Annals of Internal Medicine l CLINICAL GUIDELINES Risk Assessment for and Strategies to Reduce Perio

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Annals of Internal Medicine l CLINICAL
GUIDELINES Risk Assessment for and Strategies
to Reduce Perioperative Pulmonary Complications
for Patients Undergoing Noncardiothoracic
Surgery A Guideline from the American College
of Physicians
Annals of Internal Medicine April
2006144575-580.

• ???

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Introduction

• Postoperative pulmonary complications is an
  important risk after noncardiothoracic surgery.
• Morbidity,?Mortality,Length of Stay,Long-term
  Mortality
• Atelectasis, Pneumonia, Respiratory
  Failure.?????,
• Guideline for those who manage surgical patient.
• Adult patients, Noncardiothoracic Surgery
• Excluded
• immunosuppressive states other than HIV
• perioperative venous thromboembolism 23 months
  before and 3 months after surgery

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Recommendations 1

• Significant risk facors / reduce risk factors
• COPD, agegt60, ASA class gt II, Functional
  dependent, and CHF
• Not significant risk factors
• Obesity
• mild or moderate Asthma

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Recommendations 2

• The following procedures are at higher risk are
  should be further evaluate
• prolonged surgery (gt3hours),
• abdominal surgery,
• thoracic surgery,
• neurosurgery,
• head and neck surgery,
• vascular surgery, aortic aneurysm repair,
• emergency surgery, and
• general Anesthesia

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Recommendations 3

• Low serum albumin level (lt 35g/L) is a powerful
  marker
• Should be measured in patient suspected of
• hypoalbuminemia or
• with 1 or more risk factors

Recommendations 4

• Should receive the following procedure
• deep breathing exercises or incentive spirometry
• selective use of a nasogastric tube decompression

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Recommendations 5

• Preoperative Spirometry and Chest radiography
  should not be used routinely
• may be appropriate for COPD or Asthma patient

Recommendations 6

• The following should not be used solely for
  reduce pulmonary complications
• Right-heart catherization
• Total parenteral nutrition or total enteral
  nutrition (for mal- nourished or low serum
  albumin paitents)

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Preoperative Pulmonary Risk Stratification for
Noncardiothoracic Surgery

• Patient-Related Risk Factors
• Procedure-Related Risk Factors
• Laboratory Testing to Estimate Risk

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Patient-Related Risk Factors

• Age
• Chronic Lung Disease
• Cigarette Use
• Congestive Heart Disease
• Funtional Dependence
• ASA Classification
• Obesity
• Asthma
• Obstructive Sleep Apnea
• Impaired Sensorium, Abnormal Findings on Chest
  Examination, Alcohol Use, and Weight Loss
• Exercise Capacity, Diabetes, and HIV Infection

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Patient-Related Risk Factors

• Advanced Age is 2nd most an important predictor
• 6069 y vs gt 60 y, odds raito 2.09 (???)
• 7079 y vs gt 60 y, odds raito 3.04

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Patient-Related Risk Factors

• Chronic obstructive pulmonary disease is the
  most.
• odds raito 1.79
• no eligible study of the following
• Restrictive lung disease
• Restrictive physiology (e.g. neuromuscular
  disease)
• Chest wall deformity (e.g. kyphoscoliosis)

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Patients-Related Risk Factors

• Smoker, A modest increase in risk. The odds ratio
  for cigarette use was 1.26 (CI, 1.01 to 1.56).
• It is important to assess history of current
  smoking status and support for smoking cessation
  intervention very early in the preparation for
  nonemergency surgery.
• Congestive heart failure, odds ratio,2.93CI,
  1.028.43
• Functional dependence
• Total dependence inability for daily activity
  2.51 (1.99-3.15)
• Partial dependence need equipment or devices or
  another person. 1.65 (1.36-2.01)

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Patients-Related Risk Factors
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Patients-Related Risk Factors

• The ASA classification aims to predict
  perioperative mortality rates but has since been
  proven to predict both postoperative pulmonary
  and cardiac complications (9).
• Higher ASA class was associated with a
  substantial increase in risk when an ASA class of
  II or greater was compared with an ASA class of
  less than II (odds ratio, 4.87 CI, 3.34 to
  7.10)
• and when an ASA class of III or greater was
  compared with an ASA class of less than III (odds
  ratio, 2.25 CI, 1.73 to 3.76).

