Perioperative Management for Non-Cardiothoracic Surgery Eileen G Aniceto, MD, FPCP, FPCCP Abundio A Balgos, MD, FPCP, FPCCP PCCP Midyear Convention August 7, 2014
Objectives Discuss predictors of peri-operative pulmonary risk before noncardiothoracic surgery Discuss strategies to reduce perioperative risk Given clinical cases, formulate risk stratification evaluation and give preoperative recommendations
Clear the Patient for Surgery \
Do not just clear...evaluate risk for PPCs Evaluate the presence of comorbid conditions that may affect surgical outcome Evaluate how optimally managed a patient s comorbidities are To assure the best possible outcome
Q 1: What is the most common cause of Perioperative Mortality? A. Surgical error B. Anesthesia complications C. Acute medical problem D. Complication of existing disease
What Causes Perioperative Mortality? 0.7 0.8% All cause (4,038 out of 485,850 pts) 1:2680 Anesthesia 1:420 Surgical error 1:95 Underlying medical condition(s) 67% Progression/complication of presenting disease 44% Progression/complication of underlying disease 30% Surgery contributed to mortality < 1/3 Cardiac > 1/3 Pulmonary 1/3 Other medical conditions Fleischer, L, J Am Soc Anesthesiology, May 2002,Vol 96, Issue 5, p.1039-1041
Q2: Which of the following statement(s) is/are true? A. Cardiac post-op complications are more common than pulmo complications B. Cardiac post-op complications are more costly than pulmo complications C. Pulmonary post-op complications result in
Evaluating Pulmonary Risk Pulmonary Complications MORE COMMON than Cardiac Complications Cause Significantly LONGER Hospital Stays Lawrence, VA, Hilsenbeck, SG, et al. J Gen Intern Med 1995; 10:671 MOST COSTLY Complications Dimick, JB, Chen, SL, et al. J Am Coll Surg 2004; 199:531 Pulmonary Complications 6.8% across all types of Surgery Atelectasis, Pulmonary Infection, Prolonged Mechanical Ventilation, Respiratory Failure, Chronic Lung Disease Exacerbation, Bronchospasm Smetana, GW, Lawrence, GA, et al, Ann Intern Med 2006; 144:581
Factors related to PPCs Patient- related risk factors Operation-related risk factors Anesthetic- related risk factors Risk factors related to postoperative care
POSTOPERATIVE PULMONARY COMPLICATIONS AFTER ABDOMINAL SURGERY. Bader, Fayez; Smith, Peter; Baig, Muhammed; Akulian, Jason; Brito, Veronica; Shah, Siddarth; Bergman, Michael; Alfonso, Antonio Chest. 128(4) Supplement:388S-389S, October 2005.
Predictors of Pulmonary Complications Procedure Related Surgical Category Odds Ratio 2.3 Duration Anesth > 3 4 hr Current smoking Resp Comorbidity High Pred MVO2 4.3 2.1 2.1 2.0 Scholes, RL et al. Australian Journal of Physiotherapy. 55(3):191-198, 2009.
Predictors of Pulmonary Complications Procedure Related Surgical Site Duration > 3 4 hr Type of Anesthesia Emergency Odds Ratio Upper Abdominal 2.8 2.14 General 1.83 vs. Spinal 2.21 Qasam, A, et al, Ann Intern Med, 2006, 144:575
Arozullah AM,et al. Ann Intern Med 2001 Ann Surg 2000 Operation-related risk factors AAA-repair Postoperative respiratory failure (OR) Thoracic Upper abdomen Neck Neurosurgery Vascular 0 1 2 4 6 8 10 12 14 16
Anesthetic-related risk factors General anesthesia (thoracic, Ab, Vascular) Operation time >3 hrs 0 1 2 3 4 5 6 7 Smetana GW, et al New Engl J Med 1999
Predictors of Pulmonary Complications Patient Related Odds Ratio of Complications Age > 50, 60, 70, 80 1.5, 2.28, 3.9, 5.63 Chronic Lung Disease 2.36 Asthma Uncontrolled 3, Controlled 1 Smoking Current 5.5, 2 mo Cessation Heart Failure 1.26 Albumin BUN Functional Dependence 2.29 ASA Class >= 2 2.93 2.53 Total 2.51 Partial 1.65 4.87 Qasam, A, et al, Ann Intern Med, 2006; 144:575
Case # 1 D.C. 52 year old female, nonsmoker, known asthmatic and hypertensive, referred for preoperative pulmonary evaluation prior to laparascopic cholecystectomy under G.A. History: maintained on low dose ICS-LABA combination, complains of occasional shortness of breath and coughing at least once a week, requiring rescue doses of Salbutamol. maintained on losartan HCTZ combination
Case # 1 : D.C. Physical examination: Conscious, NIRD, BMI 28 BP 140/80, PR 85, RR 24, T 37.5, sat 98 Chest/lungs unremarkable, end expiratory wheezes
