chest comp Lecture for 3rd year MBBS

POST-OPERATIVE CARE & CHEST COMPLICATIONS

DR.NADIR MEHMOOD

Asst professor

Department ofSurgery, RMC

Learning Objectives • Accept that complications are best

anticipated and avoided.• Recognize the incidence of co-morbidity.• Understand the importance of matching

the procedure to the associated risks.• Appreciate the importance of recognizing

complications early and treating them vigorously.

• Enumerate the risk factors- Patient vs procedure related

• Enlist Prediction tools and their efficiency• Outline available guidelines• Enlist preventive measures

The Importance of Pulmonary Complications

Adversely affects mortality and morbidity

Increases the duration of hospitalization

Increases the need for intensive careIncreases the cost

Sweitzer BJ, Anesthesiology Clin 27 (2009); 673 – 86

Respiratory complications

Occur in up to 15% of general anaesthetic and major surgery

Factors related to PPCs

• Patients-related risk factors• Risk factors related to preoperative care• Operation-related risk factors• Anesthetic-related risk factors• Risk factors related to postoperative care

PHASES

• IMMEDIATE ( POST-ANAESTHETIC ) PHASE (1)

• INTERMEDIATE ( HOSPITAL STAY ) PHASE (2)

• CONVALESCENT ( AFTER DISCHARGE TO FULL RECOVERY )

AIM OF PHASES 1 & 2

• HOMEOSTASIS

• TREATMENT OF PAIN

• PREVENTION & EARLY DETECTION OF COMPLICATIONS

IMMEDIATE POST-OPERATIVE PERIOD

CAUSES OF COMPLICATIONS & DEATH

• ACUTE PULMONARY PROBLEMS

• CARDIO-VASCULAR PROBLEMS

• FLUID DERANGEMENTS

The Intermediate Post-Operative period

Starts with complete recovery from anaesthesia and lasts for the rest of the

hospital stay.

Pathophysiology

• Functional residual capacity ( FRC) and vital capacity (VC) decrease after major intra-abdominal surgery down to 40% of the Pre-Op. Level.

• These go up slowly to 60-70% by 6th -7th day and to normal Pre-Op. Level after that.

• FRC, VC, and Post-Op. pulmonary oedema (Post anaesthesia) Contribute to the changes in pulmonary functions Post-Op.

• The above changes are accentuated by obesity, heavy smoking or Pre-existing lung diseases specially in elderly.

• Post-Op. atelectasis is enhanced by shallow breathing, pain, obesity and abdominal distension (restriction of diaphragmatic movements)

• Post-Op. physiotherapy especially deep inspiration helps to decrease atelectasis. Also O2 mask and periodic hyperinflation using spirometer.

• Early mobilization helps a lot.

• Antibiotics and treatment of heart failure Post-Op. by adequate management of fluids will help reduce pulmonary oedema.

Respiratory pathophysiology during/after surgery

Postoperative pain& Muscle splinting

Diaphragmatic dysfunction due to CNS output to phrenic nerves

Changes in lung volumes

Restrictive lung function

FRC Hypoxia

Airway closure

Atelectasis


Changes in control of breathing

Residual effects of anesthetics

Narcotics for analgesics

Respiratory depression

Difficulty weaning

Hypoxia ±Hypercapnia

Deep breaths

Atelectasis


Impaired lung defence

Pain

Excessive use of analgesics

Damage to cilia

Presence of ETT

Anesthetic gases

Cough

Mucociliary clearance

AtelectasisSecretions

ColonisationInfections

Respiratory pathophysiology during/after surgeryBronchoconstriction

Aspiration of gastriccontents

Exacerbation of underlying asthma or COPD

Endotracheal intubationor surgical stimulation

Histamine releasesecondary medication

Bronchospasm

Independent Risk Factorsfor Pulmonary Complications

• Age over 60• History of COPD• History of CHF• Functional Dependence• Tobacco cessation within past 8 weeks?• ASA Class II or greater• Serum Albumin < 3.5

ASA (American Society of Anesthesiology)

Score 1 A normal healthy person2 Mild systemic disease3 Systemic disease that is not incapacitating. 4 Incapacitating systemic disease that is

a threat to life 5 Moribund, not expected to survive 24 hours

with or without operation.

Factors associated with aModerate Increase in Risk

• Chronic Tobacco or Alcohol Use• Altered Mental Status• Weight Loss (>10% in last 6 months)• History of CVA/stroke• Clinical Chest Findings/Abnormal CXR• BUN > 21• Perioperative Transfusion• Preoperative stay >4 days

No independent Risk ofPulmonary Complications

• Obesity• Controlled Asthma• Diabetes Mellitus• Obstructive Sleep Apnea• Chronic Steroid Use

• HIV Infection• History of Cardiac Arrythmias• Poor Exercise Tolerance• Abnormal Pre-Op Spirometry

Procedure-related Risk• Procedures lasting > 3 hours• Emergency Surgery• Aortic/Vascular Surgery• Thoracic or Upper Abdominal Surgery• Neurosurgery• Neck Surgery• General Anesthesia• Use of Long-acting NM blockade• Duration of anaesthesia• Nasogastric intubation• Type of surgery

Procedures not associated with increased risk

• Esophageal Surgery• Gynecologic Surgery• Urologic Surgery• Hip Fracture Repair• Open vs. Laparascopic Procedures

Respiratory complications

• Atelectasis• Pneumonia• Aspiration• Pulmonary edema• Pulmonary embolism• Acute respiratory depression• Acute respiratory failure