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Patients-Related Risk Factors

• Obesity( BMIgt25 Kg/m2) no increased risk even
  morbid obesity. Postoperative pulmonary
  complications were 6.3 and 7.0 for obese and
  nonobese patients(10,11)
• Asthma, Good evidence suggested that it is not a
  risk factor for postoperative pulmonary
  complications. Only 1 of 4 studies that examined
  the rate of postoperative pulmonary complications
  among patients with asthma was 3.
• Obstructive sleep apnea A case-control study,
  unplanned intensive care unit transfers(20 vs
  6), all serious complications(24 vs 9) and
  length of stay(6.8 days VS 5.1 days)

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Patients-Related Risk Factors

• Impaired Sensorium modestly increased risk
• 1.acute confused or delirious patient who can
  respond to verbal or mild tactile stimulation or
  both
• 2.mental status changes, delirium, or both in
  current illness
• Chest Exam, Alcohol use, Weight loss, modestly
  increased the risk
• Exercise Capacity, Diabetes, and HIV Infection
• Evidence was insufficient to support whether
  exercise capacity, diabetes, and HIV infection
  are independent risk factors for postoperative
  pulmonary complications.

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Procedure-Related Risk Factors

• Surgical Site
• Duration of Surgery
• Four studies with multivariable analyses, the
  pooled odds ratio , prolonged surgery (34hours),
  2.14CI,1.333.46
• Anesthetic Technique
• Four studies, general anesthesia, odds ratio
  1.83(CI, 1.352.46)
• Emergency Surgery
• Among studies, 6 multivariable analyses reported,
  the odds ratio 2.21(CI, 1.573.11)

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Laboratory Testing to Estimate Risk

• Spirometry
• Chest Radiographys
• Blood Urea Nitrogen (BUN),
• Oropharyngeal Culture
• Serum Albumin Measurement

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Spirometry

• few studies compared spirometric data with
  clinical data have Not consistently shown
  spirometry to be superior to history and physical
  examination in predicting postoperative pulmonary
  complications.
• value of spirometry before lung resection and in
  determining candidacy for coronary artery bypass
  
• its value before extrathoracic surgery, however,
  remains unproven.
• Spirometry should be reserved for patients who
  are thought to have undiagnosed chronic
  obstructive pulmonary disease.

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Chest Radiography

• In a recent review of this literature (13),
• 23.1 of preoperative chest radiographs were
  abnormal but
• only 3 had findings clinically important enough
  to influence management.
• An earlier review, 19661993, (14) found that
• 10 of preoperative chest radiographs were
  abnormal but
• only 1.3 showed unexpected abnormalities and
  only 0.1 influenced management.

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Chest Radiography

• Thus, the evidence suggests that clinicians may
  predict most abnormal preoperative chest
  radiographs by history and physical examination
• There is some evidence that this test is helpful
  for patients with known cardiopulmonary disease
  and those older than 50 years of age who are
  undergoing upper abdominal, thoracic, or
  abdominal aortic aneurysm surgery.

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Serum measure of renal function

• Fair evidence supports serum blood urea
  nitrogen(BUN) levels of 7.5 mmol/L or greater (21
  mg/dL) as a risk factor.
• However, the magnitude of the risk seems to be
  lower than that for low levels of serum albumin.

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Oropharyngeal Culture

• The evidence review found only a single small
  study that evaluated the value of preoperative
  oropharyngeal culture to predict postoperative
  pulmonary complication risk (15). More studies
  are needed in this area.

