34
Pulmonary complications risk: Pneumonia,respiratory insufficiency….

Pulmonary complications risk

Embed Size (px)

DESCRIPTION

risk of pulmonary complications in anesthesia and surgery,scores

Citation preview

Page 1: Pulmonary complications risk

Pulmonary complications risk

Pneumoniarespiratory insufficiencyhellip

bull Risk Assessment for and Strategies To Reduce Perioperative Pulmonary Complications for Patients Undergoing Noncardiothoracic Surgery A Guideline from the American College of Physicians

bull Amir Qaseem MD PhD MHA Vincenza Snow MD Nick Fitterman MD E Rodney Hornbake MD Valerie A Lawrence MD Gerald W Smetana MD Kevin Weiss MD MPH Douglas K Owens MD MS for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians

Annals of Internal medicine 18 April 2006 | Volume 144 Issue 8 | Pages 575-580

Relazione fra ASA PS e complicanze polmonari

Strategie tese alla riduzione delle complicanze postop

bull Lawrence VA Cornell JE Smetana GW Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery systematic review for the American College of Physicians Ann Intern Med 2005144596-608

bull Tutte le tecniche di espansione polmonare ndash spirometria incentiva ndash terapia fisicandash provocazione della tossendash drenaggio posturalendash percussione e vibrazionendash Aspirazionendash Deambulazionendash IPPBndash CPAP

bull hanno dimostrato superioritagrave rispetto ai controlli dopo chirurgia addominale

bull Non differenze fra le diverse modalitagrave di espansione neacute dalla loro combinazione

decompressione nasogastrica selettiva

bull effettuata nei pazienti con PONV incapaci di assumere nutrizione orale o con distensione addominale

ndash diminuisce la frequenza di polmonite ed atelettasia nei confronti della decompressione con sondino routinaria finche cioegrave non ritorni la motilitagrave gastrointestinale

ndash Cheatham ML Chapman WC Key SP Sawyers JL A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy Ann Surg 1995221469-76

ndash Nelson R Tse B Edwards S Systematic review of prophylactic nasogastric

decompression after abdominal operations Br J Surg 200592673-80 ndash Nelson R Edwards S Tse B Prophylactic nasogastric decompression after

abdominal surgery Cochrane Database Syst Rev 2005

Pneumonia risk

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD

William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Background Pneumonia is a common postoperative complication associated with substantial morbidity and mortalitybull Objective To develop and validate a preoperative risk index for predicting postoperative pneumoniabull Design Prospective cohort study with outcome assessment based on chart reviewbull Setting 100 Veterans Affairs Medical Centers performing major surgerybull Patients The risk index was developed by using data on 160 805 patients undergoing major noncardiac surgery bet ween 1

September 1997 and 31 August 1999 and was validated by using data on 155 266 patients undergoing surgery between 1 September 1995 and 31 August 1997 Patients with preoperative pneumonia ventilator dependence and pneumonia that developed after postoperative respiratory failure were excluded

bull Measurements Postoperative pneumonia was defined by using the Centers for Disease Control and Prevention definition of nosocomial pneumonia

bull Results A total of 2466 patients (15) developed pneumonia and the 30-day postoperative mortality rate was 21 A postoperative pneumonia risk index was developed that included type of surgery (abdominal aortic aneurysm repair thoracic upper abdominal neck vascular and neurosurgery) age functional status weight loss chronic obstructive pulmonary disease general anesthesia

bull impaired sensorium cerebral vascular accident blood urea nitrogen level transfusion emergency surgery long-term steroid use smoking and alcohol use Patients were divided into five risk classes by using risk index scores Pneumonia rates were 02 among those with 0 to 15 risk points 12 for those with 16 to 25 risk points 40 for those with 26 to 40 risk points 94 for those with 41 to 55 risk oints and 153 for those with more than 55 risk points The C-statistic was 0805 for the development cohort and 0817 for the validation cohort

bull Conclusions The postoperative pneumonia risk index identifies patients at risk for postoperative neumonia and may be useful in guiding perioperative respiratory care

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med

2001135847-857

Risk of postop pneumonia

Risk factors for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for Predicting Postoperative Pneumonia after Major

Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer

Daley MDAnn Intern Med 2001135847-857 bull Long-term steroid use bull Age older than 60 years bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6

monthsbull recent alcohol use bull Recent smoking bull history of chronic obstructive pulmonary diseasebull history of cerebral vascular accident with a residualbull deficit bull impaired sensorium

Fattori di rischio per la polmonite postoppazienteDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Somministrazione di steroidi a lungo termine bull Etagravegt60 anni bull Stato funzionale dipendentebull Perdita di peso gt 10 della massa coroorea nei 6 mesi

precedentibull uso recente di alcoholbull Fumo recentebull Storia di COPDbull Storia di accidente cerebrovascolare con deficit residuobull Disturbo di coscienza

Fattori di rischio per la polmonite postopinterventiDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857

bull abdominal aortic aneurysm repairbull thoracic bull neck bull upper abdominalbull peripheral vascular surgerybull neurosurgery

Am J Respir Crit Care Med 2005 Mar 1171(5)514-7 Incidence of and risk factors for pulmonary complications after nonthoracic

surgeryMcAlister FA Bertsch K Man J Bradley J Jacka M

bull Identifica come fattori di rischiondash lrsquoetagravegt65 annindash il fumo(gt 40 pacchettianno)ndash la diminuzione del FEV1ndash Diminuzione del FVC e del FEV1FVCndash la durata dellrsquoanestesia gt25 hrndash storia di COPDndash tosse produttiva giornalierandash incisione nellrsquoaddome supndash presenza di un SNG

bull Solo 4 sono indipendenti dopo una analisi multivariata etagravetest alla tosse positivopresenza periop del SNG e la durata dellrsquoanestesia

a preoperative risk index for predicting postoperative respiratory

failure (PRF)

Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National

Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS

OF SURGERY Vol 232 No 2 242ndash253bull Objectivebull To develop and validate a preoperative risk index for

predicting postoperative respiratory failure (PRF)bull prospective cohort studybull 44 Veterans Affairs Medical Centers (n 5 81719) were used to

develop the models Cases from 132 Veterans Affairs Medical Centers (n 5 99390) were used as a validation sample

bull PRF was defined as mechanical ventilation for more than 48 hours after surgery or reintubation and mechanical ventilation after postoperative extubation

bull Ventilator-dependent comatose do notresuscitate and female patients were excluded

bull respiratory care

Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac

Surgery Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Results bull PRF developed in 2746 patients (34) bull The respiratory failure risk index was developed from a simplified logistic

regression model and includedndash abdominal aortic aneurysm repairndash thoracic surgeryndash neurosurgery ndash upper abdominal surgery ndash Peripheral vascular surgery ndash neck surgeryndash emergency surgeryndash albumin level llt than 30 gL ndash blood urea nitrogen level gtthan 30 mgdL ndash dependent functional statusndash chronic obstructive pulmonary disease ndash agegt60

Indici prognostici di insuff resp postop Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the

National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF

SURGERY Vol 232 No 2 242ndash253

ndash Aneurismectomia aorta addominalendash Chir toracica ndash neurochir ndash Chir addominale maggiore ndash Chir vascolare periferica ndash Chir del collo ndash Chir in emergenza ndash Livelli di albumina lt 30 gL ndash BUN gt 30 mgdL ndash Dipendenza funzionalendash COPD (chronic obstructive pulmonary disease) ndash Etagrave gt60

Probability of PRF postoperative resp failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration

Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Classe punti probab PRFbull 1 lt=10 05 bull 2 11ndash19 22-18bull 3 20ndash27 53- 42bull 4 28ndash40 10-119 bull 5 gt40 309 -266

A comparison of risk factors for postoperative pneumonia and respiratory failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

ampAhsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDDevelopment and Validation of a Multifactorial Risk

Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ann Intern Med 2001135847-857

