postop pulmonary complications
TRANSCRIPT
PULMONARY COMPLICATIONS
POSTOPERATIVE
SANEESH P JSultan Qaboos University Hospital, Muscat
Respiratory complications after surgery
JACKSON EQUESTRIAN MONUMENT downtown Charlottesville, Virginia “Stonewall” Jackson
Confederate General
…dying of pneumonia 10 days after an otherwise successful ether anesthetic
1863
SIGNIFICANCE OF
PULMONARY COMPLICATIONS
POSTOPERATIVE
Lack of uniform definition
PneumoniaDefinite /Suspected Respiratory failure
Requiring mechanical ventilatory support
Bronchospasm
Lack of uniform definition
Unexplained fever
Excessive bronchial secretionsAbnormal breath sounds
“Productive” cough
Atelectasis
Hypoxemia
Cardiac / Pulmonary Complications?
Hospital stay
Complis05
10152025 22.7
9.610.75.7
PULMCARDIAC
Causes of
PULMONARY COMPLICATIONS
POSTOPERATIVE
Causes of PPCs
Disruption of normal activity of respiratory
muscles
Altered neural drive for respiration• Distribution• Timing
Causes of PPCs
Begins with induction of anesthesia
Continues into postop period
EXPIRATION
INSPIRATIONAWAKE
COORDINATED
INSPIRATIONANESTHETISED
INCOORDINATED
Incoordination of Resp Muscles
Reduces efficiency
Decreases FRC
Atelectasis in dependent lung
Impair pulmonary gas exchange
Effects of surgical trauma
Impair effectiveness
Voluntary limitation of respiratory motionDecreased phrenic
motor neuron output
Other factors
Bronchoconstriction • Airway instrumentation; drugs- release of
inflammatory mediatorsImpaired mucociliary transport• Anesthetic gases; tracheal intubationFunctional impairment of pulm inflammatory cells• Prolonged surgery, anesthesia
Surgical/anesth intervention related• Aspiration pneuminitis; ALI –after CPB;
Pneumothorax- barotrauma/surgical trauma; Negative Pr Pulm Edema
Risk factors for
PULMONARY COMPLICATIONS
POSTOPERATIVE
The most important risk factor for postoperative pulmonary complications?
A. High-risk surgical site
B. General anesthesia
C. COPD D. Obesity
GOOD evidencePatient-relatedAdvanced age
ASA PS >2
Cong Heart failureFunctional dependencyCOPD
Surgery-relatedAortic aneurysm repairThoracic surgery
Abdominal surgeryUpper abdominal surgeryNeurosurgery
Prolonged surgeryHead & Neck surgeryEmergency surgery
Vascular surgeryUse of General Anesthesia
FAIR evidence
Patient-relatedWeight-loss
Impaired sensorium
Cigarette use
Alcohol useAbnormal chest exam
Surgery-relatedPerioperative transfusion
Good evidence AGAINST being a risk factor
Patient-relatedWell-controlled asthmaObesity
Surgery-relatedHip surgery
GU/Gynaec surgery
Insufficient data
Patient-relatedObstructive sleep apnoea #Poor exercise capacity
Surgery-relatedEsophageal surgery
# - subsequent evidence : OSA – possible risk factor
Which of the following is a recently identified novel risk factor for PPCs?
C. Pulmonary Hypertension
B. Insulin-treated diabetes
A. Epidural anesthesia
D. Immobility
Strategies for risk reduction
PULMONARY COMPLICATIONS
POSTOPERATIVE
Strategies for Risk reduction
Postoperative lung expansion modalities• Incentive spirometry• Deep breathing exercises• Int. Positive Pressure
Breathing • CPAP
Strategies for Risk reduction
Selective postop NG tube useNG tubes potentially increase risk of aspirationUse in select patients:• Symptomatic abdominal distention• Inability to tolerate oral intake • Nausea
Strategies for Risk reduction
Laparoscopic (vs Open) operation
Evidence begins to follow intuitionOpen surgery:• Higher rate of sepsis• CV events
Strategies for Risk reduction
Routine TPN or enteral nutritionRight heart catheterization
While hypoalbuminemia and malnutrition increase postoperative complications, including pneumonia, routine TPN has no benefit over either TEN or no hyperalimentation.
Inadequate intake
Atrophy of intestinal villi
Bacterial translocation across
gut mucosa Subsequent sepsis
Strategies for Risk reduction
Intraop neuraxial blockadePostop epidural analgesia
Insufficient or conflicting data? Selection bias? Insufficiently powered study- Study on low-risk procedure
Strategies for Risk reduction
Intraop neuraxial blockadePostop epidural analgesia
IV PCA vs PCEA vs On-demand analgesia? Timing issues (Heparin prophylaxis)
Strategies for Risk reduction
Smoking cessation
The jury is still out!!!Early reports - those who quit shortly before surgery actually had higher complication rates Question remains unanswered
Promising New Intervention
PULMONARY COMPLICATIONS
POSTOPERATIVE
Preop Intensive Lung Expansion
Preoperative lung expansion Inspiratory Muscle Training
Preop Intensive Lung Expansion
Preop IMT can be done in chest physical therapy OPD or a pulmonary rehabilitation clinic
Take Home Messages
PULMONARY COMPLICATIONS
POSTOPERATIVE
Summary
PPCs incidence
More common than cardiac complications after non-cardiac surgery
Summary
Surgical site
Most important predictor of risk of PPCs:Aortic, thoracic and upper abdominal surgeries are high-risk procedures, even in healthy patients
Summary
OSA & Pulmonary HTN
Recently identified as risk factors;Limited available evidence does not support preop screening (in patients without symptoms)
Summary
Postop CPAP
Effective for reducing pulmonary complications in patients who are unable to perform deep breathing or incentive spirometry exercises
Summary
Smoking cessation
As an effective strategy to reduce pulmonary risk remains unanswered…
https://www.facebook.com/saneeshpj