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Serum Albumin Measurement

• Four studies that reported univariate analyses???
• serum albumin level and used a threshold of 36
  g/L to define low levels (16-19). Unadjusted
  rates of postoperative pulmonary complications
  for patients with low and normal serum albumin
  levels were 27.6 and 7.0, respectively.
• In the review of studies reporting multivariable
  analyses,
• (low values were defined variably from 30 to 39
  g/L) (20-24).
• The National VA Surgical Risk Study reported that
  a low serum albumin level was also the most
  important predictor of 30-day perioperative
  morbidity and mortality (17).
• In this report, the relationship between serum
  albumin levels and mortality was continuous when
  levels were below approximately 35 g/L without a
  clear threshold value.
• On the basis of the multivariate analysis, a
  serum albumin level less than 35 g/L is one of
  the most powerful patient-related risk factors
  and predictors of risk.

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Strategies To Reduce Postoperative Pulmonary
Complications

• Lung-Specific Strategies
• Preoperative Smoking Cessation
• Lung Expansion Modalities
• Anesthetic and Analgesic Techniques
• Neuromuscular Blockade
• Anesthesia and analgesia
• Surgical Techniques
• Perioperative Care
• Nutritional Support
• Pulmonary Artery Catheterization
• Nasogastric Decompression after Abdominal Surgery

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Strategies To Reduce Postoperative Pulmonary
Complications

• Opportunities to reduce risk for postoperative
  pulmonary complications occur throughout the
  perioperative period.
• Lawrence and colleagues' background review (8)
  discusses the evidence for
• lung-specific strategies,
• anesthetic and analgesic techniques,
• surgical techniques, and
• perioperative care.

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lung-specific strategies

• Preoperative Smoking Cessation
• The authors found only 1 randomized trial of a
  preoperative smoking cessation intervention that
  began approximately 6 to 8 weeks before hip or
  knee surgery and continued 10 days after surgery
  (25).
• Postoperative ventilatory support was the only
  measured pulmonary outcome and occurred in 1
  patient in each group.
• The risk for postoperative pulmonary
  complications is low
• Another study showed that postoperative pulmonary
  complication rates did not decrease for smokers
  who stopped smoking or reduced smoking within 2
  months of cardiothoracic surgery (26).

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lung-specific strategies

• Lung Expansion Modalities Lung expansion
  techniques include
• incentive spirometry??????
• chest physical therapy, including deep breathing
  exercises
• cough
• postural drainage
• percussion and vibration
• suctioning and ambulation
• intermittent positive-pressure breathing and
• continuous positive-airway pressure.
• Suggests patients undergoing abdominal surgery,
  any type of lung expansion intervention is better
  than no prophylaxis at all.
• However, no one modality is clearly superior, and
  the literature varies substantially regarding how
  clinicians actually administer the different
  methods.

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lung-specific strategies

• The available evidence does not suggest that
  combined methods provide additional risk
  reduction.
• Incentive spirometry may be the least
  labor-intensive and nasal continuous
  positive-airway pressure may be especially
  beneficial in patients who are unable to perform
  incentive spirometry or deep breathing exercises.

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anesthetic and analgesic techniques

• Pulmonary Neuromuscular Blockade
• pancuronium, and those patients were
  approximately 3 times more likely to develop
  postoperative pulmonary complications than
  patients without residual blockade.
• In contrast, among patients receiving an
  intermediate-acting agent (atracurium or
  vecuronium), there was no difference in the rates
  between those with and without prolonged blockade
  (4 vs. 5).
• These data directly indicate that pancuronium use
  leads to higher rates of prolonged blockade and
  indirectly suggest an increased risk for
  postoperative pulmonary complications when
  compared with shorter-acting agents.