FINESegue lavori in dettagliohellip

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern

Med 2001135847-857bull Postoperative pulmonary complications are associatedbull with substantial morbidity and mortality It hasbull been estimated that nearly one fourth of deaths occurringbull within 6 days of surgery are related to postoperativebull pulmonary complications (1) Postoperative infectionsbull are also a major source of the morbidity and mortalitybull associated with undergoing surgery Pneumonia is thebull most serious postoperative complication that is includedbull in both of these categories Pneumonia ranks as thebull third most common postoperative infection behind urinarybull tract and wound infection (2) According to thebull National Nosocomial Infection Surveillance systembull pneumonia occurred in 18 of patients after surgerybull (3) Postoperative pneumonia occurs in 9 to 40 ofbull patients and the associated mortality rate is 30 tobull 46 depending on the type of surgery (1 4)bull Previous studies of risk factors used various definitionsbull of postoperative pulmonary complications Atelectasisbull (1 4ndash7) postoperative pneumonia (1ndash2 4ndash6bull 8ndash11) the acute respiratory distress syndrome (9 12)bull and postoperative respiratory failure (6 9 11 13) havebull been classified as postoperative pulmonary complicationsbull Although the clinical significance of each of thesebull complications varies greatly they were grouped togetherbull as a single outcome in previous studies (6) Some studiesbull were limited to examination of risk factors in patientsbull undergoing abdominal or thoracic procedures or in patientsbull with specific medical conditions such as chronicbull obstructive pulmonary disease (2 4 6 10ndash12 14)bull These studies were often based on a small sample frombull one institution and studies of independent samples didbull not validate their findings (15 16

Table 1 Definition of Postoperative PneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Patient met one of the following two criteria postoperativelybull 1 Rales or dullness to percussion on physical examination of chest AND

any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull 2 Chest radiography showing new or progressive infiltrate consolidation

cavitation or pleural effusion AND any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull Isolation of virus or detection of viral antigen in respiratory secretionsbull Diagnostic single antibody titer (IgM) or fourfold increase in paired serum

samples (IgG) for pathogenbull Histopathologic evidence of pneumonia

Postoperative pneumonia risk indexDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 2: Pulmonary complications risk

bull Risk Assessment for and Strategies To Reduce Perioperative Pulmonary Complications for Patients Undergoing Noncardiothoracic Surgery A Guideline from the American College of Physicians

bull Amir Qaseem MD PhD MHA Vincenza Snow MD Nick Fitterman MD E Rodney Hornbake MD Valerie A Lawrence MD Gerald W Smetana MD Kevin Weiss MD MPH Douglas K Owens MD MS for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians

Annals of Internal medicine 18 April 2006 | Volume 144 Issue 8 | Pages 575-580

Relazione fra ASA PS e complicanze polmonari

Strategie tese alla riduzione delle complicanze postop

bull Lawrence VA Cornell JE Smetana GW Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery systematic review for the American College of Physicians Ann Intern Med 2005144596-608

bull Tutte le tecniche di espansione polmonare ndash spirometria incentiva ndash terapia fisicandash provocazione della tossendash drenaggio posturalendash percussione e vibrazionendash Aspirazionendash Deambulazionendash IPPBndash CPAP

bull hanno dimostrato superioritagrave rispetto ai controlli dopo chirurgia addominale

bull Non differenze fra le diverse modalitagrave di espansione neacute dalla loro combinazione

decompressione nasogastrica selettiva

bull effettuata nei pazienti con PONV incapaci di assumere nutrizione orale o con distensione addominale

ndash diminuisce la frequenza di polmonite ed atelettasia nei confronti della decompressione con sondino routinaria finche cioegrave non ritorni la motilitagrave gastrointestinale

ndash Cheatham ML Chapman WC Key SP Sawyers JL A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy Ann Surg 1995221469-76

ndash Nelson R Tse B Edwards S Systematic review of prophylactic nasogastric

decompression after abdominal operations Br J Surg 200592673-80 ndash Nelson R Edwards S Tse B Prophylactic nasogastric decompression after

abdominal surgery Cochrane Database Syst Rev 2005

Pneumonia risk

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD

William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Background Pneumonia is a common postoperative complication associated with substantial morbidity and mortalitybull Objective To develop and validate a preoperative risk index for predicting postoperative pneumoniabull Design Prospective cohort study with outcome assessment based on chart reviewbull Setting 100 Veterans Affairs Medical Centers performing major surgerybull Patients The risk index was developed by using data on 160 805 patients undergoing major noncardiac surgery bet ween 1

September 1997 and 31 August 1999 and was validated by using data on 155 266 patients undergoing surgery between 1 September 1995 and 31 August 1997 Patients with preoperative pneumonia ventilator dependence and pneumonia that developed after postoperative respiratory failure were excluded

bull Measurements Postoperative pneumonia was defined by using the Centers for Disease Control and Prevention definition of nosocomial pneumonia

bull Results A total of 2466 patients (15) developed pneumonia and the 30-day postoperative mortality rate was 21 A postoperative pneumonia risk index was developed that included type of surgery (abdominal aortic aneurysm repair thoracic upper abdominal neck vascular and neurosurgery) age functional status weight loss chronic obstructive pulmonary disease general anesthesia

bull impaired sensorium cerebral vascular accident blood urea nitrogen level transfusion emergency surgery long-term steroid use smoking and alcohol use Patients were divided into five risk classes by using risk index scores Pneumonia rates were 02 among those with 0 to 15 risk points 12 for those with 16 to 25 risk points 40 for those with 26 to 40 risk points 94 for those with 41 to 55 risk oints and 153 for those with more than 55 risk points The C-statistic was 0805 for the development cohort and 0817 for the validation cohort

bull Conclusions The postoperative pneumonia risk index identifies patients at risk for postoperative neumonia and may be useful in guiding perioperative respiratory care

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med

2001135847-857

Risk of postop pneumonia

Risk factors for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for Predicting Postoperative Pneumonia after Major

Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer

Daley MDAnn Intern Med 2001135847-857 bull Long-term steroid use bull Age older than 60 years bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6

monthsbull recent alcohol use bull Recent smoking bull history of chronic obstructive pulmonary diseasebull history of cerebral vascular accident with a residualbull deficit bull impaired sensorium

Fattori di rischio per la polmonite postoppazienteDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Somministrazione di steroidi a lungo termine bull Etagravegt60 anni bull Stato funzionale dipendentebull Perdita di peso gt 10 della massa coroorea nei 6 mesi

precedentibull uso recente di alcoholbull Fumo recentebull Storia di COPDbull Storia di accidente cerebrovascolare con deficit residuobull Disturbo di coscienza

Fattori di rischio per la polmonite postopinterventiDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857

bull abdominal aortic aneurysm repairbull thoracic bull neck bull upper abdominalbull peripheral vascular surgerybull neurosurgery

Am J Respir Crit Care Med 2005 Mar 1171(5)514-7 Incidence of and risk factors for pulmonary complications after nonthoracic

surgeryMcAlister FA Bertsch K Man J Bradley J Jacka M

bull Identifica come fattori di rischiondash lrsquoetagravegt65 annindash il fumo(gt 40 pacchettianno)ndash la diminuzione del FEV1ndash Diminuzione del FVC e del FEV1FVCndash la durata dellrsquoanestesia gt25 hrndash storia di COPDndash tosse produttiva giornalierandash incisione nellrsquoaddome supndash presenza di un SNG

bull Solo 4 sono indipendenti dopo una analisi multivariata etagravetest alla tosse positivopresenza periop del SNG e la durata dellrsquoanestesia

a preoperative risk index for predicting postoperative respiratory

failure (PRF)

Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National

Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS

OF SURGERY Vol 232 No 2 242ndash253bull Objectivebull To develop and validate a preoperative risk index for

predicting postoperative respiratory failure (PRF)bull prospective cohort studybull 44 Veterans Affairs Medical Centers (n 5 81719) were used to

develop the models Cases from 132 Veterans Affairs Medical Centers (n 5 99390) were used as a validation sample

bull PRF was defined as mechanical ventilation for more than 48 hours after surgery or reintubation and mechanical ventilation after postoperative extubation

bull Ventilator-dependent comatose do notresuscitate and female patients were excluded

bull respiratory care

Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac

Surgery Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Results bull PRF developed in 2746 patients (34) bull The respiratory failure risk index was developed from a simplified logistic

regression model and includedndash abdominal aortic aneurysm repairndash thoracic surgeryndash neurosurgery ndash upper abdominal surgery ndash Peripheral vascular surgery ndash neck surgeryndash emergency surgeryndash albumin level llt than 30 gL ndash blood urea nitrogen level gtthan 30 mgdL ndash dependent functional statusndash chronic obstructive pulmonary disease ndash agegt60

Indici prognostici di insuff resp postop Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the

National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF

SURGERY Vol 232 No 2 242ndash253

ndash Aneurismectomia aorta addominalendash Chir toracica ndash neurochir ndash Chir addominale maggiore ndash Chir vascolare periferica ndash Chir del collo ndash Chir in emergenza ndash Livelli di albumina lt 30 gL ndash BUN gt 30 mgdL ndash Dipendenza funzionalendash COPD (chronic obstructive pulmonary disease) ndash Etagrave gt60

Probability of PRF postoperative resp failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration

Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Classe punti probab PRFbull 1 lt=10 05 bull 2 11ndash19 22-18bull 3 20ndash27 53- 42bull 4 28ndash40 10-119 bull 5 gt40 309 -266

A comparison of risk factors for postoperative pneumonia and respiratory failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

ampAhsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDDevelopment and Validation of a Multifactorial Risk

Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ann Intern Med 2001135847-857

FINESegue lavori in dettagliohellip

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern

Med 2001135847-857bull Postoperative pulmonary complications are associatedbull with substantial morbidity and mortality It hasbull been estimated that nearly one fourth of deaths occurringbull within 6 days of surgery are related to postoperativebull pulmonary complications (1) Postoperative infectionsbull are also a major source of the morbidity and mortalitybull associated with undergoing surgery Pneumonia is thebull most serious postoperative complication that is includedbull in both of these categories Pneumonia ranks as thebull third most common postoperative infection behind urinarybull tract and wound infection (2) According to thebull National Nosocomial Infection Surveillance systembull pneumonia occurred in 18 of patients after surgerybull (3) Postoperative pneumonia occurs in 9 to 40 ofbull patients and the associated mortality rate is 30 tobull 46 depending on the type of surgery (1 4)bull Previous studies of risk factors used various definitionsbull of postoperative pulmonary complications Atelectasisbull (1 4ndash7) postoperative pneumonia (1ndash2 4ndash6bull 8ndash11) the acute respiratory distress syndrome (9 12)bull and postoperative respiratory failure (6 9 11 13) havebull been classified as postoperative pulmonary complicationsbull Although the clinical significance of each of thesebull complications varies greatly they were grouped togetherbull as a single outcome in previous studies (6) Some studiesbull were limited to examination of risk factors in patientsbull undergoing abdominal or thoracic procedures or in patientsbull with specific medical conditions such as chronicbull obstructive pulmonary disease (2 4 6 10ndash12 14)bull These studies were often based on a small sample frombull one institution and studies of independent samples didbull not validate their findings (15 16

Table 1 Definition of Postoperative PneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Patient met one of the following two criteria postoperativelybull 1 Rales or dullness to percussion on physical examination of chest AND

any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull 2 Chest radiography showing new or progressive infiltrate consolidation

cavitation or pleural effusion AND any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull Isolation of virus or detection of viral antigen in respiratory secretionsbull Diagnostic single antibody titer (IgM) or fourfold increase in paired serum

samples (IgG) for pathogenbull Histopathologic evidence of pneumonia

Postoperative pneumonia risk indexDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 3: Pulmonary complications risk

Relazione fra ASA PS e complicanze polmonari

Strategie tese alla riduzione delle complicanze postop

bull Lawrence VA Cornell JE Smetana GW Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery systematic review for the American College of Physicians Ann Intern Med 2005144596-608

bull Tutte le tecniche di espansione polmonare ndash spirometria incentiva ndash terapia fisicandash provocazione della tossendash drenaggio posturalendash percussione e vibrazionendash Aspirazionendash Deambulazionendash IPPBndash CPAP

bull hanno dimostrato superioritagrave rispetto ai controlli dopo chirurgia addominale

bull Non differenze fra le diverse modalitagrave di espansione neacute dalla loro combinazione

decompressione nasogastrica selettiva

bull effettuata nei pazienti con PONV incapaci di assumere nutrizione orale o con distensione addominale

ndash diminuisce la frequenza di polmonite ed atelettasia nei confronti della decompressione con sondino routinaria finche cioegrave non ritorni la motilitagrave gastrointestinale

ndash Cheatham ML Chapman WC Key SP Sawyers JL A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy Ann Surg 1995221469-76

ndash Nelson R Tse B Edwards S Systematic review of prophylactic nasogastric

decompression after abdominal operations Br J Surg 200592673-80 ndash Nelson R Edwards S Tse B Prophylactic nasogastric decompression after

abdominal surgery Cochrane Database Syst Rev 2005

Pneumonia risk

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD

William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Background Pneumonia is a common postoperative complication associated with substantial morbidity and mortalitybull Objective To develop and validate a preoperative risk index for predicting postoperative pneumoniabull Design Prospective cohort study with outcome assessment based on chart reviewbull Setting 100 Veterans Affairs Medical Centers performing major surgerybull Patients The risk index was developed by using data on 160 805 patients undergoing major noncardiac surgery bet ween 1

September 1997 and 31 August 1999 and was validated by using data on 155 266 patients undergoing surgery between 1 September 1995 and 31 August 1997 Patients with preoperative pneumonia ventilator dependence and pneumonia that developed after postoperative respiratory failure were excluded

bull Measurements Postoperative pneumonia was defined by using the Centers for Disease Control and Prevention definition of nosocomial pneumonia

bull Results A total of 2466 patients (15) developed pneumonia and the 30-day postoperative mortality rate was 21 A postoperative pneumonia risk index was developed that included type of surgery (abdominal aortic aneurysm repair thoracic upper abdominal neck vascular and neurosurgery) age functional status weight loss chronic obstructive pulmonary disease general anesthesia

bull impaired sensorium cerebral vascular accident blood urea nitrogen level transfusion emergency surgery long-term steroid use smoking and alcohol use Patients were divided into five risk classes by using risk index scores Pneumonia rates were 02 among those with 0 to 15 risk points 12 for those with 16 to 25 risk points 40 for those with 26 to 40 risk points 94 for those with 41 to 55 risk oints and 153 for those with more than 55 risk points The C-statistic was 0805 for the development cohort and 0817 for the validation cohort

bull Conclusions The postoperative pneumonia risk index identifies patients at risk for postoperative neumonia and may be useful in guiding perioperative respiratory care

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med

2001135847-857

Risk of postop pneumonia

Risk factors for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for Predicting Postoperative Pneumonia after Major

Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer

Daley MDAnn Intern Med 2001135847-857 bull Long-term steroid use bull Age older than 60 years bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6

monthsbull recent alcohol use bull Recent smoking bull history of chronic obstructive pulmonary diseasebull history of cerebral vascular accident with a residualbull deficit bull impaired sensorium

Fattori di rischio per la polmonite postoppazienteDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Somministrazione di steroidi a lungo termine bull Etagravegt60 anni bull Stato funzionale dipendentebull Perdita di peso gt 10 della massa coroorea nei 6 mesi

precedentibull uso recente di alcoholbull Fumo recentebull Storia di COPDbull Storia di accidente cerebrovascolare con deficit residuobull Disturbo di coscienza

Fattori di rischio per la polmonite postopinterventiDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857

bull abdominal aortic aneurysm repairbull thoracic bull neck bull upper abdominalbull peripheral vascular surgerybull neurosurgery

Am J Respir Crit Care Med 2005 Mar 1171(5)514-7 Incidence of and risk factors for pulmonary complications after nonthoracic

surgeryMcAlister FA Bertsch K Man J Bradley J Jacka M

bull Identifica come fattori di rischiondash lrsquoetagravegt65 annindash il fumo(gt 40 pacchettianno)ndash la diminuzione del FEV1ndash Diminuzione del FVC e del FEV1FVCndash la durata dellrsquoanestesia gt25 hrndash storia di COPDndash tosse produttiva giornalierandash incisione nellrsquoaddome supndash presenza di un SNG

bull Solo 4 sono indipendenti dopo una analisi multivariata etagravetest alla tosse positivopresenza periop del SNG e la durata dellrsquoanestesia

a preoperative risk index for predicting postoperative respiratory

failure (PRF)

Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National

Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS

OF SURGERY Vol 232 No 2 242ndash253bull Objectivebull To develop and validate a preoperative risk index for

predicting postoperative respiratory failure (PRF)bull prospective cohort studybull 44 Veterans Affairs Medical Centers (n 5 81719) were used to

develop the models Cases from 132 Veterans Affairs Medical Centers (n 5 99390) were used as a validation sample

bull PRF was defined as mechanical ventilation for more than 48 hours after surgery or reintubation and mechanical ventilation after postoperative extubation

bull Ventilator-dependent comatose do notresuscitate and female patients were excluded

bull respiratory care

Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac

Surgery Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Results bull PRF developed in 2746 patients (34) bull The respiratory failure risk index was developed from a simplified logistic

regression model and includedndash abdominal aortic aneurysm repairndash thoracic surgeryndash neurosurgery ndash upper abdominal surgery ndash Peripheral vascular surgery ndash neck surgeryndash emergency surgeryndash albumin level llt than 30 gL ndash blood urea nitrogen level gtthan 30 mgdL ndash dependent functional statusndash chronic obstructive pulmonary disease ndash agegt60

