Complications Respiratoires Postopératoires

Transcription

1 XXème Journée de Réanimation de Picardie (JARP) Amiens, 15 Mars 2017 Complications Respiratoires Postopératoires Prévenir plutôt que guérir? Emmanuel FUTIER, MD, PhD Department of Anesthesiology and Critical Care Medicine Estaing Hospital - University of Clermont-Ferrand INSERM U1103, CNRS 6293,

2 XXème Journée de Réanimation de Picardie (JARP) Amiens, 15 Mars 2017 Information / Conflits d intérêts Aucun lien d intérêt (autre que scientifique)

3 Clinical and economic burden of PPCs More than 200 million major surgery performed annually worldwide Incidence rate ranging from 6% to 80% depending on definition and severity related deaths in the US 4.8 million additional hospitalization days Shander A et al. Crit Care Med 2011,39:

4 Paper Temporal Patterns of Postoperative Complications Jon S. Thompson, MD; B. Timothy Baxter, MD; John G. Allison, MD; Frank E. Johnson, MD; Kelvin K. Lee, PhD; Woo Young Park, MD Total N. of patients (N=1021) 45 (4%) 35 (3%) 30 (3%) 21 (2) 5 (1) 123 (12%) 68 (7%) 20 (2%) 2 38 (4%) 16 (2%) 17 (2%) 15 (1%) 435 (42%) Arch Surg 2003;138:

5 JAMASurgery Original Investigation JAMA Surg 2017;152: Postoperative Pulmonary Complications, Early Mortality, and Hospital Stay Following Noncardiothoracic Surgery A Multicenter Study by the Perioperative Research Network Investigators A multicenter prospective 6-month observational (May-November 2014) study in 7 US academic institutions N=1202 patients - Abdominal, orthopedic and neurological procedures Main endpoint: PPC defined by Clinical diagnosis: - Pneumonia - Bronchospasm - ARDS Radiological diagnosis: - Atelectasis - Pneumothorax - Pleural effusion Therapies for respiratory insufficiency: - Prolonged (>1 day) supplemental oxygen by nasal cannula or face mask - Postoperative NIV and/or reintubation Incidence of PPCs within 7 PODs >30%

6 JAMASurgery Original Investigation Fernandez-Bustamante A et al. JAMA Surg 2017;152:

7 Unplanned tracheal intubation after surgery for postoperative respiratory failure Unplanned tracheal reintubation within 3 days after surgery is associated with an increased risk (72-fold) for in-hospital death: Mortality 16% versus 0.26% Brueckmann B et al. Anesthesiology 2013; 118:

8 Individual data analysis of 3365 patients from 12 observational and RCTs Postoperative lung injury: 3.65% Lancet Respir Med 2014; 2(12): Figure 3: Timing of PLI during hospital stay Figure 4: Kaplan-Meier estimates of overall survival in patients with and without PLI Mean time to onset of PLI: 2.9 (2.2) days In-hospital mortality: 1.4% vs 20.3% (HR 9.58, CI95% )

9 Interaction Effects of Acute Kidney Injury, Acute Respiratory Failure, and Sepsis on 30-Day Postoperative Mortality in Patients Undergoing High-Risk Intraabdominal General Surgical Procedures Minjae Kim, MD, MS,* Joanne E. Brady, PhD, and Guohua Li, MD, DrPH* Anesth Analg 2015;121: Une IRA postopératoire est associée à une augmentation significative du risque de développer un sepsis et/ou un AKI après chirurgie

