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Postop pulmonary complications

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Postop pulmonary complications

  1. 1. Sultan Qaboos University Hospital, Muscat
  2. 2. JACKSON EQUESTRIAN MONUMENT downtown Charlottesville,Virginia “Stonewall” Jackson Confederate General …dying of pneumonia 10 days after an otherwise successful ether anesthetic 1863
  4. 4. Pneumonia Definite / Suspected Respiratory failure Requiring mechanical ventilatory support Bronchospasm
  5. 5. Unexplained fever Excessive bronchial secretions Abnormal breath sounds “Productive” cough Atelectasis Hypoxemia
  6. 6. 22.7 9.610.7 5.7 0 5 10 15 20 25 Hospital stay Complis PULM CARDIAC
  7. 7. Causes of
  8. 8. Disruption of normal activity of respiratory muscles Altered neural drive for respiration • Distribution • Timing
  9. 9. Begins with induction of anesthesia Continues into postop period
  10. 10. EXPIRATION
  13. 13. Reduces efficiency Decreases FRC Atelectasis in dependent lung Impair pulmonary gas exchange
  14. 14. Impair effectiveness Voluntary limitation of respiratory motion Decreased phrenic motor neuron output
  15. 15. Bronchoconstriction • Airway instrumentation; drugs- release of inflammatory mediators Impaired mucociliary transport • Anesthetic gases; tracheal intubation Functional impairment of pulm inflammatory cells • Prolonged surgery, anesthesia Surgical/anesth intervention related • Aspiration pneuminitis;ALI –after CPB; Pneumothorax- barotrauma/surgical trauma; Negative Pr Pulm Edema
  16. 16. Risk factors for
  17. 17. The most important risk factor for postoperative pulmonary complications? A. High-risk surgical site B. General anesthesia C. COPD D. Obesity
  18. 18. Patient-related Advanced age ASA PS >2 Cong Heart failure Functional dependency COPD Surgery-related Aortic aneurysm repair Thoracic surgery Abdominal surgery Upper abdominal surgery Neurosurgery Prolonged surgery Head & Neck surgery Emergency surgery Vascular surgery Use of GeneralAnesthesia
  19. 19. Patient-related Weight-loss Impaired sensorium Cigarette use Alcohol use Abnormal chest exam Surgery-related Perioperative transfusion
  20. 20. Patient-related Well-controlled asthma Obesity Surgery-related Hip surgery GU/Gynaec surgery
  21. 21. Patient-related Obstructive sleep apnoea # Poor exercise capacity Surgery-related Esophageal surgery # - subsequent evidence : OSA – possible risk factor
  22. 22. Which of the following is a recently identified novel risk factor for PPCs? C. Pulmonary Hypertension B. Insulin-treated diabetesA. Epidural anesthesia D. Immobility
  23. 23. Strategies for risk reduction
  24. 24. Postoperative lung expansion modalities • Incentive spirometry • Deep breathing exercises • Int. Positive Pressure Breathing • CPAP
  25. 25. Selective postop NG tube use NG tubes potentially increase risk of aspiration Use in select patients: • Symptomatic abdominal distention • Inability to tolerate oral intake • Nausea
  26. 26. Laparoscopic (vs Open) operation Evidence begins to follow intuition Open surgery: • Higher rate of sepsis • CV events
  27. 27. RoutineTPN or enteral nutrition Right heart catheterization While hypoalbuminemia and malnutrition increase postoperative complications, including pneumonia, routineTPN has no benefit over eitherTEN or no hyperalimentation. Inadequate intake Atrophy of intestinal villi Bacterial translocation across gut mucosa Subsequent sepsis
  28. 28. Intraop neuraxial blockade Postop epidural analgesia Insufficient or conflicting data ? Selection bias ? Insufficiently powered study - Study on low-risk procedure
  29. 29. Intraop neuraxial blockade Postop epidural analgesia IV PCA vs PCEA vs On-demand analgesia ?Timing issues (Heparin prophylaxis)
  30. 30. Smoking cessation Early reports - those who quit shortly before surgery actually had higher complication rates Question remains unanswered
  31. 31. Promising New Intervention
  32. 32.  Preoperative lung expansion  Inspiratory MuscleTraining
  33. 33. Preop IMT can be done in chest physical therapy OPD or a pulmonary rehabilitation clinic
  34. 34. Take Home Messages
  35. 35. PPCs incidence More common than cardiac complications after non- cardiac surgery
  36. 36. Surgical site Most important predictor of risk of PPCs: Aortic, thoracic and upper abdominal surgeries are high- risk procedures, even in healthy patients
  37. 37. OSA & Pulmonary HTN Recently identified as risk factors; Limited available evidence does not support preop screening (in patients without symptoms)
  38. 38. Postop CPAP Effective for reducing pulmonary complications in patients who are unable to perform deep breathing or incentive spirometry exercises
  39. 39. Smoking cessation As an effective strategy to reduce pulmonary risk remains unanswered…
  40. 40.