Indici prognostici di insuff resp postop Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the

National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF

SURGERY Vol 232 No 2 242ndash253

ndash Aneurismectomia aorta addominalendash Chir toracica ndash neurochir ndash Chir addominale maggiore ndash Chir vascolare periferica ndash Chir del collo ndash Chir in emergenza ndash Livelli di albumina lt 30 gL ndash BUN gt 30 mgdL ndash Dipendenza funzionalendash COPD (chronic obstructive pulmonary disease) ndash Etagrave gt60

Probability of PRF postoperative resp failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration

Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Classe punti probab PRFbull 1 lt=10 05 bull 2 11ndash19 22-18bull 3 20ndash27 53- 42bull 4 28ndash40 10-119 bull 5 gt40 309 -266

A comparison of risk factors for postoperative pneumonia and respiratory failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

ampAhsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDDevelopment and Validation of a Multifactorial Risk

Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ann Intern Med 2001135847-857

FINESegue lavori in dettagliohellip

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern

Med 2001135847-857bull Postoperative pulmonary complications are associatedbull with substantial morbidity and mortality It hasbull been estimated that nearly one fourth of deaths occurringbull within 6 days of surgery are related to postoperativebull pulmonary complications (1) Postoperative infectionsbull are also a major source of the morbidity and mortalitybull associated with undergoing surgery Pneumonia is thebull most serious postoperative complication that is includedbull in both of these categories Pneumonia ranks as thebull third most common postoperative infection behind urinarybull tract and wound infection (2) According to thebull National Nosocomial Infection Surveillance systembull pneumonia occurred in 18 of patients after surgerybull (3) Postoperative pneumonia occurs in 9 to 40 ofbull patients and the associated mortality rate is 30 tobull 46 depending on the type of surgery (1 4)bull Previous studies of risk factors used various definitionsbull of postoperative pulmonary complications Atelectasisbull (1 4ndash7) postoperative pneumonia (1ndash2 4ndash6bull 8ndash11) the acute respiratory distress syndrome (9 12)bull and postoperative respiratory failure (6 9 11 13) havebull been classified as postoperative pulmonary complicationsbull Although the clinical significance of each of thesebull complications varies greatly they were grouped togetherbull as a single outcome in previous studies (6) Some studiesbull were limited to examination of risk factors in patientsbull undergoing abdominal or thoracic procedures or in patientsbull with specific medical conditions such as chronicbull obstructive pulmonary disease (2 4 6 10ndash12 14)bull These studies were often based on a small sample frombull one institution and studies of independent samples didbull not validate their findings (15 16

Table 1 Definition of Postoperative PneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Patient met one of the following two criteria postoperativelybull 1 Rales or dullness to percussion on physical examination of chest AND

any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull 2 Chest radiography showing new or progressive infiltrate consolidation

cavitation or pleural effusion AND any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull Isolation of virus or detection of viral antigen in respiratory secretionsbull Diagnostic single antibody titer (IgM) or fourfold increase in paired serum

samples (IgG) for pathogenbull Histopathologic evidence of pneumonia

Postoperative pneumonia risk indexDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 4: Pulmonary complications risk

Strategie tese alla riduzione delle complicanze postop

bull Lawrence VA Cornell JE Smetana GW Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery systematic review for the American College of Physicians Ann Intern Med 2005144596-608

bull Tutte le tecniche di espansione polmonare ndash spirometria incentiva ndash terapia fisicandash provocazione della tossendash drenaggio posturalendash percussione e vibrazionendash Aspirazionendash Deambulazionendash IPPBndash CPAP

bull hanno dimostrato superioritagrave rispetto ai controlli dopo chirurgia addominale

bull Non differenze fra le diverse modalitagrave di espansione neacute dalla loro combinazione

decompressione nasogastrica selettiva

bull effettuata nei pazienti con PONV incapaci di assumere nutrizione orale o con distensione addominale

ndash diminuisce la frequenza di polmonite ed atelettasia nei confronti della decompressione con sondino routinaria finche cioegrave non ritorni la motilitagrave gastrointestinale

ndash Cheatham ML Chapman WC Key SP Sawyers JL A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy Ann Surg 1995221469-76

ndash Nelson R Tse B Edwards S Systematic review of prophylactic nasogastric

decompression after abdominal operations Br J Surg 200592673-80 ndash Nelson R Edwards S Tse B Prophylactic nasogastric decompression after

abdominal surgery Cochrane Database Syst Rev 2005

Pneumonia risk

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD

William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Background Pneumonia is a common postoperative complication associated with substantial morbidity and mortalitybull Objective To develop and validate a preoperative risk index for predicting postoperative pneumoniabull Design Prospective cohort study with outcome assessment based on chart reviewbull Setting 100 Veterans Affairs Medical Centers performing major surgerybull Patients The risk index was developed by using data on 160 805 patients undergoing major noncardiac surgery bet ween 1

September 1997 and 31 August 1999 and was validated by using data on 155 266 patients undergoing surgery between 1 September 1995 and 31 August 1997 Patients with preoperative pneumonia ventilator dependence and pneumonia that developed after postoperative respiratory failure were excluded

bull Measurements Postoperative pneumonia was defined by using the Centers for Disease Control and Prevention definition of nosocomial pneumonia

bull Results A total of 2466 patients (15) developed pneumonia and the 30-day postoperative mortality rate was 21 A postoperative pneumonia risk index was developed that included type of surgery (abdominal aortic aneurysm repair thoracic upper abdominal neck vascular and neurosurgery) age functional status weight loss chronic obstructive pulmonary disease general anesthesia

bull impaired sensorium cerebral vascular accident blood urea nitrogen level transfusion emergency surgery long-term steroid use smoking and alcohol use Patients were divided into five risk classes by using risk index scores Pneumonia rates were 02 among those with 0 to 15 risk points 12 for those with 16 to 25 risk points 40 for those with 26 to 40 risk points 94 for those with 41 to 55 risk oints and 153 for those with more than 55 risk points The C-statistic was 0805 for the development cohort and 0817 for the validation cohort

bull Conclusions The postoperative pneumonia risk index identifies patients at risk for postoperative neumonia and may be useful in guiding perioperative respiratory care

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med

2001135847-857

Risk of postop pneumonia

Risk factors for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for Predicting Postoperative Pneumonia after Major

Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer

Daley MDAnn Intern Med 2001135847-857 bull Long-term steroid use bull Age older than 60 years bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6

monthsbull recent alcohol use bull Recent smoking bull history of chronic obstructive pulmonary diseasebull history of cerebral vascular accident with a residualbull deficit bull impaired sensorium

Fattori di rischio per la polmonite postoppazienteDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Somministrazione di steroidi a lungo termine bull Etagravegt60 anni bull Stato funzionale dipendentebull Perdita di peso gt 10 della massa coroorea nei 6 mesi

precedentibull uso recente di alcoholbull Fumo recentebull Storia di COPDbull Storia di accidente cerebrovascolare con deficit residuobull Disturbo di coscienza

Fattori di rischio per la polmonite postopinterventiDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857

bull abdominal aortic aneurysm repairbull thoracic bull neck bull upper abdominalbull peripheral vascular surgerybull neurosurgery

Am J Respir Crit Care Med 2005 Mar 1171(5)514-7 Incidence of and risk factors for pulmonary complications after nonthoracic

surgeryMcAlister FA Bertsch K Man J Bradley J Jacka M

bull Identifica come fattori di rischiondash lrsquoetagravegt65 annindash il fumo(gt 40 pacchettianno)ndash la diminuzione del FEV1ndash Diminuzione del FVC e del FEV1FVCndash la durata dellrsquoanestesia gt25 hrndash storia di COPDndash tosse produttiva giornalierandash incisione nellrsquoaddome supndash presenza di un SNG

bull Solo 4 sono indipendenti dopo una analisi multivariata etagravetest alla tosse positivopresenza periop del SNG e la durata dellrsquoanestesia

a preoperative risk index for predicting postoperative respiratory

failure (PRF)

Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National

Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS

OF SURGERY Vol 232 No 2 242ndash253bull Objectivebull To develop and validate a preoperative risk index for

predicting postoperative respiratory failure (PRF)bull prospective cohort studybull 44 Veterans Affairs Medical Centers (n 5 81719) were used to

develop the models Cases from 132 Veterans Affairs Medical Centers (n 5 99390) were used as a validation sample

bull PRF was defined as mechanical ventilation for more than 48 hours after surgery or reintubation and mechanical ventilation after postoperative extubation

bull Ventilator-dependent comatose do notresuscitate and female patients were excluded

bull respiratory care

Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac

Surgery Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Results bull PRF developed in 2746 patients (34) bull The respiratory failure risk index was developed from a simplified logistic

regression model and includedndash abdominal aortic aneurysm repairndash thoracic surgeryndash neurosurgery ndash upper abdominal surgery ndash Peripheral vascular surgery ndash neck surgeryndash emergency surgeryndash albumin level llt than 30 gL ndash blood urea nitrogen level gtthan 30 mgdL ndash dependent functional statusndash chronic obstructive pulmonary disease ndash agegt60

Indici prognostici di insuff resp postop Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the

National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF

SURGERY Vol 232 No 2 242ndash253

ndash Aneurismectomia aorta addominalendash Chir toracica ndash neurochir ndash Chir addominale maggiore ndash Chir vascolare periferica ndash Chir del collo ndash Chir in emergenza ndash Livelli di albumina lt 30 gL ndash BUN gt 30 mgdL ndash Dipendenza funzionalendash COPD (chronic obstructive pulmonary disease) ndash Etagrave gt60

Probability of PRF postoperative resp failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration

Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Classe punti probab PRFbull 1 lt=10 05 bull 2 11ndash19 22-18bull 3 20ndash27 53- 42bull 4 28ndash40 10-119 bull 5 gt40 309 -266

A comparison of risk factors for postoperative pneumonia and respiratory failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

ampAhsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDDevelopment and Validation of a Multifactorial Risk

Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ann Intern Med 2001135847-857

FINESegue lavori in dettagliohellip

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern

Med 2001135847-857bull Postoperative pulmonary complications are associatedbull with substantial morbidity and mortality It hasbull been estimated that nearly one fourth of deaths occurringbull within 6 days of surgery are related to postoperativebull pulmonary complications (1) Postoperative infectionsbull are also a major source of the morbidity and mortalitybull associated with undergoing surgery Pneumonia is thebull most serious postoperative complication that is includedbull in both of these categories Pneumonia ranks as thebull third most common postoperative infection behind urinarybull tract and wound infection (2) According to thebull National Nosocomial Infection Surveillance systembull pneumonia occurred in 18 of patients after surgerybull (3) Postoperative pneumonia occurs in 9 to 40 ofbull patients and the associated mortality rate is 30 tobull 46 depending on the type of surgery (1 4)bull Previous studies of risk factors used various definitionsbull of postoperative pulmonary complications Atelectasisbull (1 4ndash7) postoperative pneumonia (1ndash2 4ndash6bull 8ndash11) the acute respiratory distress syndrome (9 12)bull and postoperative respiratory failure (6 9 11 13) havebull been classified as postoperative pulmonary complicationsbull Although the clinical significance of each of thesebull complications varies greatly they were grouped togetherbull as a single outcome in previous studies (6) Some studiesbull were limited to examination of risk factors in patientsbull undergoing abdominal or thoracic procedures or in patientsbull with specific medical conditions such as chronicbull obstructive pulmonary disease (2 4 6 10ndash12 14)bull These studies were often based on a small sample frombull one institution and studies of independent samples didbull not validate their findings (15 16

Table 1 Definition of Postoperative PneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Patient met one of the following two criteria postoperativelybull 1 Rales or dullness to percussion on physical examination of chest AND

any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull 2 Chest radiography showing new or progressive infiltrate consolidation

cavitation or pleural effusion AND any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull Isolation of virus or detection of viral antigen in respiratory secretionsbull Diagnostic single antibody titer (IgM) or fourfold increase in paired serum

samples (IgG) for pathogenbull Histopathologic evidence of pneumonia

Postoperative pneumonia risk indexDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 5: Pulmonary complications risk

decompressione nasogastrica selettiva

bull effettuata nei pazienti con PONV incapaci di assumere nutrizione orale o con distensione addominale

ndash diminuisce la frequenza di polmonite ed atelettasia nei confronti della decompressione con sondino routinaria finche cioegrave non ritorni la motilitagrave gastrointestinale

ndash Cheatham ML Chapman WC Key SP Sawyers JL A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy Ann Surg 1995221469-76

ndash Nelson R Tse B Edwards S Systematic review of prophylactic nasogastric

decompression after abdominal operations Br J Surg 200592673-80 ndash Nelson R Edwards S Tse B Prophylactic nasogastric decompression after

abdominal surgery Cochrane Database Syst Rev 2005

Pneumonia risk

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD

William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Background Pneumonia is a common postoperative complication associated with substantial morbidity and mortalitybull Objective To develop and validate a preoperative risk index for predicting postoperative pneumoniabull Design Prospective cohort study with outcome assessment based on chart reviewbull Setting 100 Veterans Affairs Medical Centers performing major surgerybull Patients The risk index was developed by using data on 160 805 patients undergoing major noncardiac surgery bet ween 1

September 1997 and 31 August 1999 and was validated by using data on 155 266 patients undergoing surgery between 1 September 1995 and 31 August 1997 Patients with preoperative pneumonia ventilator dependence and pneumonia that developed after postoperative respiratory failure were excluded

bull Measurements Postoperative pneumonia was defined by using the Centers for Disease Control and Prevention definition of nosocomial pneumonia

bull Results A total of 2466 patients (15) developed pneumonia and the 30-day postoperative mortality rate was 21 A postoperative pneumonia risk index was developed that included type of surgery (abdominal aortic aneurysm repair thoracic upper abdominal neck vascular and neurosurgery) age functional status weight loss chronic obstructive pulmonary disease general anesthesia

bull impaired sensorium cerebral vascular accident blood urea nitrogen level transfusion emergency surgery long-term steroid use smoking and alcohol use Patients were divided into five risk classes by using risk index scores Pneumonia rates were 02 among those with 0 to 15 risk points 12 for those with 16 to 25 risk points 40 for those with 26 to 40 risk points 94 for those with 41 to 55 risk oints and 153 for those with more than 55 risk points The C-statistic was 0805 for the development cohort and 0817 for the validation cohort

bull Conclusions The postoperative pneumonia risk index identifies patients at risk for postoperative neumonia and may be useful in guiding perioperative respiratory care

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med

2001135847-857

Risk of postop pneumonia

Risk factors for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for Predicting Postoperative Pneumonia after Major

Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer

Daley MDAnn Intern Med 2001135847-857 bull Long-term steroid use bull Age older than 60 years bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6

monthsbull recent alcohol use bull Recent smoking bull history of chronic obstructive pulmonary diseasebull history of cerebral vascular accident with a residualbull deficit bull impaired sensorium

Fattori di rischio per la polmonite postoppazienteDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Somministrazione di steroidi a lungo termine bull Etagravegt60 anni bull Stato funzionale dipendentebull Perdita di peso gt 10 della massa coroorea nei 6 mesi

precedentibull uso recente di alcoholbull Fumo recentebull Storia di COPDbull Storia di accidente cerebrovascolare con deficit residuobull Disturbo di coscienza

Fattori di rischio per la polmonite postopinterventiDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857

bull abdominal aortic aneurysm repairbull thoracic bull neck bull upper abdominalbull peripheral vascular surgerybull neurosurgery

Am J Respir Crit Care Med 2005 Mar 1171(5)514-7 Incidence of and risk factors for pulmonary complications after nonthoracic

surgeryMcAlister FA Bertsch K Man J Bradley J Jacka M

bull Identifica come fattori di rischiondash lrsquoetagravegt65 annindash il fumo(gt 40 pacchettianno)ndash la diminuzione del FEV1ndash Diminuzione del FVC e del FEV1FVCndash la durata dellrsquoanestesia gt25 hrndash storia di COPDndash tosse produttiva giornalierandash incisione nellrsquoaddome supndash presenza di un SNG

bull Solo 4 sono indipendenti dopo una analisi multivariata etagravetest alla tosse positivopresenza periop del SNG e la durata dellrsquoanestesia

a preoperative risk index for predicting postoperative respiratory

failure (PRF)

Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National

Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS

OF SURGERY Vol 232 No 2 242ndash253bull Objectivebull To develop and validate a preoperative risk index for

predicting postoperative respiratory failure (PRF)bull prospective cohort studybull 44 Veterans Affairs Medical Centers (n 5 81719) were used to

develop the models Cases from 132 Veterans Affairs Medical Centers (n 5 99390) were used as a validation sample

bull PRF was defined as mechanical ventilation for more than 48 hours after surgery or reintubation and mechanical ventilation after postoperative extubation

bull Ventilator-dependent comatose do notresuscitate and female patients were excluded

bull respiratory care

Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac

Surgery Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Results bull PRF developed in 2746 patients (34) bull The respiratory failure risk index was developed from a simplified logistic

regression model and includedndash abdominal aortic aneurysm repairndash thoracic surgeryndash neurosurgery ndash upper abdominal surgery ndash Peripheral vascular surgery ndash neck surgeryndash emergency surgeryndash albumin level llt than 30 gL ndash blood urea nitrogen level gtthan 30 mgdL ndash dependent functional statusndash chronic obstructive pulmonary disease ndash agegt60