10 Complications Respiratoires Postopératoires Comment peut-on faire mieux? 1. Identifier les patients à risque

11 Identification of modifiable or non-modifiable risk factors of PPCs Risk factors Procedure-related factors Anesthetic-related factors Patient-related factors Surgical procedure Excessive fluid administration Age >65yr Vascular Blood transfusion (> 4 units) ASA physical status 3 Thoracic Residual NMBAs History of respiratory disease (COPD) Upper abdominal Intraoperative hypothermia Obstructive sleep apnea Neurosurgery Mechanical ventilation settings Preoperative SpO2 <96% Head and Neck GA (vs locoregional) History of congestive heart failure Emergent (vs elective) Inhaled anesthetics (vs IV)? Recent respiratory infection (<1 mo) Reintervention Surgical duration 2 h Open laparotomy (vs Partial or total functional dependency Active smoking Alcohol abuse Preoperative sepsis Weight loss >10% in the last 6 months Preoperative anemia (<10 g/dl) Obesity Futier E et al. Anesthesiology 2014; 121:400 8 Canet J et al. Anesthesiology 2010;113: Arozullah AM et al. Ann Intern Med 2001;135:847-57

12 Individual Risk Estimation of PPCs ARISCAT score OR (95%CI) Risk scoring Patient-related factors Age, yr ( ) 3 > ( ) 16 Low preoperative SpO2 breathing room air value, % ( ) ( ) 24 Upper or lower respiratory tract infection in the month before surgery 5.5 ( ) 17 Preoperative anemia (Hb concentration <10 g/dl) 3.0 ( ) 11 Surgical procedure-related factors Location of surgical incision Peripheral 1 Upper abdominal 4.4 ( ) 15 Intrathroracic 11.4 ( ) 24 Surgical duration, hrs 2 1 > ( ) 16 >3 9.7 ( ) 23 Emergency procedure 2.2 ( ) 8 Anesthesiology Dec;113(6):

13 Complications Respiratoires Postopératoires Comment peut-on faire mieux? 1. Identifier les patients à risque 2. Stratégie multimodale peropératoire

14 Silva et al. Critical Care 2013, 17:R288 The effect of excess fluid balance on the mortality rate of surgical patients: a multicenter prospective study João M Silva Jr 1,2,4*, Amanda Maria Ribas Rosa de Oliveira 2,3, Fernando Augusto Mendes Nogueira 1, Pedro Monferrari Monteiro Vianna 1, Marcos Cruz Pereira Filho 1, Leandro Ferreira Dias 1, Vivian Paz Leão Maia 1, Cesar de Souza Neucamp 1, Cristina Prata Amendola 3, Maria José Carvalho Carmona 2 and Luiz M Sá Malbouisson 2 Variables Fluid balance NOT excessive Fluid balance excessive P Value Postoperative organ dysfunction (%) <0.001 Respiratory (%) <0.001 Cardiovascular (%) <0.001 Renal (%) Infection (%) ICU stay (days) 3.0 ( ) 4.0 ( ) <0.001

15 Preoperative and Intraoperative Predictors of Postoperative Acute Respiratory Distress Syndrome in a General Surgical Population 50,367 hospitalizations analyzed (from June 1, 2004 to May 31, 2004 ) 93 (0.2%) were complicated by postoperative ARDS Intraoperative Predictors of ARDS after matching on Preoperative Risk of ARDS Odds ratio Median drive pressure 1.17 (1.09, 1.31) Packed erythrocyte transfusion 5.36 (1.39, 11.11) Median FiO (1.00, 1.05) Crystalloid (liters) 1.43 (1.15, 1.93) Blum JM et al. Anesthesiology 2013;118:19-29

16 JAMA Surg 2016;151: N=1540 patients - elective AAA repair Primary outcome: all-cause mortality Figure 2. Survival and Use of Combination Epidural and General Anesthesia 26% (95%CI 24% to 28%) vs 35% (95%CI 32% to 38%) log-rank P<0.01

17 Table 2. Multivariable Logistic Regression and Cox Proportional Hazards Regression Models Evaluating the Association of EA-GA Anesthesia With Postoperative Outcomes and Patient Survival JAMA Surg 2016;151:

18 Anesthesiology 2011; 115:315 21

19 DOES INHALED ANESTHETICS improve pulmonary outcome?

20 Anesthesiology Jul;115(1):65-74

21 Volatile vs TIVA Christopher Uhlig et al. Anesthesiology 2016; 124:

22 A. Ventilation at LOW lung volume B. Ventilation at HIGH lung volume Atelectrauma Lung inhomogeneity Overdistention N Engl J Med 2013;369:

23 1. Structural consequences Barotrauma Epithelial mesenchymal transformations Surfactant dysfunction Hyaline membranes Pulmonary edema Atelectasis Fibroproliferation Increased alveolar capillary permeability Alveolus 2. Biologic alterations -! Release of mediators (TNF-!, IL-1", IL-6) -! Recruitment of Pulmonary Alveolar Macrophage (PAM) -! Activation of endothelium and epithelium TNF-! PAM PMN IL-6 "-Catenin 3. Systemic effects -! Increased apoptosis -! Multiorgan dysfunction -! Death Capillary Slutsky AS, Ranieri VM. N Engl J Med 2013;369:

24 Multiple "hits" during surgery Futier E et al. Anesthesiology 2014; 121:400 8

25 IMPROVE trial N Engl J Med 2013;369:428-37

26 IMPROVE Trial A pragmatic multicenter, double-blinded, randomized controlled trial Lung-Protective Ventilation N=200 VT 6 to 8 ml/kg PBW PEEP 6 to 8 cmh2o Recruitment Maneuver VS. Non-Protective Ventilation N=200 VT 10 to 12 ml/kg PBW No PEEP No Recruitment Maneuver In both groups: - Plateau pressure <30 cmh2o - Volume-controlled ventilation mode - FiO2 adjusted to maintain SpO2 95% - RR adjusted to maintain ETCO2 between 35 and 40 mmhg

27 ORIGINAL ARTICLE! A Trial of Intraoperative Low-Tidal-Volume Ventilation in Abdominal Surgery IMPROVE study Probability of Event Adjusted Relative Risk 0.45 [95%CI, ] p< % 10.5% Nonprotective ventilation Lung-protective ventilation Number of events (%) Secondary outcome: Need for invasive or noninvasive ventilation for ARF to postoperative day % 5% P< Days since randomization 0 Nonprotective ventilation group (N=200) Lung-protective ventilation group (N=200) CONCLUSIONS The use of a lung-protective ventilation strategy composer of low VT ventilation, moderate PEEP and repeated recruitment maneuvers in intermediate-risk and high-risk patients undergoing major abdominal surgery was associated with improved clinical outcomes N Engl J Med 2013;369:428-37

28 High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre randomised controlled trial The PROVE Network Investigators* for the Clinical Trial Network of the European Society of Anaesthesiology N=900 PROVHILO trial Lower PEEP group ("2 cmh2o) Higher PEEP group (12 cmh2o) 40% in the higher PEEP group versus 39% in the lower PEEP group (relative risk 1.01, 95% CI ; p=0.84) Lancet May 30. pii: S

29 High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre randomised controlled trial The PROVE Network Investigators* for the Clinical Trial Network of the European Society of Anaesthesiology PROVHILO trial Higher PEEP group (n=445) Lower PEEP group (n=449) Relative risk (95%CI) P Intraoperative complications Rescue strategy for desaturation 11/442 (2%) 34/445 (8%) 0.34 ( ) Hypotension 205/441 (46%) 162/449 (36%) 1.29 ( ) Vasoactive drugs needed 274/444 (62%) 228/445 (51%) 1.20 ( ) New arrhythmias needing intervention 12/442 (3%) 5/445 (1%) 2.38 ( ) 0.09 Lancet May 30. pii: S

30 High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre randomised controlled trial The PROVE Network Investigators* for the Clinical Trial Network of the European Society of Anaesthesiology Interpretation A strategy with a high level of PEEP and recruitment manoeuvres during open abdominal surgery does not protect against postoperative pulmonary complications. PROVHILO trial An intraoperative protective ventilation strategy should include a low tidal volume and low PEEP (i.e., 2 cmh2o) without recruitment manoeuvres. too high Lancet May 30. pii: S