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anesthetic and analgesic techniques

• Anesthesia and Analgesia
• A recent meta-analysis examined 141 randomized,
  controlled trials of general anesthesia versus
  neuraxial blockade in patients undergoing varied
  types of surgery (27).
• Complication rates with and without neuraxial
  blockade were, respectively,
• 3 and 5 for pneumonia (odds ratio, 0.61 CI,
  0.48 to 0.76) and
• 0.5 and 0.8 for respiratory failure (odds
  ratio, 0.41 CI, 0.23 to 0.73).

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anesthetic and analgesic techniques

• In a subgroup analysis of trials of neuraxial
  blockade alone versus general anesthesia alone,
  results were similar.
• Overall, current evidence suggests that
  shorter-acting neuromuscular blocking drugs may
  prevent postoperative pulmonary complications.

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surgical techniques

• Overall, literature on laparoscopic versus open
  procedures did not systematically assess or
  report pulmonary complications, and most studies
  did not have sufficient statistical power to
  detect differences in rates of postoperative
  pulmonary complications. The evidence is not
  clear, and further studies are needed.

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perioperative care

• Nutritional Support
• Taken as a whole, the body of evidence, which
  includes a meta-analysis (28) and a multisite
  randomized trial (29), indicates no proven
  advantage to total parenteral nutrition over no
  supplementation or total enteral nutrition in
  reducing postoperative pulmonary complications.

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perioperative care

• Nasogastric Decompression after Abdominal Surgery
  
• Selective use of nasogastric tubes refers to use
  only if postoperative nausea or vomiting,
  inability to tolerate oral intake, or symptomatic
  abdominal distention occur.
• Patients receiving selective nasogastric
  decompression had a significantly lower rate of
  pneumonia and atelectasis. There was no
  difference in aspiration rates. These results
  were confirmed in a more recent meta-analysis
• Nelson R, Tse B, Edwards S. Systematic review of
  prophylactic nasogastric decompression after
  abdominal operations. Br J Surg. 200592673-80.

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Summary

• Employ strategies to reduce postoperative
  pulmonary complications in patients who are at
  high risk after clinical risk stratification.
• Good evidence shows that patient-related risk
  factors, such as COPD, age older than 60 years,
  ASA class of II or higher, functional dependence,
  and congestive heart failure, increase the risk
  for postoperative pulmonary complications.
• In addition, patients undergoing such procedures
  as prolonged surgery, abdominal surgery, thoracic
  surgery, neurosurgery, head and neck surgery,
  vascular surgery, aortic aneurysm repair, and
  emergency surgery are at higher risk.
• General anesthesia and serum albumin levels lt 35
  g/L are also a strong marker of increased risk.

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Summary

• Good evidence exists to support risk reduction
  strategies, including incentive spirometry and
  deep breathing exercises, and
• fair evidence exists to support selective
  nasogastric tube decompression after abdominal
  surgery.
• Fair evidence also suggests that short-acting
  neuroaxial blockade reduces postoperative
  pulmonary complications compared with long-acting
  neuroaxial blockade.

Thank you for your Attention
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perioperative care

• Pulmonary Artery Catheterization
• Only 1 randomized, controlled trial of pulmonary
  artery catheters in high-risk surgical patients
  has been published (30). Patients 60 years of age
  or older undergoing major abdominal, thoracic,
  vascular, or hip fracture surgery were randomly
  assigned to usual care or treatment guided by the
  use of a perioperative pulmonary artery catheter.
  
• The 2 groups did not differ in the primary
  outcome of in-hospital all-cause mortality, and
  postoperative pneumonia rates were also similar.
• This report shows no beneficial effect of
  pulmonary artery catheters as a strategy to
  reduce postoperative pulmonary complications

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Thank you for your Attention
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Patients-Related Risk Factors

• Age,
• chronic lung condition disease,
• cigarette use,
• congestive heart failure, comorbid condition
  measures,
• functional dependence,
• obesity,
• obstructive sleep apnea,
• impaired sensorium,
• others factors

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• Assessing Study Quality U.S. Preventive Services
  Task Force criteria
• Statistical Analysis odds ratio, Trim-and-fill
  estimates risk factor

