2. Case of Mr. Lung
• 78 year old man
• L3-5 laminectomy and fusion, which will take 4 hours
• Severe COPD, diabetes, and hypertension, 40 pack-years but quit 2 yrs ago
• Takes tiotropium, lisinopril, metformin.
• Dyspneic when hurrying on level ground or walking up a hill, at his baseline
(mMRC). Functionally independent.
• Resting O2 sat 95%. Normal work of breathing. Slightly diminished breath
sounds, no wheezes. Cardiovascular exam is normal. Mental status is
normal.
• Hgb 13, BUN 15, Cr 0.8, Albumin 3.5
3. Preoperative evaluation overview
• Determine and mitigate surgical risk
• Assess and optimize medical conditions
• Perform preoperative testing
• Manage medications perioperatively
4. Postoperative pulmonary complications (PPC)
are a big problem
• Postop pulmonary vs cardiac complications
• At least as common
• More costly
• Longer length of stay
• Rate of complications across all types of surgery is 6.8%
Smetana et al. Ann Intern Med. 2006;144(8):581.
5. Risk factors for PPC
• Patient-related risk factors
• Age
• General health status (ASA Class, Functional status)
• Smoking
• Cardiopulmonary disease (Heart failure, PH, COPD, Asthma, OSA, infection)
• Metabolic factors
• Procedure-related factors
• Site
• Duration
• Anesthesia
6. Risk factors for PPC
PATIENT
Risk Factors
Adjusted OR
Functional
dependence
Total 4.07-4.33
Partial 1.93-2.16
Age 60-69 2.09
>70 3.04
OSA 1.86-2.46
COPD 1.79
ASA class (>=4) 1.28
Smoking 1.26
PROCEDURAL
Risk Factors
Adjusted OR
Aortic 2.94
Foregut/hepatobiliary 2.64
Surgical site Brain 2.08
Other abdominal 1.27-1.78
ENT 1.11
Prolonged (>2 hours) 2.21
Emergency surgery 2.21
General anesthesia 1.83
8. ARISCAT
2500 patients
59 centers in Spain
Arozullah
82,000 pts – Resp failure
160,000 pts - Pneumonia
VA NSQIP
Gupta
211,000 pts
Resp failure and
pneumonia
ACS NSQIP
ACS NSQIP Universal
Calculator
1.4 Million patients
ACS NSQIP
9. Comparison of Risk Models
ARISCAT - Overall
Age
Preop SpO2
Resp infection w/in 1 mo
Preop hemoglobin <=10
Type of surgery
Duration of surgery
Emergency procedure
Arozullah – Resp failure
Age
History of COPD
Dependent functional status
BUN >30
Albumin <3
Type of surgery
Emergency procedure
Arozullah - Pneumonia
Age
History of COPD
Dependent functional status
History of stroke
Weight loss >10% in 6mo
Impaired sensorium
Current smoker within 1yr
Alcohol >2/d past 2 wks
Steroid for chronic condition
Transfusion >4 units
BUN
General anesthesia
Type of surgery
Gupta – Respiratory failure
Dependent functional status
ASA class
Preoperative sepsis
Type of surgery
Emergency surgery
Gupta - Pneumonia
Age
History of COPD
Dependent functional status
ASA class
Preoperative sepsis
Type of surgery
Smoking before operation
3% of patients develop postop respiratory failure
25% of these patients die within 30 days
10. Preoperative evaluation overview
• Determine and mitigate surgical risk
• Assess and optimize medical conditions
• Perform preoperative testing
• Manage medications perioperatively
12. Condition-specific evaluation
• Asthma only a risk factor when not well-controlled
• More than 2 symptoms or albuterol uses per week or 2 exac/yr is not well controlled
• Any recent ED or office visits, rescue inhaler within the last month?
• Peak flow measurement
• COPD
• Recent respiratory infection?
• No lower limit of FEV1 where surgery cannot be performed
• Obstructive sleep apnea
• Screening with STOP-BANG criteria1
• Increased PPCs if score >=52
• Smoking
• Current smoking increases risk
• Cessation 2-4 weeks: OR 0.99 compared to non-smokers3
• Pulmonary hypertension
• Especially with history of PE, OSA, poor functional status
• Interstitial lung disease
• Worse dyspnea, higher PCO2/PO2, low DLCO, FEV1 or FCV <60% all higher risk
• Complications less than those seen in COPD
1Joshi GP et al. Anesth Analg. 2012;115(5):1060-68.