31 Transient hemodynamic effects of recruitment maneuvers in three experimental models of acute lung injury* Sung-Chul Lim, MD; Alexander B. Adams, MPH; Dana A. Simonson, BA; David J. Dries, MSE, MD; Alain F. Broccard, MD; John R. Hotchkiss, MD; John J. Marini, MD 1.0 Cardiac output! Mean arterial pressure 1.0 Fraction of baseline CO 0.9!!!! ! 0.6! 0.5! 0.4 PreRM RM OAI VILI PNM Fraction of baseline MAP! 0.9!!! 0.8!! ! PreRM RM OAI VILI PNM Time (min) Time (min) Sung-Chul Lim et al. Crit Care Med 2004; 32:

32 ml/kg vs 10 ml/kg PEEP set at LIP of P/V curve LVT CVT Recruitment (ml) Before RM After RM Am J Respir Crit Care Med 2001;163:

33 Dose-Response Relationship Between PPC and VT Tidal volume (ml/kg PBW) 3-5 (n=137) 6-8 (n=1348) 8-11 (n=468)!12 (n=175) Relative Risk of PPCs Dose-relationship curve between VT and PPCs PROVE Network. Anesthesiology 2015,123:66-78

34 The proportion of lung available for ventilation is markedly decreased in ARDS, which is reflected by lower respiratory-system compliance (CRS) Normalizing VT to CRS and using the driving pressure (#P = Pplat - PEEP) indicating the functional size of the lung would provide a better predictor of outcomes in patients with ARDS than VT alone N Engl J Med 2015;372:747-55

35 PEEP Driving pressure Plateau pressure PEEP (cmh2o) P Plat (cmh2o) !P (cmh2o) N Engl J Med 2015;372:747-55

36 PEEP Driving pressure Plateau pressure N Engl J Med 2015;372:747-55

37 Survival in patients under protective ventilator settings (All with Plateau-pressure " 30 cmh2o and VT " 7 ml/kg IBW), N=1745 * : survival adjusted for Age, APACHE/SAPS risk, Arterial-pH, P/F ratio, and Trial N Engl J Med 2015;372:747-55

38 Dose-Response Relationship Between PPC and Driving Pressure Data from 17 randomized controlled trials, including 2250 patients Tidal Volume and Driving Pressure in surgical patients PROVE Network. Lancet Respir Med 2016, pii: S (16)

39 Dose-Response Relationship Between PPC and Driving Pressure Data from 17 randomized controlled trials, including 2250 patients PEEP and Driving Pressure in surgical patients PROVE Network. Lancet Respir Med 2016, pii: S (16)

40 Dose-Response Relationship Between PPC and Driving Pressure Postoperative pulmonary complications according to response of driving pressure after increase of PEEP PROVE Network. Lancet Respir Med 2016, pii: S (16)

41 Complications Respiratoires Postopératoires Comment peut-on faire mieux? 1. Identifier les patients à risque 2. Stratégie multimodale peropératoire 3. Support ventilatoire postopératoire

42 The P.O.P Ventilation concept A multifaceted bundle of Perioperative Positive Pressure Futier E, Jaber S. Anesthesiology 2014; 121:400 8

43 Postoperative NIV 1 2 NIV Prophylactic use NIV Curative use Postoperative ARF: NO Objective: To prevent ARF Postoperative ARF: YES Objective: To avoid intubation CPAP PSV+PEEP CPAP PSV+PEEP

44 Continuous positive airway pressure (CPAP) during the postoperative period for prevention of postoperative morbidity and mortality following major abdominal surgery (Review) Ireland CJ, Chapman TM, Mathew SF, Herbison GP, Zacharias M Cochrane Database Syst Rev Aug 1;(8):CD008930