Q3: Which laboratory test would be needed? A. Chest Xray B. Arterial Blood Gases C. Pulmonary Function Test D. All of the above
Preoperative pulmonary evaluations History and physical examination Chest radiography Arterial blood gas analysis Pulmonary function test Quantitative lung scan Exercise test
history and physical examination include past and current medical history surgical history, family history, social history history of allergies, current and recent drug therapy any previous problems with anesthetics complete review of systems, emphasis on problems of cardiovascular and respiratory symptoms PE includes assessment of airway, lungs and heart, vital signs
Recommendation for preoperative CXR Age > 50 years Known pre-existing cardiopulmonary diseases S/S likelihood of cardiopulmonary disease Smetana GW, et al Med Clin N Am 2003
Role of Chest X ray Commonly ordered as preoperative study regardless of a concern for preexisting pulmonary disease One review found a lower rate of PPCs in patients who received preoperative chest roentgenograms (12.8% vs 16%), but, interestingly, the Joo, HS et al Can J Anaesth 2005; 52, 568-5 results only altered management in 1
Role of Arterial blood gas Small study series identified Hypercarbia(PaCO2>45 ) risk for PPCs Milledge JR, et al. BMJ 1975 Stein M, et al. JAMA 1962 Recent systematic review by Fisher BW, et al 2002 does not find hypercarbia useful
Role of PFT Accurately identify patients who are not likely to survive resectional thoracic surgical procedures, and those who will not have a prolonged survival following lung volume reduction surgery Beckles, MA, et al Chest 2003; 123(suppl), 105S-114S The role of preoperative pulmonary function assessment for patients undergoing other types of operations is less clear McAlister, FA et al Am J Respir Crit Care Med 2003; 167, 7 no lower limit of FEV 1 below which a PPC will definitely occur PPCs can occur even when the preoperative FEV is normal
Preoperative PFTs Thoracic surgery Upper abdominal surgery with respiratory symptoms remain unexplained after careful evaluation Routine PFTs should not ordered solely without clinical assessment Arozullah AM. Med Clin N Am 2003; 87: 153-173
CXR result: no new infiltrates Case #1: CXR
Case # 1: ECG Within normal limits
Case # 1: other lab tests CBC: Hgb: 125, Hct: 35, WBC: 6.8, N 60%, L 35%, E 3%, M 2% creat 0.8, sgpt 35
Q4: What would be your next step? A. Clear the patient for surgery B. Increase the dose of ICS- LABA C. Add a course of oral steroids D. Add short-acting
Preoperative evaluation of patients with asthma
Implications of asthma in perioperative setting Present for an anesthetic with poorly optimized asthma Bronchospasm may be precipitated by instrumentation, a variety of drugs, aspiration, infection or trauma Emergence from anesthesia presents a risk of laryngospasm and bronchospasm Pain, fluid shifts and delayed mobilization can contribute to increased risk of PPC
The asthmatic patient undergoing surgery is at risk for perioperative morbidity and mortality Large retrospective review: incidence of intraoperative bronchospasm and laryngospasm was low (1.7%) Complications more frequent in Warner DO, Warner MA, Barnes RD, older patients and those with Anesthesiology1996;85: 460 7 active asthma et al. Perioperative respiratory complications in patients
Although bronchospasm comprised only 2% of large data base of patients undergoing surgery, 90% of the claims involve severe brain injury or death Cheney FW, Posner KL, Caplan RA. Adverse respiratory events infrequently leading to malpractice suits. A closed claims analysis. Anesthesiology1991;75: 932 9
Intraoperative bronchospasm is uncommon but potentially devastating complication of anesthesia
When asthma is well controlled, no additional risk for perioperative complications; when it is poorly controlled, it almost always does Smetana GW, Conde MV. Preoperative pulmonary update. Clin Geriatr Med 2008;24: 607 24, vii
History Frequent exacerbations? Recent hospital visits? History of prior intubations and mechanical ventilation? Prior perioperative exacerbation?