Indici prognostici di insuff resp postop Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the

National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF

SURGERY Vol 232 No 2 242ndash253

ndash Aneurismectomia aorta addominalendash Chir toracica ndash neurochir ndash Chir addominale maggiore ndash Chir vascolare periferica ndash Chir del collo ndash Chir in emergenza ndash Livelli di albumina lt 30 gL ndash BUN gt 30 mgdL ndash Dipendenza funzionalendash COPD (chronic obstructive pulmonary disease) ndash Etagrave gt60

Probability of PRF postoperative resp failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration

Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Classe punti probab PRFbull 1 lt=10 05 bull 2 11ndash19 22-18bull 3 20ndash27 53- 42bull 4 28ndash40 10-119 bull 5 gt40 309 -266

A comparison of risk factors for postoperative pneumonia and respiratory failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

ampAhsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDDevelopment and Validation of a Multifactorial Risk

Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ann Intern Med 2001135847-857

FINESegue lavori in dettagliohellip

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern

Med 2001135847-857bull Postoperative pulmonary complications are associatedbull with substantial morbidity and mortality It hasbull been estimated that nearly one fourth of deaths occurringbull within 6 days of surgery are related to postoperativebull pulmonary complications (1) Postoperative infectionsbull are also a major source of the morbidity and mortalitybull associated with undergoing surgery Pneumonia is thebull most serious postoperative complication that is includedbull in both of these categories Pneumonia ranks as thebull third most common postoperative infection behind urinarybull tract and wound infection (2) According to thebull National Nosocomial Infection Surveillance systembull pneumonia occurred in 18 of patients after surgerybull (3) Postoperative pneumonia occurs in 9 to 40 ofbull patients and the associated mortality rate is 30 tobull 46 depending on the type of surgery (1 4)bull Previous studies of risk factors used various definitionsbull of postoperative pulmonary complications Atelectasisbull (1 4ndash7) postoperative pneumonia (1ndash2 4ndash6bull 8ndash11) the acute respiratory distress syndrome (9 12)bull and postoperative respiratory failure (6 9 11 13) havebull been classified as postoperative pulmonary complicationsbull Although the clinical significance of each of thesebull complications varies greatly they were grouped togetherbull as a single outcome in previous studies (6) Some studiesbull were limited to examination of risk factors in patientsbull undergoing abdominal or thoracic procedures or in patientsbull with specific medical conditions such as chronicbull obstructive pulmonary disease (2 4 6 10ndash12 14)bull These studies were often based on a small sample frombull one institution and studies of independent samples didbull not validate their findings (15 16

Table 1 Definition of Postoperative PneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Patient met one of the following two criteria postoperativelybull 1 Rales or dullness to percussion on physical examination of chest AND

any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull 2 Chest radiography showing new or progressive infiltrate consolidation

cavitation or pleural effusion AND any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull Isolation of virus or detection of viral antigen in respiratory secretionsbull Diagnostic single antibody titer (IgM) or fourfold increase in paired serum

samples (IgG) for pathogenbull Histopathologic evidence of pneumonia

Postoperative pneumonia risk indexDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 6: Pulmonary complications risk

Pneumonia risk

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD

William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Background Pneumonia is a common postoperative complication associated with substantial morbidity and mortalitybull Objective To develop and validate a preoperative risk index for predicting postoperative pneumoniabull Design Prospective cohort study with outcome assessment based on chart reviewbull Setting 100 Veterans Affairs Medical Centers performing major surgerybull Patients The risk index was developed by using data on 160 805 patients undergoing major noncardiac surgery bet ween 1

September 1997 and 31 August 1999 and was validated by using data on 155 266 patients undergoing surgery between 1 September 1995 and 31 August 1997 Patients with preoperative pneumonia ventilator dependence and pneumonia that developed after postoperative respiratory failure were excluded

bull Measurements Postoperative pneumonia was defined by using the Centers for Disease Control and Prevention definition of nosocomial pneumonia

bull Results A total of 2466 patients (15) developed pneumonia and the 30-day postoperative mortality rate was 21 A postoperative pneumonia risk index was developed that included type of surgery (abdominal aortic aneurysm repair thoracic upper abdominal neck vascular and neurosurgery) age functional status weight loss chronic obstructive pulmonary disease general anesthesia

bull impaired sensorium cerebral vascular accident blood urea nitrogen level transfusion emergency surgery long-term steroid use smoking and alcohol use Patients were divided into five risk classes by using risk index scores Pneumonia rates were 02 among those with 0 to 15 risk points 12 for those with 16 to 25 risk points 40 for those with 26 to 40 risk points 94 for those with 41 to 55 risk oints and 153 for those with more than 55 risk points The C-statistic was 0805 for the development cohort and 0817 for the validation cohort

bull Conclusions The postoperative pneumonia risk index identifies patients at risk for postoperative neumonia and may be useful in guiding perioperative respiratory care

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med

2001135847-857

Risk of postop pneumonia

Risk factors for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for Predicting Postoperative Pneumonia after Major

Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer

Daley MDAnn Intern Med 2001135847-857 bull Long-term steroid use bull Age older than 60 years bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6

monthsbull recent alcohol use bull Recent smoking bull history of chronic obstructive pulmonary diseasebull history of cerebral vascular accident with a residualbull deficit bull impaired sensorium

Fattori di rischio per la polmonite postoppazienteDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Somministrazione di steroidi a lungo termine bull Etagravegt60 anni bull Stato funzionale dipendentebull Perdita di peso gt 10 della massa coroorea nei 6 mesi

precedentibull uso recente di alcoholbull Fumo recentebull Storia di COPDbull Storia di accidente cerebrovascolare con deficit residuobull Disturbo di coscienza

Fattori di rischio per la polmonite postopinterventiDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857

bull abdominal aortic aneurysm repairbull thoracic bull neck bull upper abdominalbull peripheral vascular surgerybull neurosurgery

Am J Respir Crit Care Med 2005 Mar 1171(5)514-7 Incidence of and risk factors for pulmonary complications after nonthoracic

surgeryMcAlister FA Bertsch K Man J Bradley J Jacka M

bull Identifica come fattori di rischiondash lrsquoetagravegt65 annindash il fumo(gt 40 pacchettianno)ndash la diminuzione del FEV1ndash Diminuzione del FVC e del FEV1FVCndash la durata dellrsquoanestesia gt25 hrndash storia di COPDndash tosse produttiva giornalierandash incisione nellrsquoaddome supndash presenza di un SNG

bull Solo 4 sono indipendenti dopo una analisi multivariata etagravetest alla tosse positivopresenza periop del SNG e la durata dellrsquoanestesia

a preoperative risk index for predicting postoperative respiratory

failure (PRF)

Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National

Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS

OF SURGERY Vol 232 No 2 242ndash253bull Objectivebull To develop and validate a preoperative risk index for

predicting postoperative respiratory failure (PRF)bull prospective cohort studybull 44 Veterans Affairs Medical Centers (n 5 81719) were used to

develop the models Cases from 132 Veterans Affairs Medical Centers (n 5 99390) were used as a validation sample

bull PRF was defined as mechanical ventilation for more than 48 hours after surgery or reintubation and mechanical ventilation after postoperative extubation

bull Ventilator-dependent comatose do notresuscitate and female patients were excluded

bull respiratory care

Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac

Surgery Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Results bull PRF developed in 2746 patients (34) bull The respiratory failure risk index was developed from a simplified logistic

regression model and includedndash abdominal aortic aneurysm repairndash thoracic surgeryndash neurosurgery ndash upper abdominal surgery ndash Peripheral vascular surgery ndash neck surgeryndash emergency surgeryndash albumin level llt than 30 gL ndash blood urea nitrogen level gtthan 30 mgdL ndash dependent functional statusndash chronic obstructive pulmonary disease ndash agegt60

Indici prognostici di insuff resp postop Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the

National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF

SURGERY Vol 232 No 2 242ndash253

ndash Aneurismectomia aorta addominalendash Chir toracica ndash neurochir ndash Chir addominale maggiore ndash Chir vascolare periferica ndash Chir del collo ndash Chir in emergenza ndash Livelli di albumina lt 30 gL ndash BUN gt 30 mgdL ndash Dipendenza funzionalendash COPD (chronic obstructive pulmonary disease) ndash Etagrave gt60

