The incidence rate of pulmonary complications in the immediate postoperative period of non-cardiac surgery equals the incidence rate of cardiovascular complications. Patients undergoing surgery in the upper abdomen or any major abdominal operation are at the greatest risk. Exacerbation of chronic lung disease, respiratory failure, development of atelectasis and pneumonia are the most common and the most significant pulmonary complications in the early postoperative period. Patient’s health status, preoperative preparation and the type of surgery are the factors playing the leading role in the incidence of these complications. Prolonged hospitalization, increased treatment costs and longer recovery are additional significant issues requiring the routine introduction of procedures to reduce the incidence rate of perioperative pulmonary complications.Učestalost plućnih komplikacija u neposrednom poslijeoperacijskom periodu nakon nekardijalnih operacija jednaka je pojavnosti komplikacija od strane kardiovaskularnog sustava. Najvećem riziku izloženi su bolesnici nakon kirurških zahvata u gornjem abdomenu ili drugih velikih operacija u trbušnoj šupljini. Egzarcerbacija kronične plućne bolesti, respiratorna insuficijencija, razvoj atelektaza i posljedičnih pneumonija najčešće su i najznačajnije plućne komplikacije u ranom postoperacijskom periodu. Zdravstveni status bolesnika, prijeoperacijska priprema te vrsta kirurškog postupka glavni su čimbenici pojavnosti ovih komplikacija. Prolongiranje bolničkog liječenja, povećanje troškova i dugotrajniji oporavak su dodatni značajni problemi koji nam nameću potrebu za rutinskim uvođenjem postupaka kojim ćemo smanjiti učestalost plućnih komplikacija u perioperacijskom periodu