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• Pulmonary risk indices These indices allow
  clinicians to reconsider for surgery in a
  high-risk patient and suggest patient to reduce
  the risk for postoperative pulmonary
  complications
• Older than 60 years of age, postoperative
  complication only pulmonary and renal
  complications predicted long-term mortality
• Esophagectomy for cancer, postoperative
  pneumonia was second only to tumor stage in
  predictable long-term mortality than
  postoperative cardiac, renal, or hepatic
  complication
• No similar guideline for perioperative cardiac
  risk evaluation of perioperative pulmonary risk

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Spirometry(2)

• Spirometry1989, value was unproven
• mean FEV1, mean FVC values, difference were small
  and were unlikely to help risk stratification
  Lowest FEV1 with high post-op pulmonary
  complication(31.4 14.6) The same with FVC and
  FEV1-FVC ratio
• Wong and colleagues FEV1FVC less than 50 was
  independent risk factors
• Respiratory med. 2000 FEV1 lt 61 predicted
  independent factor
• Chronic mucus hypersecretion( sputum production
  than gt 3 months each year) was strongest factor
  to greater degree than any spirometric value

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Spirometry(3)

• Few studies compared spirometry with clinical
  data not consistently shown spirometry to be
  superior to history and physical examination
• No literature identify use spirometry to stratify
  risk for patients with restrictive pulmonary
  disease and restrictive physiology
• 107 patients, severe chronic obstructive
  pulmonary disease (FEV1lt50 predicted FEV1-FVC
  ratio lt70 ) 6 deaths and 7 severe postoperative
  pulmonary complication

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• Stop smoking shortly before surgery have MORE
  postoperative pulmonary complication than
  continue smoking habits, adjust odds ratio 6.7

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Chest Radiography

• 46 with abnormal CXR had postoperative pulmonary
  complication VS 25 of normal CXR

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Patient-Related Risk Factors

• Table 1. Patient-Related Risk Factorfor
  Postoperative Complications
  .
• Risk Factor Studies, N Pooled Estimate
  Odds I2,? Trim-and-Fill Estimate
• Ratio (95 CI) ? Odds Ratio(95 CI)
• __________________________________________________
  ________________________
• Age
• 50-59 y 2 1.5(1.31-1.71) 0.0 -
• 60-69 y 7 2.28 (1.86-2.80) 50.4 2.09
  (1.65-2.64)
• 70-79 y 4 3.90 (2.70-5.65) 81.6 3.04
  (2.11-4.39)
• ? 80 y 1 5.63 (4.63-6.85) - -
• ASA class
• ? II 6 4.87 3.34-7.10() 0.0 4.87
  (3.34-7.10)
• ? III 11 3.12 (2.17-4.48) 65.2 2.55
  (1.73-3.76)
• Abnormal CXR 2 4.81(2.43-9.55) 0.0 -
• CHF 3 2.93 (1.02-8.43) 92.1 2.93
  (1.02-8.03)
• Arrhytmia 1 2.90 (1.10-7.50) - -

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Patient-Related Risk Factors

• Table 1. Patient-Related Risk Factorfor
  Postoperative Complications (continue)
  
• Risk Factor Studies, N Pooled Estimate
  Odds I2,? Trim-and-Fill Estimate
• Ratio (95 CI) ? Odds Ratio(95 CI)
• __________________________________________________
  ________________________
• COPD 8 2.36 (1.90-2.93) 82.0 1.97
  (1.44-2.22)
• Weight loss 2 1.26(1.17-2.26) 91.7 -
• Medical comorbid 1 1.48 (1.10-1.97) - -
• condition
• Cigarette use 5 1.40 (1.17-1.68) 67.5 1.26
  (1.01-1.56)
• Impaired sensorium 2 1.39 (1.08-1.79)
  63.0 -
• Corticosteroid use 1 1.33 (1.12-1.58) - -
• Alcohol use 2 1.21 (1.11-1.32) 0.0 -
• __________________________________________________
  ________________________

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