Probability of PRF postoperative resp failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration

Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Classe punti probab PRFbull 1 lt=10 05 bull 2 11ndash19 22-18bull 3 20ndash27 53- 42bull 4 28ndash40 10-119 bull 5 gt40 309 -266

A comparison of risk factors for postoperative pneumonia and respiratory failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

ampAhsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDDevelopment and Validation of a Multifactorial Risk

Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ann Intern Med 2001135847-857

FINESegue lavori in dettagliohellip

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern

Med 2001135847-857bull Postoperative pulmonary complications are associatedbull with substantial morbidity and mortality It hasbull been estimated that nearly one fourth of deaths occurringbull within 6 days of surgery are related to postoperativebull pulmonary complications (1) Postoperative infectionsbull are also a major source of the morbidity and mortalitybull associated with undergoing surgery Pneumonia is thebull most serious postoperative complication that is includedbull in both of these categories Pneumonia ranks as thebull third most common postoperative infection behind urinarybull tract and wound infection (2) According to thebull National Nosocomial Infection Surveillance systembull pneumonia occurred in 18 of patients after surgerybull (3) Postoperative pneumonia occurs in 9 to 40 ofbull patients and the associated mortality rate is 30 tobull 46 depending on the type of surgery (1 4)bull Previous studies of risk factors used various definitionsbull of postoperative pulmonary complications Atelectasisbull (1 4ndash7) postoperative pneumonia (1ndash2 4ndash6bull 8ndash11) the acute respiratory distress syndrome (9 12)bull and postoperative respiratory failure (6 9 11 13) havebull been classified as postoperative pulmonary complicationsbull Although the clinical significance of each of thesebull complications varies greatly they were grouped togetherbull as a single outcome in previous studies (6) Some studiesbull were limited to examination of risk factors in patientsbull undergoing abdominal or thoracic procedures or in patientsbull with specific medical conditions such as chronicbull obstructive pulmonary disease (2 4 6 10ndash12 14)bull These studies were often based on a small sample frombull one institution and studies of independent samples didbull not validate their findings (15 16

Table 1 Definition of Postoperative PneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Patient met one of the following two criteria postoperativelybull 1 Rales or dullness to percussion on physical examination of chest AND

any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull 2 Chest radiography showing new or progressive infiltrate consolidation

cavitation or pleural effusion AND any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull Isolation of virus or detection of viral antigen in respiratory secretionsbull Diagnostic single antibody titer (IgM) or fourfold increase in paired serum

samples (IgG) for pathogenbull Histopathologic evidence of pneumonia

Postoperative pneumonia risk indexDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 7: Pulmonary complications risk

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD

William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Background Pneumonia is a common postoperative complication associated with substantial morbidity and mortalitybull Objective To develop and validate a preoperative risk index for predicting postoperative pneumoniabull Design Prospective cohort study with outcome assessment based on chart reviewbull Setting 100 Veterans Affairs Medical Centers performing major surgerybull Patients The risk index was developed by using data on 160 805 patients undergoing major noncardiac surgery bet ween 1

September 1997 and 31 August 1999 and was validated by using data on 155 266 patients undergoing surgery between 1 September 1995 and 31 August 1997 Patients with preoperative pneumonia ventilator dependence and pneumonia that developed after postoperative respiratory failure were excluded

bull Measurements Postoperative pneumonia was defined by using the Centers for Disease Control and Prevention definition of nosocomial pneumonia

bull Results A total of 2466 patients (15) developed pneumonia and the 30-day postoperative mortality rate was 21 A postoperative pneumonia risk index was developed that included type of surgery (abdominal aortic aneurysm repair thoracic upper abdominal neck vascular and neurosurgery) age functional status weight loss chronic obstructive pulmonary disease general anesthesia

bull impaired sensorium cerebral vascular accident blood urea nitrogen level transfusion emergency surgery long-term steroid use smoking and alcohol use Patients were divided into five risk classes by using risk index scores Pneumonia rates were 02 among those with 0 to 15 risk points 12 for those with 16 to 25 risk points 40 for those with 26 to 40 risk points 94 for those with 41 to 55 risk oints and 153 for those with more than 55 risk points The C-statistic was 0805 for the development cohort and 0817 for the validation cohort

bull Conclusions The postoperative pneumonia risk index identifies patients at risk for postoperative neumonia and may be useful in guiding perioperative respiratory care

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med

2001135847-857

Risk of postop pneumonia

Risk factors for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for Predicting Postoperative Pneumonia after Major

Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer

Daley MDAnn Intern Med 2001135847-857 bull Long-term steroid use bull Age older than 60 years bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6

monthsbull recent alcohol use bull Recent smoking bull history of chronic obstructive pulmonary diseasebull history of cerebral vascular accident with a residualbull deficit bull impaired sensorium

Fattori di rischio per la polmonite postoppazienteDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Somministrazione di steroidi a lungo termine bull Etagravegt60 anni bull Stato funzionale dipendentebull Perdita di peso gt 10 della massa coroorea nei 6 mesi

precedentibull uso recente di alcoholbull Fumo recentebull Storia di COPDbull Storia di accidente cerebrovascolare con deficit residuobull Disturbo di coscienza

Fattori di rischio per la polmonite postopinterventiDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857

bull abdominal aortic aneurysm repairbull thoracic bull neck bull upper abdominalbull peripheral vascular surgerybull neurosurgery

Am J Respir Crit Care Med 2005 Mar 1171(5)514-7 Incidence of and risk factors for pulmonary complications after nonthoracic

surgeryMcAlister FA Bertsch K Man J Bradley J Jacka M

bull Identifica come fattori di rischiondash lrsquoetagravegt65 annindash il fumo(gt 40 pacchettianno)ndash la diminuzione del FEV1ndash Diminuzione del FVC e del FEV1FVCndash la durata dellrsquoanestesia gt25 hrndash storia di COPDndash tosse produttiva giornalierandash incisione nellrsquoaddome supndash presenza di un SNG

bull Solo 4 sono indipendenti dopo una analisi multivariata etagravetest alla tosse positivopresenza periop del SNG e la durata dellrsquoanestesia

a preoperative risk index for predicting postoperative respiratory

failure (PRF)

Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National

Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS

OF SURGERY Vol 232 No 2 242ndash253bull Objectivebull To develop and validate a preoperative risk index for

predicting postoperative respiratory failure (PRF)bull prospective cohort studybull 44 Veterans Affairs Medical Centers (n 5 81719) were used to

develop the models Cases from 132 Veterans Affairs Medical Centers (n 5 99390) were used as a validation sample

bull PRF was defined as mechanical ventilation for more than 48 hours after surgery or reintubation and mechanical ventilation after postoperative extubation

bull Ventilator-dependent comatose do notresuscitate and female patients were excluded

bull respiratory care

Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac

Surgery Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Results bull PRF developed in 2746 patients (34) bull The respiratory failure risk index was developed from a simplified logistic

regression model and includedndash abdominal aortic aneurysm repairndash thoracic surgeryndash neurosurgery ndash upper abdominal surgery ndash Peripheral vascular surgery ndash neck surgeryndash emergency surgeryndash albumin level llt than 30 gL ndash blood urea nitrogen level gtthan 30 mgdL ndash dependent functional statusndash chronic obstructive pulmonary disease ndash agegt60

Indici prognostici di insuff resp postop Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the

National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF

SURGERY Vol 232 No 2 242ndash253

ndash Aneurismectomia aorta addominalendash Chir toracica ndash neurochir ndash Chir addominale maggiore ndash Chir vascolare periferica ndash Chir del collo ndash Chir in emergenza ndash Livelli di albumina lt 30 gL ndash BUN gt 30 mgdL ndash Dipendenza funzionalendash COPD (chronic obstructive pulmonary disease) ndash Etagrave gt60

Probability of PRF postoperative resp failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration

Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Classe punti probab PRFbull 1 lt=10 05 bull 2 11ndash19 22-18bull 3 20ndash27 53- 42bull 4 28ndash40 10-119 bull 5 gt40 309 -266

A comparison of risk factors for postoperative pneumonia and respiratory failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

ampAhsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDDevelopment and Validation of a Multifactorial Risk

Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ann Intern Med 2001135847-857

