Accurate Diagnosis Of Postoperative Pneumonia Requires Objective Data

Transcription

1 Accurate Diagnosis Of Postoperative Pneumonia Requires Objective Data David Ebler, MD David Skarupa, MD Andrew J. Kerwin, MD, FACS Jhun de Villa, MD Michael S. Nussbaum, MD, FACS J.J. Tepas III, MD, FACS Nothing To Disclose Department of Surgery University of Florida College of Medicine - Jacksonville

2 Background Postoperative pneumonia (PNA) Costly complication of surgical care Diagnosis based on the presence of specific clinical findings - Chest Radiological Exam (X-ray or CT) Column A - Signs/Symptoms/Labs Column B

3 Diagnosis of PNA Column A- Radiology ONE Chest radiological exam* with at least ONE of the following: New or progressive and persistent infiltrate Consolidation or opacity Cavitation * NOTE: In patients with underlying pulmonary or cardiac disease two or more serial chest radiological exams are required

4 Diagnosis of PNA Column B- Signs/Sxs/Labs Scenario #1 At least ONE of the following: Fever with no other recognized cause Leukopenia (<4000 WBC/mm3) or leukocytosis ( 12,000 WBC/mm3) 70 years old, altered MS with no other recognized cause AND At least ONE of the following: Positive growth in blood culture unrelated to other source Positive growth in culture of pleural fluid Bronchoalveolar lavage (BAL) -intracellular bacteria on direct microscopic exam Positive quantitative culture from minimally contaminated lower respiratory tract (LRT) specimen

5 Diagnosis of PNA Column B- Signs/Sxs/Labs Scenario #1 At least ONE of the following: Fever with no other recognized cause Leukopenia (<4000 WBC/mm3) or leukocytosis ( 12,000 WBC/mm3) 70 years old, altered MS with no other recognized cause AND At least ONE of the following: Positive growth in blood culture unrelated to other source Positive growth in culture of pleural fluid Bronchoalveolar lavage (BAL) -intracellular bacteria on direct microscopic exam Positive quantitative culture from minimally contaminated lower respiratory tract (LRT) specimen

6 Diagnosis of PNA Column B - Signs/Sxs/Labs SCENARIO #2 (B ) At least ONE of the following: Fever (>380C or >100.40F) with no other recognized cause Leukopenia (<4000 WBC/mm3) or leukocytosis ( 12,000 WBC/mm3) For adults 70 years old, altered mental status with no other recognized cause AND At least TWO of the following: New onset of purulent sputum, or change in character of sputum, or increased respiratory secretions, or increased suctioning requirements New onset or worsening cough, or dyspnea, or tachypnea Rales (crackles) or rhonchi Worsening gas exchange (e.g. O2 desaturations (e.g., PaO2/FiO2 240), increased oxygen requirements, or increased ventilator demand)

7 Diagnosis of PNA Column B - Signs/Sxs/Labs SCENARIO #2 (B ) At least ONE of the following: Fever (>380C or >100.40F) with no other recognized cause Leukopenia (<4000 WBC/mm3) or leukocytosis ( 12,000 WBC/mm3) For adults 70 years old, altered mental status with no other recognized cause AND At least TWO of the following: New onset of purulent sputum, or change in character of sputum, or increased respiratory secretions, or increased suctioning requirements New onset or worsening cough, or dyspnea, or tachypnea Rales (crackles) or rhonchi Worsening gas exchange (e.g. O2 desaturations (e.g., PaO2/FiO2 240), increased oxygen requirements, or increased ventilator demand)

8 BAL Unchained New or changing infiltrate At least TWO of the following: temperature >38 o C or <36 o C, macroscopically purulent sputum, white blood cell count >10,000 cells/mm 3 presence of >10% bands Positive >10 5 CFU/ml Negative <10 5 CFU/ml Empiric Broad Spectrum Coverage De-escalation

9 In this era of accountability. Absolute confirmation of PNA requires documentation of >100,000 cfu/ml pathogenic organisms from bronchial alveolar lavage (BAL) culture Question: How does NSQIP PNA criteria compare to BAL and any other culture technique findings? Methods: 2012 NSQIP Surgical case data queried for all patients with PNA not present at time of surgery. Microbiology laboratory bronchial culture results from BAL or any other source queried for same period to identify +cultures for all matching NSQIP sampled cases Incidence of +BAL calculated for NSQIP identified PNA patients and for the NSQIP patients w/o PNA

10 1,326 general & vascular NSQIP patients 251 patients 16.2% 498 complications 17 with NSQIP criteria for pneumonia 10 NSQIP pneumonia patients had confirmatory positive cultures. PPV= 59% 7 patients (41%): no positive bronchial cultures 4 Neg BAL 3 NO BAL = NO PNA 1 negative sputum, 2 no cultures 234 NSQIP patients with complications other than pneumonia: 2 with BAL positive cultures NPV = 99%

11 SUMMARY What (else) can we learn from NSQIP? In 2012: 243 patients 486 BAL Empiric Broad Spectrum Coverage De-escalation Positive yield = 40% NSQIP pneumonia patients had PPV= 59%

12 Conclusions NSQIP SCR criteria have high specificity and NPV Cult + Cult - SCR % SCR % 83.3% 97.1% Postoperative Pneumonia (PNA): Adds additional cost to surgical care Potential indicator of deficient quality of care Therefore: Patients with any clinical suspicion of PNA must have objective confirmation by appropriate bronchial culture 40% BAL yield vs. 59% PPV of SCR mandates better documentation of reasons for BAL