History Triggering agents Type, dose, frequency and degree of benefit of existing therapy Respiratory infections, including sinus infections can trigger an asthma attack
Physical examination Focus on detecting signs of acute bronchospasm or active lung infection, chronic lung disease and right heart failure
Our patient DC.. Has symptoms once a week despite ICS LABA medications One week prior to consult, developed cough and colds with daily doses of salbutamol puff Slightly tachypneic on PE, with end expiratory wheezing Chest xray no new infiltrates
Pre operative preparation Lung function should be improved to baseline or as near to baseline by optimizing medications and compliance Consider short course of oral steroids: oral methylprednisolone 40mg for 5 days prior to surgery has been shown to decrease post intubations wheezing Silvanus MT, Groeben H, Peters J..Anesthesiology2004;100
Pre operative preparation Patients on systemic steroids for 2 weeks within 6 months prior to surgery may be prone to steroid-induced adrenal suppression Give short acting steroids: hydrocortisone 100mg iv q 8 during perioperative period Expert Panel Report 3 (EPR-3). Guidelines for the d management of asthma summary report 2007.J Al Immunol 2007;12: S94 138
Preoperative Preparation Short-acting bronchodilator therapy given prophylactically has likely benefit MDI or nebulizer delivery is equivalent if proper technique is used Elective surgery should not be performed in the presence of active bronchospasm, and the cause (e.g. a new respiratory infection) and symptoms should be actively treated until the patient is back to baseline status
Preoperative Preparation An optimal premedication allays anxiety, improves work of breathing, and possibly averts the induction of bronchospasm, while eschewing oversedation and respiratory depression. No ideal drug or drug combination exists for this. The a -2 agonist dexmedetomidine has a favourable profile, including anxiolysis, sympatholysis, and drying of secretions without respiratory depression
Keys to uncomplicated perioperative period in patients with asthma Detailed preoperative assessment Maintenance of anti inflammatory and bronchodilatory regimen Potential trigger agents should be identified and avoided Acute bronchospasm can still occur, especially at induction and emergence, and should be promptly and methodically managed.
Case # 2: V.T. 65 year old male, current smoker, with 40 pack smoking history referred to you for pulmonary evaluation prior to herniorraphy he is also known hypertensive controlled on telmisartan-amlodipine combination
Case # 2: V.T. CP history: Chronic cough, for more than 2 years, minimally productive of whitish sputum Denies shortness of breath at rest or exertion, but admits to getting short of breath on climbing to the second storey of his building. No chest pains
Case # 2: V.T. Physical examination: Weight 70 kg, height 5 8 HR 58, RR 18, BP 140/90, T = 36.9 sat 94% Decreased breath sounds, no wheezes or rhonchi
Case # 2: CXR Results: flattened diaphragms, hyperaerated lungs, no new infiltrates
Results: sinus bradycardia Case # 2: ECG
Case # 2: PFT Results: FEV/FVC pre = 58.85 post = 46.55 FEV1 pre = 1.91 (62%) (48%) post = 1.47 FVC pre = 3.25 (88%)
Q5: Which statement is true? A.The increased frequency of PPCs in patients COPD may be explained by comorbidities (e.g. cardiovascular disease) rather than by airway obstruction. B.The incidence of PPCs (except atelectasis) does not parallel the severity of respiratory impairment C. It is generally agreed that 2 weeks of smoking cessation reduces postoperative complications.
Preoperative evaluation of patients with COPD
Large numbers of high risk respiratory patients as a consequence of Prolonged life expectancy Increasing prevalence of COPD Greater needs for invasive diagnostic procedures and surgical interventionshalbert et al 2006
The prevalence of COPD is even higher among surgical candidates compared with aged-matched population groups 5% 10% of COPD patients in general surgery 10% 12% in cardiac surgery 40% in thoracic surgery vs. 5% of COPD patients in the McAlister et al 20 Halbert et al 200 Licker et al 2006
As common risk factors (ie, smoking, advanced age and sedentarity) are shared by cardiac and pulmonary diseases, a large proportion of COPD patients are afflicted with hypertension (34%) occlusive or aneurysmal arterial disease (12%) heart failure (5%) cardiac arrhythmia or conduction blockade (12%) Sin et al 2005
Patients with pre-existing organ dysfunction (eg, ischemic heart disease, COPD and renal insufficiency) are more likely to develop an acute coronary syndrome, heart failure, bronchopneumonia or respiratory failure following major interventions Kaafarani et al 2004 The increased frequency of PPCs in patients with chronic obstructive pulmonary disease (COPD) may be explained by co-morbidities (e.g. cardiovascular disease) rather than by
Patients with COPD may have chronically fatigued respiratory muscles. Impaired nutrition, electrolyte and endocrine disorders can contribute to respiratory muscle weakness Patients with COPD should be examined for unrecognized cor pulmonale
The presence of either obstructive or restrictive pulmonary disease places the patient at increased risk of developing perioperative respiratory complications. In COPD patients [with FEV1 1.2 L and FEV1/FVC < 75%] undergoing non-cardiothoracic surgery, incidence of PPC as high as 37% and a 2 year mortality of 47% Wong et al Anesth Analg; 1995, 80:276-84.
