Postoperative pulmonary complications
•Download as PPTX, PDF•
26 likes•8,128 views
2013 Northern Ireland Intensive Care Society Coppel Prize presentation by Dr Christopher Wasson
Recommended
Recommended
More Related Content
What's hot
What's hot (20)
Viewers also liked
Viewers also liked (20)
Similar to Postoperative pulmonary complications
Similar to Postoperative pulmonary complications (20)
More from NHS
More from NHS (10)
Recently uploaded
Recently uploaded (20)
Postoperative pulmonary complications
- 1. Post operative pulmonary complications Chris Wasson St3 Anaesthesia
- 2. • PPC’s • Audit project • interventions • iCough bundle • summary • questions/discussion
- 3. What are PPCs? • Respiratory failure • Atelectasis • Acute lung injury • Pneumonia • Pneumothorax • Pneumonitis • Exacerbation COPD
- 4. Why are they important • Common; incidence of 1.2 – 10.9% • Increased mortality – 10.7% • Increased ICU stay • Increased Hospital day 8-14 days • Increased hospital costs -75%
- 5. Risk factors • Patient • Surgical • Anaesthetic
- 7. Project • Prospective cohort • January to June • 100 major cases followed up for 10 post operative days
- 8. Aims • Identify rate of PPC • Identify high risk groups
- 9. Data collected • • • • • • AGE Pre-op functional status ASA score BMI OSA Congestive heart failure hx [use NYHA if known or mild, moderate, severe] • Cigarette use • Asthma/COPD • Diabetes [IDDM/NIDDM]
- 10. Post operative pneumonia • Temp >38.5 • Wheeze • New onset purulent sputum • WCC and CRP • CXR • Anti-biotics • New nebs
- 11. Cohort • 102 patients • Male 62 Female 40 • Average age 62.1 ASA: I – 11 II – 41 III – 47 IV - 3
- 12. Patient Characteristics • 32% overweight • 20.5% obese • 21.6% smokers • 32.3% ex smokers • 21 patients with prior respiratory disease • 17 diabetics
- 13. Surgical factors • Elective – 83 • Emergency – 19 • Average duration of surgery 208 minutes
- 14. Speciality • General – 35 • HPB – 25 • Upper GI – 13 • Vascular – 11 • Urology – 8 • Gynae – 7 • Transplant – 3
- 15. Results • Rate of PPC 20.5% • Rate of post op pneumonia 14.7%
- 16. Analysis • Rate pneumonia 14.7% • Per specialty: • 14.3 % general • 27.3% vascular • 30.8% upper GI • 14.3% gynaecology • 0% transplant
- 17. Asa • 1 – 0% • 2 – 9.8% • 3 – 21.3% • 4 – 33.3%
- 18. • Emergency - 10.2% • Elective – 15.7% • EX-smoker – 21.9% • Smoker 27% • Non-smoker – 3.8% • Overweight – 12.5% • Obese – 14.6% • Diabetes – 23.5%
- 19. analysis • Pulmonary disease – 33.3 % • Upper abdominal incision – 19.4% • Elective surgical time – 232 minutes • Epidural 45% • 26% in epidural group • 5.4% in non epidural group • 80% post op pneumonia had epidural
- 20. At risk groups • ASA 3 • Prolonged surgery (>180 minutes) • Pre existing pulmonary disease • Upper abdominal incision • Diabetics • Smoking history
- 21. What to do about it?