45 CPAP versus Usual treatment Outcome: Atelectasis Cochrane Database Syst Rev Aug 1;(8):CD008930

46 CPAP versus Usual treatment Outcome: Pneumonia Cochrane Database Syst Rev Aug 1;(8):CD008930

47 CPAP versus Usual treatment Outcome: Reintubation Cochrane Database Syst Rev Aug 1;(8):CD008930

48 Effect of Postextubation High-Flow Nasal Cannula vs Conventional Oxygen Therapy on Reintubation in Low-Risk Patients A Randomized Clinical Trial N=527 patients at low risk of reintubation Primary outcome: Reintubation within 72 hours after extubation - All adult patients receiving MV duration >12 hours - Low risk of reintubation: Younger than 65 years Absence of heart failure as the primary indication for MV Absence of moderate-to-severe COPD APACHE II score <12 points BMI < 30 Absence of airway patency problems, Ability to manage respiratory secretions (adequate cough reflex or suctioning <2 times within 8 hours before extubation Simple weaning Fewer than 2 comorbidities No prolonged mechanical ventilation (> 7days) Gonzalo Hernandez et al. JAMA. 2016;315(13):

49 Effect of Postextubation High-Flow Nasal Cannula vs Conventional Oxygen Therapy on Reintubation in Low-Risk Patients A Randomized Clinical Trial N=527 patients at low risk of reintubation Primary outcome: Reintubation within 72 hours after extubation Figure 2. Kaplan-Meier Analysis of Time From Extubation to Reintubation Gonzalo Hernandez et al. JAMA. 2016;315(13):

50 Effect of early postextubation high"flow nasal cannula vs conventional oxygen therapy on hypoxaemia in patients after major abdominal surgery: The OPERA Trial Emmanuel Futier 1,2, Catherine Paugam$Burtz 3, Thomas Godet 1, Linda Khoy$Ear 3, Sacha Rozencwajg 3, Jean$Marc Delay 4, Daniel Verzilli 4, Jeremie Dupuis 1, Gerald Chanques 4,6, Jean$Etienne Bazin 1, Jean$Michel Constantin 1,2, Bruno Pereira 5, Samir Jaber 4,6 * and OPERA study investigators Patients without any pulmonary complications until day 7 Patients without postoperative pulmonary complications (%) Intensive Care Med. 2016;42: Adjusted Hazard ratio 0.81 (95%CI ) Days since extubation HFNC oxygen Usual care

51 Effect of Noninvasive Ventilation on Tracheal Reintubation Among Patients With Hypoxemic Respiratory Failure Following Abdominal Surgery A Randomized Clinical Trial N=300 patients with ARF following abdominal surgery Primary endpoint: Any cause of reintubation within 7 days following randomization NIV (!6h during the first 24 hours) vs Standard O2 NIVAS study 45.5% 33.1% Jaber S et al. JAMA 2016,315:

52 Effect of Noninvasive Ventilation on Tracheal Reintubation Among Patients With Hypoxemic Respiratory Failure Following Abdominal Surgery A Randomized Clinical Trial N=300 patients with ARF following abdominal surgery Secondary endpoint: Mortality NIV (!6h during the first 24 hours) vs Standard O2 NIVAS study Jaber S et al. JAMA 2016,315:

53 Complications Respiratoires Postopératoires Conclusion Complications respiratoires postopératoires restent un problème fréquent et responsable d une morbi-mortalité importante Changement de paradigme: prévenir plutôt que traiter! Une ventilation protectrice améliore le pronostic des patients chirurgicaux Seule une stratégie multimodale peut permettre de réduire efficacement et durablement l incidence des CPPs

54 Original Investigation JAMA Surg. 2013;148(8): I COUGH Reducing Postoperative Pulmonary Complications With a Multidisciplinary Patient Care Program Michael R. Cassidy, MD; Pamela Rosenkranz, RN, BSN, MEd; Karen McCabe, RN, BSN; Jennifer E. Rosen, MD; David McAneny, MD Pneumonia Intubation rate

55 Fin Merci pour votre attention