3Jung KH et al. Gastric Cancer 2014.
Snoring loudly
Tired during the day
Observed apnea
Pressure high (HTN)
BMI > 35
Age > 50
Neck > 40cm
Gender=Male
2Chung F et al. Chest. 2013; 143(5):1284-93.
13. Preoperative evaluation overview
• Determine and mitigate surgical risk
• Assess and optimize medical conditions
• Perform preoperative testing
• Manage medications perioperatively
14. Preoperative Testing
• FEV1 correlates with rate of complications, but to a small degree
• Studies mixed; do not clearly show superior predictive value over H&P
• Reasonable to get in 1) unexplained dyspnea, or 2) if control of COPD/Asthma
unclear
• Value of screening CXR has been questioned
• Rates of abnormalities increase with age
• Most of the findings are chronic/predictable and do not affect management*
• Sleep study for STOP-BANG
• STOP-BANG 5-6
• STOP-BANG 3-4 + HCO3 >= 28
• STOP>=2 + Male + BMI > 35
*Archer et al. Can J Anaesth. 1993;40:1022-7.
15. Preop interventions
• Continue existing inhalers perioperatively
• Optimize chronic lung disease based on your assessment
• Consider preop bronchodilators or preop steroids on a case-by-case basis
• Inspiratory muscle training in high risk patients reduced PPC (RR 0.48,
95% CI 0.26 to 0.89)1 in cardiothoracic and upper abd surgery
• Another systematic review in cardiac surgery showed that any preop
intervention helps (RR 0.39, CI 0.23 to 0.66)2
1Mans CM et al. Clin Rehab 2014; 1-13
2Snowden D et al. Physiotherapy 2014; 60:66-77
17. Intra- and Postop interventions
• Some postop lung expansion modality is better than nothing
• Don’t know if one is better than the other
• Low quality evidence favors postop CPAP* (for non-OSA) in abdominal surgery
• Low quality evidence with lack of IS effectiveness**
• Studies of regional vs general anesthesia have been mixed
• For high risk of severe OSA, sleep study vs empiric CPAP
*Ireland et al. Cochrane Database of Systematic Reviews 2014, Issue 8. Art. No.: CD008930.
**do Nascimento et al. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD006058.
18. Guidelines
• Systematic review by ACP
• Use some type of lung expansion intervention
• Use nasogastric tubes selectively (not routinely) after abdominal surgery
• Insufficient evidence for epidural anesthesia/analgesia, smoking cessation,
laparoscopic vs open
• Routine TEN or TPN does not reduce risk
Smetana et al. Ann Intern Med. 2006;144:581-595.
19. Case of Mr. Lung
• 78 year old man
• L3-5 laminectomy and fusion, which will take 4 hours
• Severe COPD, diabetes, and hypertension, 40 pack-years but quit 2 yrs ago
• Takes tiotropium, lisinopril, metformin.
• Dyspneic when hurrying on level ground or walking up a hill, at his
baseline. Functionally independent.
• Resting O2 sat 95%. Normal work of breathing. Slightly diminished breath
sounds, no wheezes. Cardiovascular exam is normal. Mental status is
normal.