ARDS

Postoperative Pulmonary Complications

A. Atelectasis:– 90% postoperative pulmonary complicationsEtiology:

1. Obstruction of the tracheobronchial airwaya) Changes in bronchial secretionsb) Defects in expulsion mechanismc) Reduction in bronchial caliber

2. Pulmonary insufficiency (hypoventilation)– Decrease surfactant

Postoperative Atelectasis

A. Normal bronchiole and alveolus

B. Mucous plug in bronchiole

C. Collapse of alveoli due to absorption of air


A. Atelectasis:Predisposing factors:

1. Smoking2. Pulmonary problem (bronchitis, asthma, etc)3. Anesthesia:

– GA - duration and depth– Postop narcotics – depress cough reflex

4. Depress cough reflex – Chest pain– Immobilization– Splinting w/ bandages

5. NGT – increased secretions and predisposed aspiration6. Congestion of the bronchial walls


A. Atelectasis:Manifestations:

1st 24 hrs postop ----> fever, tachycardia, rales, decrease breath sound ----> persist ----> pneumonia (increase fever, dyspnea, tachycardia and cyanosis) ---> lung abscess


A. Atelectasis:Treatment:1. Preop prophylaxis:

a. No smoking (2 wks)b. Treatment of pulmonary problem

2. Postop prophylaxis:− Minimal use of depressant drugs− Prevent pain− Early ambulation− Changes body position− Deep breathing and coughing exercises

3. Drugs:a. Expectorantsb. Mucolyticc. bronchodilators


B. Pulmonary Aspiration:– General anesthesia – pts are in supine

position and absence of normal protective reflexes.

– Increased risk:1. Pregnant2. Elderly3. Obese4. Pts w/ bowel obstruction


B. Pulmonary Aspiration:Prevention:• NPO 6hrs prior to surgery• Emergency – NGT do gastric lavage and give

antacid to prevent dev. of Mendelian’s Syndrome.

Treatment:• Continuous mechanical ventilation• antibiotics


C. Pulmonary Edema:Etiology:

1. Circulatory overload (infusion of fluid during operation)

Most common cause

2. Left ventricular failure (incomplete cardiac emptying)

Due to anesthetic, narcotic or hypnotic agents w/c decrease myocardial contractility

Decrease peripheral perfusion -----> peripheral vasoconstriction ----> cause blood to shift centrally ----> pulmonary edema

3. Negative pressure in airway.


C. Pulmonary Edema:Treatment:

1. Provide oxygen (increase inspired concentration)2. Remove obstructing fluid (diuretics, head up or

sitting position, phlebotomy, spinal anesthesia, ganglionic blocking agents)

3. Correcting the circulatory overload4. Increase airway pressure (PEEP)


D. Respiratory Failure:– 25% of postoperative deaths– Tachypnea > 25-30/min– Low tidal volume < 4ml /kg – High Pco2 > 45mmHg while the patient is

breathing room air– Low Po2 < 60mmHg in the absence of metabolic

alkalosis– Usually seen in patients who underwent

operations for major trauma or who have multisystem disease.

– Mechanism is unknown


D. Respiratory Failure:Etiologic Factors:

1. Sepsis2. Massive transfusion3. Fat embolism4. Pancreatitis5. Aspiration

– Associated w/ a decreased Functional Residual Lung Capacity, indicating that the amount of air w/ in the lung at the end of normal expiration is reduced ----> diminished ventilation-perfusion ratio and ultimately arterial hypoxemia

Treatment:• Mechanical ventilation (PEEP)

Pulmoary embolism

• A very serious complication of DVT

• 10% die within the first hour

• 90% live longer than one hour-of these patients 70 percent go undiagnosed and of these 30 % die

Pulmonary Embolus

Diagnosis of PE• Clinical

– dyspnea– chest pain– Hypotension

• D-dimers

• Imaging– CT– Ventilation perfusion scan

Treatment of PE

• Medical management– supportive care– anticogualtion– thrombolysis

• Surgical management

Preoperative Pulmonary Evaluation

• Determination of Risks

• Prevention of Risks

• Rescheduling/ Cancel of the operation?

The evaluation of patient

• Clinical Evaluation (History - Physical Examination) • Laboratory Evaluation

Functional evaluation (PFT)Arterial Blood GasesChest X-rayECG

• General Condition AssessmentClassification of ASA (American Society of Anesthesiologists)Cardiopulmonary Risk Index

PREVENTION• RECOVERY ROOM :

ANAESTHETIST RESPONSIBILITIES TOWARDS CARDIO-PULMONARY FUNCTIONS.SURGEON’S RESPONSIBILITIES TOWARDS THE OPERATION SITE.

• TRAINED NURSING STAFF :T0 HANDLE INSTRUCTIONS.

• CONTINUOUS MONITORING OF PATIENT (VITAL SIGNS etc.)

Post-Op recommendations to reduce Pulmonary Complications

• Deep Breathing Exercises/Incentive Spirometry

• CPAP – if patient cannot cooperate for I.S.• Avoid routine use of NG tubes• Adequate Pain Control

Smoking cessation for ≥8 weeks Treatment for patients with underlying asthma / COPD (PFT) Delay elective surgery and treat with antibiotics if respiratory

infection is present Patient education regarding lung expansion maneuvers Obese patients should be managed to lose weight Choose procedure lasting < 4 hrs (if possible) Minimize duration of anesthesia Avoid use of long-acting neuroblockers (ie pancuronium) in high risk

patients

Prevention of Risks

QUESTIONS?

chest comp Lecture for 3rd year MBBS

Health & Medicine