The incidence of PPCs (except atelectasis) most often parallels the severity of respiratory impairment Moderate if FEV1 50-80%, Severe if FEV1 < 50% Especially in patients with abnormal clinical findings and marked alterations of gas exchange requiring o2 therapy The worst prognosis is expected in patients with pulmonary artery hypertension and chronically fatigued respiratory muscles given the risk of right ventricular failure with hemodynamic Jaber collapse et al 2005 and
Generally, all patients with COPD / asthma who require home oxygen therapy or have required hospitalization for respiratory problems in the past 6 months are assumed to be at greater risk.
In the post operative period the changes in the chest wall function caused by the anesthesia Implications of COPD in the perioperative setting Anesthesia results in the disruption of the intricate coordination between multiple chest wall muscles that facilitate breathing and motion of the chest wall becomes uncoordinated Induction of anesthesia results in decrease in FRC leading to atelectasis and impaired gas exchange
Impairment of upper airway reflexes caused by prolonged tracheal intubation or incomplete reversal of neuromuscular blockade may increase the risk of aspiration and pneumonia In smokers, there is an inherent impairment of defensive mechanisms that act against developing lung infection Airway manipulation could result in bronchospasm
All of these, combined with post operative atelectasis and impaired coughing prepare the stage for PPCs
Preoperative preparation of COPD patients
Assessment of general physical status treatment of any reversible signs/ symptoms treatment of any reversible component of lung pathology (antibiotics, bronchodilators, steroids, etc) pulmonary function should be optimized preoperatively by standard guidelines
Spirometry is used as guide for treatment. Chest radiograph is necessary to evaluate symptoms. Arterial blood gas measurements are performed if spirometric values of FEV1and FVC < 50% predicted or an FEV1< 1 lt or a FVC < 1.5 lts A PaCO2 value > 45 mmhg is a strong risk factor for PPCs A PaCO2value > 50 mmhg is likely to require a period of postoperative ventilation
Postpone elective surgery if improvement of pulmonary function is possible and requires more time. Preoperative education would improve the final outcome deep breathing exercises incentive spirometry continuous positive airway pressure
COPD Smokers It is generally agreed that 6 weeks of abstinence reduces postoperative complications. Within 12 to 48 hours of abstinence, effects attributable to CO and nicotine disappear Airway reactivity is significantly reduced at 1 week at 2 weeks a 50% reduction of sputum volume six to 8 weeks of abstinence reduce wound complications 12 weeks of abstinence is needed for full
Prevent and Treat Bronchospasm In patients with reactive airways, all possible steps should be taken to PREVENT bronchospasm Treat the airway inflammation Inhaled B2 agonists, esp if with plan to intubate try to avoid tracheal intubation Propofol, ketamine or volatile anesthetics are the induction agents of choice
in COPD... Preoperative optimization of respiratory status help prevent PPCs the preoperative risk evaluation, composite scoring system are more efficacious
Steps for pulmonary risk evaluation
Recommendations for Assessment of Pulmonary Risk History and Physical Exam Identify Pulmonary Risk Factors American Society of Anesthesiologists - Global Assessment of Pulmonary Risk Arozulla Multifactorial Risk Index for Postoperative Respiratory Failure Smetana, G, et al, Ann Intern Med, 2006; 144:581
ASA Postoperative Pulmonary Complications Class Pulmonary Complications 1 Healthy 1.2% 2 Mild Systemic Disease 5.4% 3 Severe Systemic Disease, limits 11.4% activity, but not incapacitating 4 Incapacitating systemic disease, 10.9% which is a constant threat to life 5 Moribund, not expected to survive NA 24 hrs with or without surgery Qasim, A, et al. Ann Intern Med, 2006; 144:575-580
Arozullah, AM, Daley, J, et al, Ann Surg 2000; 232:242
Respiratory Failure Index Scoring Arozullah, AM, Daley, J, et al, Ann Surg 2000; 232:242