Brozović, Gordana

Marić, Stela

Čulav, Katja

Štefančić, Ljilja

English

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69REVIEW Libri Oncol., Vol. 35 (2007), No 1-3, 69 – 72RISK ASSESSMENT AND PREVENTIONOF PERIOPERATIVE PULMONARY COMPLICATIONSLJILJA [TEFAN^I], STELA MARI], GORDANA BROZOVI] and KATJA ^ULAVDepartment of Anesthesiology and ICU, University Hospital for tumors, Zagreb, CroatiaSummaryThe incidence rate of pulmonary complications in the immediate postoperative period of non-cardiac surgery equals the incidence rate of cardiovascular complications. Patients undergoing surgery in the upper abdomen or any major ab-dominal operation are at the greatest risk. Exacerbation of chronic lung disease, respiratory failure, development of atelec-tasis and pneumonia are the most common and the most significant pulmonary complications in the early postoperative period. Patient’s health status, preoperative preparation and the type of surgery are the factors playing the leading role in the incidence of these complications. Prolonged hospitalization, increased treatment costs and longer recovery are addi-tional significant issues requiring the routine introduction of procedures to reduce the incidence rate of perioperative pul-monary complications.KEY WORDS: pulmonary complications, perioperative period, abdominal surgery, risk factorsPROCJENA RIZIKA I PREVENCIJA PLU]NIH KOMPLIKACIJAU PERIOPERACIJSKOM PERIODUSa`etakU~estalost plu}nih komplikacija u neposrednom poslijeoperacijskom periodu nakon nekardijalnih operacija jednaka je pojavnosti komplikacija od strane kardiovaskularnog sustava. Najve}em riziku izlo`eni su bolesnici nakon kirur{kih zahvata u gornjem abdomenu ili drugih velikih operacija u trbu{noj {upljini. Egzarcerbacija kroni~ne plu}ne bolesti, respi-ratorna insuficijencija, razvoj atelektaza i posljedi~nih pneumonija naj~e{}e su i najzna~ajnije plu}ne komplikacije u ranom postoperacijskom periodu. Zdravstveni status bolesnika, prijeoperacijska priprema te vrsta kirur{kog postupka glavni su ~imbenici pojavnosti ovih komplikacija. Prolongiranje bolni~kog lije~enja, pove}anje tro{kova i dugotrajniji oporavak su dodatni zna~ajni problemi koji nam name}u potrebu za rutinskim uvo|enjem postupaka kojim }emo smanjiti u~estalost plu}nih komplikacija u perioperacijskom periodu.KLJU^NE RIJE^I: plu}ne komplikacije, perioperacijski period, abdominalne operacije, ~imbenici rizikaINTRODUCTIONThe incidence rate of perioperative pulmo-nary complications following any major abdomi-nal surgery is rather high. The risk is particularly high in patients over 70 years of age with a type of restrictive or obstructive pulmonary disease, or any associated disease of other organ systems.The development of these complications can be anticipated, and their incidence rate can be sig-nificantly reduced by using preventive therapeu-tic procedures and choosing less invasive surgical and appropriate anesthetic techniques. The risk assessment and resulting preventive actions are indispensable for the management of surgical pa-tients.Libri Oncol., Vol. 35 (2007), No 1–3, 69 – 7270Strategy for reducing the incidence rate of postoperative pulmonary complications takes two steps:1.  Risk assessment for developing complica-tions2. Risk reduction proceduresRisk assessment for developingcomplicationsThe risk assessment for developing pulmo-nary complications based on clinical examination and appropriate diagnostic tests is the first step to patient’s care. The risk factors can be divided into two basic categories:patient-dependent risk factorsrisk factors related to the type and location of surgical procedurePatient-related risk factorsRisk factors for developing pulmonary com-plications in surgical patients are related to patient general health status, and also to patient’s habits (smoking, alcohol consumption, etc.). The most significant among myriad of risk factors include:1.  Age – A series of studies show the inci-dence rate is higher in patients over 60 years of age, especially in those over 70.2.  Chronic lung diseases, dyspnea at rest or during slight effort – especially COPD, unlike restrictive pulmonary disease that shows less risk except in cases of severe restriction of the pulmonary parenchyma.3.  Smoking – significantly increases risk and encouraging the patient to stop smoking reduces the incidence rate of complica-tions in elective surgery4.  Congestive heart disease – associated with a high incidence rate of respiratory failure and complications5.  Patient ASA status >II6.  Both abrupt weight loss and excess weight, neurological disorders, diabetes mellitusSurgical procedure-related risk factorsMany studies have shown that procedures performed for the purpose of surgical treatment significantly influence both the speed and quality of patient recovery and possible occurrence of pulmonary complications.––Procedures most commonly correlated with the development of these complications are as fol-lows:1.  Type of surgery – aortal surgery, chest surgery, abdominal surgery, and upper abdominal surgery in particular2.  Duration of surgery – operations that take over two hours3.  Emergency surgical procedures4.  Anesthesia technique5.  Transfusion of blood or blood-based prod-ucts – more than 4 units of blood6.  Postoperative painDiagnostic procedures for risk assessmentPreoperative preparations include physical examination, laboratory and x-ray tests, and, de-pending on comorbidity, additional specialist ex-ams to evaluate and assess the risk of any surgical procedure. Tests for the purpose of evaluating pulmonary status of the surgical patient and as-sessing the risk of developing pulmonary compli-cations include as follows:1.  Spirometry – is routinely performed in pa-tients with chronic pulmonary disease. In a series of studies, spirometry has been shown to be a poor predictor of these com-plications. However, it provides an im-portant insight into the functional status of patients with obstructive pulmonary disease, non-treated patients in particular, or it shows the therapy efficacy or revers-ibility of changes in the lungs.2.  Lung x-ray – is a routine test with its pre-dictive value being more significant in heart than in lung patients; changes in lung parenchyma that can be seen in the elderly do not have a higher prognostic value for the development of pulmonary complications.3.  