Abnormal Pre-Op Spirometry No independent Risk ofPulmonary Complications

  8. 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

  9. Procedures not associated with increased risk • Esophageal Surgery • Gynecologic Surgery • Urologic Surgery • Hip Fracture Repair • Open vs. Laparascopic Procedures

  10. 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

  11. AAA Surgery (27) Thoracic Surg (21) Neurosurg (14) Upper Abd Surg (14) Vascular Surg (14) Neck Surg (11) Emergency Surg (11) Serum Alb <3.0 (9) BUN >30 (8) Dependency (7) Hx COPD (6) Age 70 or over (6) Age 60-69 (4) >40 pts: 26.6% risk 28-40 pts: 10.1% 20-27 pts: 4.2% 11-19 pts: 1.8% <10 pts: 0.5% Arozullah Respiratory Failure Index

  12. 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

  13. 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

  14. 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

  15. 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

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