- 22. Bundles • Simple • Inexpensive • Implementable • Easily audited
- 23. Examples • VAP • Central line – matching Michigan • Sepsis 6 - Rivers
- 24. Interventions • “Manchester Respiratory Intervention” • Pre operative • Peri operative • Post operative
- 25. Pre operative • Patient education • Teeth brushing • Chlorhexidine mouthwash • Pulmonary optomisation
- 26. Peri operative • Polyurethane tapered tube • Sub glottic suctioning
- 28. ICOUGH Bundle of preventative measures for PPC's • Boston Medical Centre USA, Aug 2010 • All general and vascular surgical patients • Post op pneumonia 2.55% down to 1.62% • Unplanned intubations 1.98% down to 1.16%
- 29. 6 Elements I - Incentive spirometry C - Cough/deep breathing exercises O - Oral Care U - Understanding/education G - Getting out of bed H - Head of bed elevation
- 30. Important ICOUGH Features • Bundle of simple nursing/physio interventions • Basic and inexpensive • Estimated cost of PPC per patient between £4000 - £16 000 • Length of hospital stay increased by 8-14days • Effective in reducing PPCs • Implemented through check-lists • Easy to measure effectiveness and re-audit
- 31. ICOUGH Development Audit of the pre-intervention practices of nurses and physios Set up a multi-disciplinary pulmonary care working group Development of ICOUGH bundle Programmes of education for doctors, nurses, physios and patients Preparation of check-list bundle Audit of post intervention practices
- 32. Patient Audit • 50 patients over 6 week period + followed them daily • Post-op HDU following major surgery • Average duration of surgery 3h 30min PPC Incidence Types of PPC 1 24% 1 No PPC 76% Pneumonia Atelectasis 2 PPC 8 patients Pnemothorax Pleural Effusion
- 33. Education and Mobilisation Education Were risks of PPCs and preventative measures explained? Yes - 36% No or couldn’t remember - 64% ACTION : Educate all patients on risks or and measures to prevent PPCs Mobilisation Good early mobilisation – 22% Partial mobilisation – 40% Little or no early mobilisation – 38% ACTION: Promote early and regular mobilisation (chair and/or walking)
- 34. Oral Hygiene and Deep Breathing Oral Hygiene Tooth brushing ≥ 2/day - 70% Tooth brushing < 2/day - 24% Data not available - 6% ACTION: Implement consistent oral hygiene regime for all patients Deep breathing ≥ once every 2h - 56% < once every 2h - 40% Data not available - 4% ACTION: To standardise the deep breathing regimes for patients and to regularly prompt patients
- 35. Incentive Spirometer and Position Incentive Spirometer Only 20% of patients received an incentive spirometer and instructions on how to use it ACTION: To issue incentive spirometers before surgery and educate patients in their use and benefits Position The head of the bed was elevated by 30 degrees or more for all patients for which is was appropriate ACTION: None
- 36. Other ICOUGH Research Vancouver General Hospital, Nov 2012 The results for their "ICOUGH" compliance were: Measure % patients Vancouver % patients MRI Incentive spirometry 17% 20% Deep Breathing (≥1/2h) 52% 56% Oral Care 60% 70% Understanding/education 21% 36% Get out of bed 17% into a chair 76% walking 62% Head of bed elevation 48% 100%
- 37. What Should Happen Next? 1. Decide on whether to implement ICOUGH 2. If yes - Create an implementation plan 3. Identify any obstacles and involve all staff in addressing these 4. Regularly monitor the PPC incidence 5. Review the handover from HDU to wards
- 38. Potential Barriers to Implementation Examples of Potential Barriers • Work load on the nursing staff • Lack of chairs/space for chairs • Mobilisation of patients with attachments • Need for help in manual handling of patients
- 39. Manchester Respiratory Intervention Preoperative Intraoperative Postoperative • Lung optimisation • Prevent aspiration • HDU ICOUGH + fluid limitation •Patient Education •Endotracheal tube design •Oral Decontamination • Cuff pressure monitoring • Critical care surgical pathway • Surgical ward ICOUGH
- 40. Thank You
- 41. Other PPC Prevention Bundles • NICE (UK) 2008 • British Society of Antimicrobial Chemotherapy 2008 • Scottish Intensive Care Society 2008 • European HAP Working Group 2008 • Canadian Clinical Trials Group 2008 • American Society for Critical Care 2008 • Institute for Healthcare Improvement (US) 2006 • American Thoracic Society 2005 • Center for Disease Control (US) 2003
- 42. References • Peri-operative Respiratory Complications and the Post-operative Consequences – Atelectasis and Risk Factors Paolo Pelosi and Cesare Gregoretti • Polyurethane cuffed endotracheal tubes to prevent early postoperative pneumonia after cardiac surgery: A pilot study Stijn Blot Jan Poelaert, Pieter Depuydt, Annick De Wolf, Stijn Van de Velde, Ingrid Herck J Thorac Cardiovasc Surg 2008;135:771-776 What’s new in the prevention of ventilator-associated pneumonia? Stijn Blot1, Jordi Rello2, and Dirk Vogelaers1
Editor's Notes
- So what is ICOUGH? ICOUGH is a standardised bundle of measures designed to reduce the incidence of post-operative pulmonary complications in patients undergoing major surgery. The bundle was developed at the Boston University Medical Centre, Massachusetts, USA and implemented in the BMC August 2010. It has been applied to all general and vascular surgical patients at the BMC since then. The baseline incidence of PPCs was monitored in the period 2009-2010. The effectiveness of ICOUGH was tested in 2012 (for the two year period for which it had been implemented) and the incidence of post-operative pneumonia was down from 2.55% to 1.62% and unplanned intubations down from 1.98% to 1.16%. Say it was ICU,HDU and surgical wards