Put It All Together Step 1 ASA 1 and To OR Low Risk PRF 1 Step 2 ASA 2 or Consider Further Testi PRF 2-3 CXR, PFT if will cha management. Step 3 ASA >= 3 or Reconsider Surgery High Risk PRF >= 4 Shorter Procedur Spinal or Epidural For all: Deep Breathing Exercises/Incentive spirometry Treat Identified Risk Factors & Special Conditions Smetana, G, et al, Ann Intern Med, 2006;144:581
Arozullah AM,et al. Ann Intern Med 2001 Ann Surg 2000 Limitation of risk indicies Developed from male, high co morbid level; may not generalized to healthy population Hospital based study from Veterans Hospital
Risk reduction strategies(1) Smoking cessation at least 8 weeks Perioperative lung expansion maneuver Incentive spirometry Chest physical therapy Intermittent positive pressure breathing (IPPB) Continuous positive airway pressure (CPAP)
Strategies to Reduce Postoperative Pulmonary Complications What Works Pre-op Asthma Evaluation Aggressive Tx. For COPD Inspiratory Muscle Training Pre-op Patient Education Selective Post-op NG decompression What Doesn t Smoking Cessation Pre-op Antibiotics Tube Feed or TPN Median Length of Stay 1 day shorter Complication rate vs controls 18% vs.35% Hulzebos, EH, et al, JAMA, 2006; 296:1851
Bluman LG, et al. chest 1998 Warner MA, et al. Mayo Clin Proc 1989 Paradoxical increase PPCs after short-term abstinence Sicker pts tend to quit smoking closer to surgery Stop smoking decrease irritation decrease stimulus for cough Still have bronchial hypersecretion increase sputum retention
Lung Expansion Techniques incentive spirometry deep breathing exercises chest physical therapy intermittent positive pressure breathing continuous positive pressure breathing
Perioperative lung expansion maneuvers A meta-analysis evaluating: upper abdominal surgery Similar in efficacy Incentive spirometry (IS) Deep breathing exercise (DB) Intermittent positive pressure breathing (IPPB) Better than no respiratory therapy Thomas JA, et al. Physical Therapy 1994; 74:3-10.
Strategies To Reduce Postoperative Pulmonary Complications after Noncardiothoracic Surgery: A systematic review for the ACP Valerie A.Ann Intern Med.2006;144:596-608 MEDLINE English language literature search, Jan 1, 1980 to June 30 2005 RCTs, Systematic reviews or metaanalysis The search and inclusion criteria identified 20 randomized clinical trials and 11 systematic reviews or meta-analyses
First of 2 systematic review identified 14 RCTs on upper abdominal surgery across all lung expansion modalities a trend favored fewer post op pulmonary complications (Odds ratio 0.85) in 2 studies, post op pulmonary complications occurred less often in patients receiving IS (Odds ratio 0.44) in 4 studies, post op pulmonary complications occurred less often in patients assigned to deep breathing exercises (Odds ratio 0.43)
Perioperative lung expansion maneuvers No specific lung expansion maneuver is clearly superior CPAP may be beneficial in patients unable to perform DB or IS Initiating lung expansion maneuver preoperatively is more effective in reducing PPCs than postoperatively Arozullah AM. Med Clin N Am 2003; 87: 153-173
Risk-reduction strategies (2) Maximize pulmonary function Bronchodilator Inhaled corticosteroid Theophylline Antibiotic Smetana GW, et al. New Engl J Med 1999; 346: 937-944.
Risk-reduction strategies: Intraoperatively Limit duration of surgery to <3 hours Use spinal or epidural anesthesia Use laparoscopic procedure when possible Smetana GW, et al. New Engl J Med 1999; 346: 937-944.
Risk-reduction strategies: postoperatively Adequate pain control (post-op analgesia) Early ambulation Use lung expansion maneuver Maximized pulmonary function (with adequate medication) Smetana GW, et al. New Engl J Med 1999; 346: 937-944. Lawrence VA et al. Ann Intern Med 2006; 144: 596--608.
Strength of Evidence for Risk Reduction Strategies Lawrence VA et al. Ann Intern Med 2006; 144: 596--608.
Preoperative Care of Pulmonary Patients: Conclusion Many factors related to PPCs Working as a team plays major roles Assessment of the risks,conduct of appropriate testing and modification of risk factors are the keys of preoperative caring and reduction of post-operative complications