Laboratory tests – blood urea (>7.5mmol/l) and albumin (<35-39g/l) levels have been shown to be an important predictor for the development of pulmonary complications.4.  Blood gas analysis, or PCO2 levels (>45mm Hg) indicate a high probability of pulmo-nary complications development or mor-tality. The PO2 level of <50 mmHg is a contraindication for elective surgery. At the same time, both test results are a sim-71Libri Oncol., Vol. 35 (2007), No 1–3, 69 – 72ple indicator of success of performed ther-apeutic procedures.5.  Microbiological analysis of the oropharyn-geal mucosa is not a routine test during the preoperative preparation of patients; clinical trials, however, confirm that pul-monary infections in operated patients usually originate from the oral cavity.Procedures for reducing pulmonarycomplicationsAfter assessing the risk of developing pulmo-nary complications, steps for minimalizing their occurrence are to be taken. Preventive procedures are required in patients with chronic obstructive pulmonary disease (COPD) or patients undergo-ing surgeries associated with a high percentage of pulmonary complications. They are to be started in the preoperative, and continued during the op-erative and postoperative period. Such treatment necessarily requires a multidisciplinary approach that, besides the anesthesiologist and surgeon, in-cludes also other specialties (internal medicine specialist, cardiologist, pulomonologist, neurolo-gist, physical medicine specialist).Preoperative periodIn this period, any procedures to improve the pulmonary function, or pulmonary expansions are involved. According to clinical research stud-ies that are currently available, there are no reli-able techniques for respiratory function recovery, although any of the techniques or their combina-tion may be considered beneficial.1.  Routine mechanical cleansing of the oral cavity and two-day disinfection of the mouth and nose with chlorhexitidine is performed to reduce the frequency of pul-monary infections that develop due to bacterial translocation during intubation or other manipulations in the oral and na-sal cavity.2.  In COPD patients, physical therapy aimed at respiratory muscles strengthening, se-cretion mobilization, cough stimulation, postural drainage, breathing exercises, in-halatory and, when required, antibiotic therapy, bronchodilator aerosol therapy, high dose corticosteroid administration that are to be gradually reduced in the postoperative period. Antibiotic therapy in case of infected sputum takes about ten days and for this period, the elective pro-cedure should be cancelled.3.  Abstinence from smoking for a minimum of two months before any elective surgery. Smoking cessation immediately before the procedure may result in increased secre-tion and the development of respiratory complications.Intraoperative proceduresDuring this period, both the surgical and an-esthesia techniques should be tailored to the pa-tient.1.  Anesthesia procedures to reduce the pos-sibility of developing pulmonary compli-cations during general anesthesia include bronchodilator administration during the induction of anesthesia. The administra-tion of lower FiO2 in the inspiratory air mixture, exclusion of nitrogen oxidule, administration of short-acting muscle re-laxant agents, administration of PEEP (risk of barotrauma) and small-volume ventila-tion (6-7ml/kg) are required during sur-gery.2.  Regional anesthesia techniques, delivered independently or in combination with general anesthesia with reduced adminis-tration of anesthetics, relaxants, and local anesthetic positive effects on the cardiocir-culatory stability and reduced bronchial reactibility, as well as a reduced need for postoperative mechanical ventilation can produce favorable effects on the postop-erative recovery and the occurrence of pulmonary complications.3.  The placement of nasogastric tube is indi-cated only in case of selective gastric de-compression.4.  Less invasive surgical methods (laparo-scopic surgeries) to spare muscles of the abdominal wall and diaphragm are to be chosen, and a surgical technique devel-oped and improved to shorten the dura-tion of surgery and to reduce the frequen-cy of pulmonary complications.Libri Oncol., Vol. 35 (2007), No 1–3, 69 – 7272Postoperative proceduresThe following procedures are only a continu-ation of the preventive measures already taken:1.  Good postoperative analgesia techniques, primarily those for continuation analgesia or PCA, either intravenous or epidural, enable balanced deep breathing and pain-less cough2.  Accelerated patient mobilization: sitting, getting up, as well as physical and respira-tory therapy3.  Early enteral or combination of enteral and parenteral diet enriched with gluta-mines, vitamins, selenium and other mi-cronutrients,4.  Oxigenotherapy, bronchodilators and cor-ticosteroid therapy.CONCLUSIONThe routine assessment of risks for develop-ing postoperative pulmonary complications and the implementation of preventive procedures to lower their incidence rate in patients at risk, re-duce postoperative mortality and morbidity. A further follow-up of therapeutic value of any pro-cedures as well as the evaluation of diagnostic tests in relation to their predictive value for the development of pulmonary complications are re-quired.REFERENCES1. Doyle RL. Assessing and modifying the risk of post-operative pulmonary complications. Chest 1999; 115 (5): 77S-81S.2. Qaseem A, Snow V, Fitterman N, Hornbake ER, Law-rence VA, Smetana GW, Weiss K, Owens DK, Aron-son M, Barry P, Casey DE Jr, Cross JT Jr, Fitterman N, Sherif KD, Weiss KB. Risk assessment for and strate-gies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. Ann Intern Med. 2006; 144(8): 575-80.3. Celli, BR. Perioperative respiratory care of the patient undergoing upper abdominal surgery. Clin Chest Med. 1993; 14(2): 253-61.4. Manku K, Bacchetti P, Leung JM. Prognostic signifi-cance of postoperative in-hospital complications in elderly patients. I. Long term survival. Anesth Analg. 2003; 96 (2): 583-9.5. Smetana GW. Preoperative pulmonary evaluation. N Engl J Med. 1999; 340(12):937-44.Author’s address: Lilja [tefan~i}, M.D., Department of Anesthesiology and ICU, University Hospital for tumors, Ilica 197, 10 000 Zagreb, Croatia

Procjena rizika i prevencija plućnih komplikacijau perioperacijskom periodu

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