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Pre-operative Pulmonary/Cardiac Criteria

Josh Adams Nathan DeWitt

Definition of Post-Op Pulmonary Complications

Pulmonary abnormality that produces identifiable disease or dysfunction that is clinically significant and adversely affects the clinical course

Categories of Clinically Significant Complications

Atelectasis Infection, including bronchitis and pneumonia Prolonged mechanical ventilation and respiratory failure Exacerbation of underlying chronic lung disease Bronchospasm

Peri-operative lung physiology

Thoracic and Abdominal Surgery

Vital capacity (VC) is reduced by 50 to 60 percent and may remain decreased for up to one week Functional residual capacity (FRC) is reduced by about 30 percent

Diaphragmatic dysfunction appears to play the most important role in these changes Reduction of the FRC below closing volumes contributes to the risk of atelectasis, pneumonia, and ventilation/perfusion (V/Q) mismatching

Residual effects of anesthesia itself and postoperative opioids both depress the respiratory drive Inhibition of cough and impairment of mucociliary clearanceIncreased risk of infection

Patient Related Risk Factors

Definite Risk Factors

Upper abdominal and thoracic surgery lasting greater than three hours Chronic obstructive lung disease Smoking hx within past 8 weeks Use of pancuronium as a neuromuscular blocker General Anesthesia (when compared to spinal or epidural anesthesia) Emergency surgery PaCO2 > 45 mm Hg Current upper respiratory tract infection Abnormal chest x-ray Age >65 Peri-operative NG tube placement

Probable Risk Factors

Possible Risk Factors

Pre-operative Risk Assessment

Complete H&P is most important tool for evaluation & risk assesement

Significant risk factors should be identified

Physical examination should be directed toward evidence for obstructive lung disease Laboratory tests serve as adjuncts to the clinical evaluation and should be obtained only in selected patients

Pulmonary function tests (PFTs) Arterial blood gas analysis Chest radiographs Exercise testing

Recommended Strategies

Preoperative Strategies

Smoking cessation for 8 weeks Inhaled ipratropium for all patients with clinically significant COPD Inhaled beta-agonists for patients with COPD or asthma who have wheezes or dyspnea Preoperative corticosteriods for patients with COPD or asthma who are not optimized to best baseline and whose airway obstruction has not been maximally reduced Delay elective surgery if respiratory infection present Antibiotics for patients with infected sputum

Recommended Strategies Cont.

Intraoperative Strategies

Choose alternative procedure lasting less than 3 to 4 hours when possible Minimize duration of anesthesia Surgery other than upper abdominal or thoracic when possible Choose laparoscopic rather than open abdominal surgery when possible Regional anesthesia (nerve block) in very high-risk patients Epidural or spinal anesthesia in lieu of general anesthesia in high risk patients Avoid use of pancuronium as a muscle relaxant in high risk patients

Recommended Strategies Cont.

Postoperative Strategies

Deep breathing exercises or incentive spirometry in high risk patients Epidural analgesia in lieu of parenteral opioids Continuous positive airway pressure (CPAP)

Perioperative Cardiac Risk

Each year approximately 50,000 patients have perioperative MIs, and about 40% of them will die Most perioperative MIs occur without the typical chest pain, due to analgesics after surgery, residual effects from the anesthesia, and other perioperative painful stimuli

Periop Cardiac Risk

In studies evaluating incidence of MI after general anesthesia for patients who previously had an MI within 3 months, there was a reinfarction rate of 27-37%. Reinfarction was 11-16% for those who had an MI 3-6 months previously. Reinfarction rate remained stable at 5% for those who had an MI >6 months previous to surgery.

In 1977 Goldman and colleagues developed a preop cardiac risk index for patients undergoing non-cardiac surgery. They reported nine variables associated with an increased risk for perioperative cardiac complications. Each risk factor was assigned a point score, and patients were stratified into four risk categories based on their total points.

Goldman Preop Cardiac Risk Index

3rd Heart sound (S3)

9 Individual risk factors and their scores are as follows:

Elevated JV pressure

MI in past 6 months
ECG: premature atrial contractions or any rhythm other than sinus ECG shows >5 premature ventricular contractions per minute Age >70 years Emergency Procedure Intra-thoracic, intra-abdominal or aortic surgery Poor general status, metabolic or bedridden

11 11 10 7 7 5 4 3 3

Goldman Criteria Results

Patients with scores >25 had a 56% incidence of death, with a 22% incidence of severe cardiovascular complications Patients with scores <26 had a 4% incidence of death, with a 17% incidence of severe cardiovascular complications. Patients with scores <6 had a 0.2% incidence of death, with a 0.7% incidence of severe cardiovascular complications.

Detskys Modified Cardiac Risk Index

In 1986 Detsky and colleagues modified the original multifactorial index by adding variables such as angina and pulmonary edema. Patients are stratified into three risk categories based on their total points

Age older than 70 years

MI within 6 months MI after 6 mo previously Canadian CV society angina Classification: Class III Class IV Unstable angina in past 6 mo Alveolar Pulm Edema: in past week Alv. Pulm Edema: Ever

10 5 10 20 10 10 5

Suspected Critical Aortic Stenosis

Arrhythmia: Rhythm other than sinus or atrial premature beats More than 5 premature ventricular beats Emergency Operation

5 5 10 5

Poor General Medical Status

Class I II III

Points 0-15 20-30 31+


ACP guidelines