chest comp Lecture for 3rd year MBBS
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The document discusses postoperative care and chest complications. It covers several key points: 1) Respiratory complications occur in up to 15% of major surgeries and can negatively impact outcomes through increased mortality, morbidity, hospitalization duration, and costs. 2) Patients face respiratory risks in the immediate postoperative period from issues like atelectasis, pulmonary edema, and respiratory failure due to changes in lung volumes and function. 3) Preventing postoperative pulmonary complications requires evaluating patient risk factors, optimizing pre- and postoperative pulmonary status through measures like smoking cessation, treating infections, and encouraging deep breathing exercises.
chest comp Lecture for 3rd year MBBS
- 2. POST-OPERATIVE CARE & CHEST COMPLICATIONS DR.NADIR MEHMOOD Asst professor Department ofSurgery, RMC
- 3. 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
- 4. The Importance of Pulmonary Complications Adversely affects mortality and morbidity Increases the duration of hospitalization Increases the need for intensive care Increases the cost Sweitzer BJ, Anesthesiology Clin 27 (2009); 673 – 86
- 5. Respiratory complications Occur in up to 15% of general anaesthetic and major surgery
- 6. 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
- 7. PHASES • IMMEDIATE ( POST-ANAESTHETIC ) PHASE (1) • INTERMEDIATE ( HOSPITAL STAY ) PHASE (2) • CONVALESCENT ( AFTER DISCHARGE TO FULL RECOVERY )
- 8. AIM OF PHASES 1 & 2 • HOMEOSTASIS • TREATMENT OF PAIN • PREVENTION & EARLY DETECTION OF COMPLICATIONS
- 10. CAUSES OF COMPLICATIONS & DEATH • ACUTE PULMONARY PROBLEMS • CARDIO-VASCULAR PROBLEMS • FLUID DERANGEMENTS
- 11. The Intermediate Post-Operative period Starts with complete recovery from anaesthesia and lasts for the rest of the hospital stay.
- 12. 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.
- 13. • 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.
- 14. 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
- 15. Respiratory pathophysiology during/after surgery Changes in control of breathing Residual effects of anesthetics Narcotics for analgesics Respiratory depression Difficulty weaning Hypoxia Hypercapnia Deep breaths Atelectasis
- 16. Respiratory pathophysiology during/after surgery Impaired lung defence Pain Excessive use of analgesics Damage to cilia Presence of ETT Anesthetic gases Cough Mucociliary clearance AtelectasisSecretions ColonisationInfections
- 17. Respiratory pathophysiology during/after surgery Bronchoconstriction Aspiration of gastric contents Exacerbation of underlying asthma or COPD Endotracheal intubation or surgical stimulation Histamine release secondary medication Bronchospasm
- 18. Independent Risk Factors for 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
- 19. ASA (American Society of Anesthesiology) Score 1 A normal healthy person 2 Mild systemic disease 3 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.
- 20. Factors associated with a Moderate 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
- 21. No independent Risk of Pulmonary 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
- 22. 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
- 23. Procedures not associated with increased risk • Esophageal Surgery • Gynecologic Surgery • Urologic Surgery • Hip Fracture Repair • Open vs. Laparascopic Procedures
- 24. Respiratory complications • Atelectasis • Pneumonia • Aspiration • Pulmonary edema • Pulmonary embolism • Acute respiratory depression • Acute respiratory failure
- 30. ARDS
- 31. Postoperative Pulmonary Complications A. Atelectasis: – 90% postoperative pulmonary complications Etiology: 1. Obstruction of the tracheobronchial airway a) Changes in bronchial secretions b) Defects in expulsion mechanism c) Reduction in bronchial caliber 2. Pulmonary insufficiency (hypoventilation) – Decrease surfactant
- 32. Postoperative Atelectasis A. Normal bronchiole and alveolus B. Mucous plug in bronchiole C. Collapse of alveoli due to absorption of air
- 33. Postoperative Pulmonary Complications A. Atelectasis: Predisposing factors: 1. Smoking 2. 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 aspiration 6. Congestion of the bronchial walls
- 34. Postoperative Pulmonary Complications A. Atelectasis: Manifestations: 1st 24 hrs postop ----> fever, tachycardia, rales, decrease breath sound ----> persist ----> pneumonia (increase fever, dyspnea, tachycardia and cyanosis) ---> lung abscess
- 35. Postoperative Pulmonary Complications 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. Expectorants b. Mucolytic c. bronchodilators
- 36. Postoperative Pulmonary Complications B. Pulmonary Aspiration: – General anesthesia – pts are in supine position and absence of normal protective reflexes. – Increased risk: 1. Pregnant 2. Elderly 3. Obese 4. Pts w/ bowel obstruction
- 37. Postoperative Pulmonary Complications 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
- 38. Postoperative Pulmonary Complications 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.
- 39. Postoperative Pulmonary Complications 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 overload 4. Increase airway pressure (PEEP)
- 40. Postoperative Pulmonary Complications 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
- 41. Postoperative Pulmonary Complications D. Respiratory Failure: Etiologic Factors: 1. Sepsis 2. Massive transfusion 3. Fat embolism 4. Pancreatitis 5. 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)
- 42. 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
- 44. Diagnosis of PE • Clinical – dyspnea – chest pain – Hypotension • D-dimers • Imaging – CT – Ventilation perfusion scan
- 45. Treatment of PE • Medical management – supportive care – anticogualtion – thrombolysis • Surgical management
- 46. Preoperative Pulmonary Evaluation • Determination of Risks • Prevention of Risks • Rescheduling/ Cancel of the operation?
- 47. The evaluation of patient • Clinical Evaluation (History - Physical Examination) • Laboratory Evaluation Functional evaluation (PFT) Arterial Blood Gases Chest X-ray ECG • General Condition Assessment Classification of ASA (American Society of Anesthesiologists) Cardiopulmonary Risk Index
- 48. 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.)
- 49. 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
- 50. 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
- 52. QUESTIONS?