• Hgb 13, BUN 15, Cr 0.8, Albumin 3.5
20. Risks for Mr. L
ARISCAT Arozullah Gupta ACS Surgical Risk
Overall 13.3%
Postop pneumonia 1.18% 1.75% 1.9%
Postop respiratory
failure
1.8% 1.42%
Recommend
• postoperative lung expansion modalities
• monitoring for bronchospasm and use of bronchodilators
• early mobility
• continue home inhaler
21. Summary
• Assess risk factors for postoperative pulmonary complications
• Determine the status of chronic lung conditions and optimize
• Use a risk prediction to objectively predict complications
• Use preoperative testing judiciously and not routinely
• For high risk patients, consider less aggressive approach
• Use lung expansion techniques (take your pick), use NGT selectively
25. ARISCAT – Using the Model
Predictor Multivariate
Analysis OR
Risk
score
Age 51-80 1.4 3
Age >80 5.1 16
Preop SpO2 91-95 2.2 8
Preop SpO2 <= 90 10.7 24
Resp infection w/in 1 mo 5.5 17
Preop hemoglobin <=10 3.0 11
Upper abdominal incision 4.4 15
Intrathoracic incision 11.4 24
Surgery >2-3 hrs 4.9 16
Surgery >3 hrs 9.7 23
Emergency procedure 2.2 8
Risk category PPC rate
Low risk <26 points 1.6%
Intermediate risk 26-44 points 13.3%
High risk >= 45 points 42.1%
Back
26. Arozullah Respiratory failure risk index
• Prospective, multicenter data set
• 44 VA Medical Centers participating in National VA Surgical Quality
Improvement Program (NSQIP)
• 81,719 patients undergoing major noncardiac surgery
• Studied only men
Arozullah et al. Ann Surg 2000; 232:242
27. Arozullah Respiratory failure risk index
Predictor Multivariate
Analysis OR
Risk
score
Age 60-69 1.5 4
Age >=70 1.9 6
History of COPD 1.8 6
Partially/fully dependent
functional status
1.9 7
BUN >30 2.3 8
Albumin <3 2.5 9
Neck surgery 3.1 11
NSGY, upper abd, peripheral
vascular
4.2 14
Thoracic 8.1 21
AAA 14.3 27
Emergency 3.1 11
Risk category PPC rate
Class 1, <= 10 points 0.5%
Class 2, 11-19 points 1.8%
Class 3, 20-27 points 4.2%
Class 4, 28-40 points 10.1%
Class 5, >40 points 26.6%
28. Arozullah Postoperative Pneumonia Risk Index
• Prospective, multicenter data set
• 100 VA Medical Centers
• 160,805 patients undergoing major noncardiac surgery
• Primary outcome: Nosocomial pneumonia (CDC definition)
Arozullah et al. Ann Intern Med. 2001;135:847-857.
29. Arozullah Postoperative Pneumonia Risk Index
Predictor Multivariate
Analysis OR
Risk
score
Age 50-59 1.5 4
Age 60-69 2.4 9
Age 70-79 3.6 13
Age >=80 5.6 17
History of COPD 1.7 5
History of stroke 1.5 4
Weight loss >10% in 6mo 1.9 7
Impaired sensorium 1.5 4
Partially dependent
functional status
1.8 6
Fully dependent 2.8 10
Current smoker within 1yr 1.3 3
Alcohol >2/d past 2 wks 1.2 2
Predictor Multivariate
Analysis OR
Risk
score
Steroid for chronic condition 1.3 3
Transfusion >4 units 1.3 3
BUN <8 1.5 4
BUN 22-30 1.2 2
BUN >30 1.4 3
General anesthesia 1.6 4
Vascular 1.3 3
Neck surgery 2.3 8
Neurosurgery 2.1 8
Upper abdominal 2.7 10
Thoracic 3.9 14
AAA 4.3 15
Emergency 1.3 3
30. Postoperative Pneumonia Risk Index vs
Respiratory Failure Risk Index
Risk category PPC rate
Class 1, 0-15 points 0.24%
Class 2, 16-25 points 1.18%
Class 3, 26-40 points 4.6%
Class 4, 41-55 points 10.8%
Class 5, >55 points 15.9%
Risk category PPC rate
Class 1, <= 10 points 0.5%
Class 2, 11-19 points 1.8%
Class 3, 20-27 points 4.2%
Class 4, 28-40 points 10.1%
Class 5, >40 points 26.6%
Postoperative Pneumonia Risk Index Respiratory Failure Risk Index
Back
31. Gupta Perioperative Risk Calculators
• Prospective, multicenter data set
• 183 academic and community hospitals
• American College of Surgeons National Surgical Quality Improvement
Program (NSQIP)
• 211,410 patients undergoing major surgery
Gupta et al. CHEST 2011; 140(5):1207–1215
Gupta et al. May Clin Proc 2013; 88(11):1241–1249
Surgicalriskcalculator.com
32. Predictors of Resp Failure
Dependent functional status
ASA class
Preoperative sepsis
Type of surgery
Emergency surgery
Gupta Perioperative Risk Calculators
Predictors of Pneumonia
Dependent functional status
ASA class
Preoperative sepsis
Type of surgery
Age
COPD
Smoking before operation
Gupta et al. CHEST 2011; 140(5):1207–1215
Gupta et al. May Clin Proc 2013; 88(11):1241–1249
Surgicalriskcalculator.com
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