- The multidisciplinary team at the Boston Medical Centre developed the acronym I COUGH as a reminder of the key elements of the bundle. The ICOUGH program encompasses 6 elements and these are: Incentive spirometry The purpose of incentive spirometry is to improve the functioning of the lungs and to minimise the build up of fluid in the lungs. The back pressure while using the incentive spirometer opens the alveoli – it is the same manoeuvre that occurs during a yawn. The incentive spirometer provides an indicative gauge of how well the lungs are functioning and it is normally applied for 5 minutes 5/day or 10 sets/ hour with 3 -5 efforts/ set. Coughing and deep breathingEncourages patients to cough and deep breathe every 2 hours this should help stimulate the removal of lung secretions Oral care Mouth care mornings and evenings – brushing teeth and rinsing with mouthwash UnderstandingPatient should understand the risk of developing a PPC, the consequences of developing a PPC and the importance of preventative measures. Getting out of bedMobilisation from bed to chair at least once on the day of the operation and at least 3/day following this. Head-of-bed elevation Correct positioning of the patient so that the head of bed is elevated above 30o
- A important feature of the ICOUGH bundle is that all patients get a standardised system of optimal care.And this is achieved by an easily performed patient care strategy involving a multidisciplinary team.Another important feature of ICOUGH is that it provides basic patient care without needing expensive equipment for example a cost of an incentive spirometer is approximately 5-10 pounds per unit. These costs are small when compared to the estimated cost of between £4000 - £16 000 depending on the severity of the PPC developed.
- The ICOUGH development at the Boston Medical Centre was part of the US National Surgical Quality Improvement Programme. GO THROUGH SLIDEThis method of developing a bundle is recognised as the optimal way of implementing evidenced-based improvements in patient care.
- Part of my project was to evaluate the incidence of PPCs in a cohort of 50 patients. All these patients had undergone major surgery and had spent the first phase of their recovery in the HDU. This cohort of 50 patients was believed to be large enough to be a representative sample of all post-operative patients on HDU.
- Introduce ICOUGH slides:Now I am going to present 3 slides giving the result of my audit of ICOUGH compliance. I shall deal with 2 ICOUGH elements per slide. You might find it surprising that about 1 third of the patients couldn’t remember whether they had been informed or not. However, some of these patients were old, had language or learning difficulties or felt that they were told too much information prior to surgery. As you can see there is a large percentage who are only being partially mobilised or receive no early mobilisation after surgery. The HDU staff report that some patients are not keen to be mobilised, possibly because of post operative pain. It might really help if the reasons for early mobilisation were explained to each patient before surgery.
- There is a large variation in the oral hygiene regime between patients. The reasons for this degree of variation are not clear. For the deep breathing exercises there is a wide variation between patients. Many patients seem to forget their deep breathing exercises unless reminded by the nurses or physios.
- The 20% of patients who received an incentive spirometer all had similar types of surgery for which incentive spirometer is already advised. For example a number of these patients had cardio-oseophagectomies. Note that the use of incentive spirometry is somewhat controversial. Many papers support its effectiveness in improving lung function but, in 2001, a Canadian systematic review of IS concluded that “the evidence does not support the use of IS for decreasing the incidence of PPCs following cardiac or upper abdominal surgery”. However, this Canadian review also indicated that there was no evidence of incentive spirometry causing any harm to patients. But for patients suffering from confusion or poor memory, IS may provide a visual prompt to carry out deep breathing exercises. The HDU staff routinely elevate the head of the bed to greater than 30 for patients in which it is appropriate.
- 62% for good early mobilisation
- Following the studies at the MRI, we need to decide whether to implement a bundle to prevent PPCs in the HDU and which specific elements should be included in this bundle. If yes – it is important to involve all staff in how the bundle is implementedAnd once implemented it is important to review the effectiveness of the measuresPatients are often transferred from HDU to the wards during days 3-5 post op. And most PPCS only become apparent from days 5-9 and hence the continuity of application of preventative measures from the HDU to the wards is important, hence the need for a handover review which includes continuation of some of the PPC prevention measures.
- If it is agreed that implementation of a PPC prevention bundle is a key way of improving the quality of patient care then none of these potential barriers should prevent its implementation but the barriers do need to be resolved by the multidisciplinary team.
- Some of these bundles are more appropriate for preventing VAP rather than POP e.g. SICS.