FINESegue lavori in dettagliohellip

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern

Med 2001135847-857bull Postoperative pulmonary complications are associatedbull with substantial morbidity and mortality It hasbull been estimated that nearly one fourth of deaths occurringbull within 6 days of surgery are related to postoperativebull pulmonary complications (1) Postoperative infectionsbull are also a major source of the morbidity and mortalitybull associated with undergoing surgery Pneumonia is thebull most serious postoperative complication that is includedbull in both of these categories Pneumonia ranks as thebull third most common postoperative infection behind urinarybull tract and wound infection (2) According to thebull National Nosocomial Infection Surveillance systembull pneumonia occurred in 18 of patients after surgerybull (3) Postoperative pneumonia occurs in 9 to 40 ofbull patients and the associated mortality rate is 30 tobull 46 depending on the type of surgery (1 4)bull Previous studies of risk factors used various definitionsbull of postoperative pulmonary complications Atelectasisbull (1 4ndash7) postoperative pneumonia (1ndash2 4ndash6bull 8ndash11) the acute respiratory distress syndrome (9 12)bull and postoperative respiratory failure (6 9 11 13) havebull been classified as postoperative pulmonary complicationsbull Although the clinical significance of each of thesebull complications varies greatly they were grouped togetherbull as a single outcome in previous studies (6) Some studiesbull were limited to examination of risk factors in patientsbull undergoing abdominal or thoracic procedures or in patientsbull with specific medical conditions such as chronicbull obstructive pulmonary disease (2 4 6 10ndash12 14)bull These studies were often based on a small sample frombull one institution and studies of independent samples didbull not validate their findings (15 16

Table 1 Definition of Postoperative PneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Patient met one of the following two criteria postoperativelybull 1 Rales or dullness to percussion on physical examination of chest AND

any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull 2 Chest radiography showing new or progressive infiltrate consolidation

cavitation or pleural effusion AND any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull Isolation of virus or detection of viral antigen in respiratory secretionsbull Diagnostic single antibody titer (IgM) or fourfold increase in paired serum

samples (IgG) for pathogenbull Histopathologic evidence of pneumonia

Postoperative pneumonia risk indexDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 8: Pulmonary complications risk

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med

2001135847-857

Risk of postop pneumonia

Risk factors for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for Predicting Postoperative Pneumonia after Major

Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer

Daley MDAnn Intern Med 2001135847-857 bull Long-term steroid use bull Age older than 60 years bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6

monthsbull recent alcohol use bull Recent smoking bull history of chronic obstructive pulmonary diseasebull history of cerebral vascular accident with a residualbull deficit bull impaired sensorium

Fattori di rischio per la polmonite postoppazienteDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Somministrazione di steroidi a lungo termine bull Etagravegt60 anni bull Stato funzionale dipendentebull Perdita di peso gt 10 della massa coroorea nei 6 mesi

precedentibull uso recente di alcoholbull Fumo recentebull Storia di COPDbull Storia di accidente cerebrovascolare con deficit residuobull Disturbo di coscienza

Fattori di rischio per la polmonite postopinterventiDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857

bull abdominal aortic aneurysm repairbull thoracic bull neck bull upper abdominalbull peripheral vascular surgerybull neurosurgery

Am J Respir Crit Care Med 2005 Mar 1171(5)514-7 Incidence of and risk factors for pulmonary complications after nonthoracic

surgeryMcAlister FA Bertsch K Man J Bradley J Jacka M

bull Identifica come fattori di rischiondash lrsquoetagravegt65 annindash il fumo(gt 40 pacchettianno)ndash la diminuzione del FEV1ndash Diminuzione del FVC e del FEV1FVCndash la durata dellrsquoanestesia gt25 hrndash storia di COPDndash tosse produttiva giornalierandash incisione nellrsquoaddome supndash presenza di un SNG

bull Solo 4 sono indipendenti dopo una analisi multivariata etagravetest alla tosse positivopresenza periop del SNG e la durata dellrsquoanestesia

a preoperative risk index for predicting postoperative respiratory

failure (PRF)

Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National

Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS

OF SURGERY Vol 232 No 2 242ndash253bull Objectivebull To develop and validate a preoperative risk index for

predicting postoperative respiratory failure (PRF)bull prospective cohort studybull 44 Veterans Affairs Medical Centers (n 5 81719) were used to

develop the models Cases from 132 Veterans Affairs Medical Centers (n 5 99390) were used as a validation sample

bull PRF was defined as mechanical ventilation for more than 48 hours after surgery or reintubation and mechanical ventilation after postoperative extubation

bull Ventilator-dependent comatose do notresuscitate and female patients were excluded

bull respiratory care

Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac

Surgery Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Results bull PRF developed in 2746 patients (34) bull The respiratory failure risk index was developed from a simplified logistic

regression model and includedndash abdominal aortic aneurysm repairndash thoracic surgeryndash neurosurgery ndash upper abdominal surgery ndash Peripheral vascular surgery ndash neck surgeryndash emergency surgeryndash albumin level llt than 30 gL ndash blood urea nitrogen level gtthan 30 mgdL ndash dependent functional statusndash chronic obstructive pulmonary disease ndash agegt60

Indici prognostici di insuff resp postop Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the

National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF

SURGERY Vol 232 No 2 242ndash253

ndash Aneurismectomia aorta addominalendash Chir toracica ndash neurochir ndash Chir addominale maggiore ndash Chir vascolare periferica ndash Chir del collo ndash Chir in emergenza ndash Livelli di albumina lt 30 gL ndash BUN gt 30 mgdL ndash Dipendenza funzionalendash COPD (chronic obstructive pulmonary disease) ndash Etagrave gt60

Probability of PRF postoperative resp failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration

Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Classe punti probab PRFbull 1 lt=10 05 bull 2 11ndash19 22-18bull 3 20ndash27 53- 42bull 4 28ndash40 10-119 bull 5 gt40 309 -266

A comparison of risk factors for postoperative pneumonia and respiratory failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

ampAhsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDDevelopment and Validation of a Multifactorial Risk

Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ann Intern Med 2001135847-857

FINESegue lavori in dettagliohellip

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern

Med 2001135847-857bull Postoperative pulmonary complications are associatedbull with substantial morbidity and mortality It hasbull been estimated that nearly one fourth of deaths occurringbull within 6 days of surgery are related to postoperativebull pulmonary complications (1) Postoperative infectionsbull are also a major source of the morbidity and mortalitybull associated with undergoing surgery Pneumonia is thebull most serious postoperative complication that is includedbull in both of these categories Pneumonia ranks as thebull third most common postoperative infection behind urinarybull tract and wound infection (2) According to thebull National Nosocomial Infection Surveillance systembull pneumonia occurred in 18 of patients after surgerybull (3) Postoperative pneumonia occurs in 9 to 40 ofbull patients and the associated mortality rate is 30 tobull 46 depending on the type of surgery (1 4)bull Previous studies of risk factors used various definitionsbull of postoperative pulmonary complications Atelectasisbull (1 4ndash7) postoperative pneumonia (1ndash2 4ndash6bull 8ndash11) the acute respiratory distress syndrome (9 12)bull and postoperative respiratory failure (6 9 11 13) havebull been classified as postoperative pulmonary complicationsbull Although the clinical significance of each of thesebull complications varies greatly they were grouped togetherbull as a single outcome in previous studies (6) Some studiesbull were limited to examination of risk factors in patientsbull undergoing abdominal or thoracic procedures or in patientsbull with specific medical conditions such as chronicbull obstructive pulmonary disease (2 4 6 10ndash12 14)bull These studies were often based on a small sample frombull one institution and studies of independent samples didbull not validate their findings (15 16

Table 1 Definition of Postoperative PneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Patient met one of the following two criteria postoperativelybull 1 Rales or dullness to percussion on physical examination of chest AND

any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull 2 Chest radiography showing new or progressive infiltrate consolidation

cavitation or pleural effusion AND any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull Isolation of virus or detection of viral antigen in respiratory secretionsbull Diagnostic single antibody titer (IgM) or fourfold increase in paired serum

samples (IgG) for pathogenbull Histopathologic evidence of pneumonia

Postoperative pneumonia risk indexDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 9: Pulmonary complications risk

Risk factors for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for Predicting Postoperative Pneumonia after Major

Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer

Daley MDAnn Intern Med 2001135847-857 bull Long-term steroid use bull Age older than 60 years bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6

monthsbull recent alcohol use bull Recent smoking bull history of chronic obstructive pulmonary diseasebull history of cerebral vascular accident with a residualbull deficit bull impaired sensorium

Fattori di rischio per la polmonite postoppazienteDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Somministrazione di steroidi a lungo termine bull Etagravegt60 anni bull Stato funzionale dipendentebull Perdita di peso gt 10 della massa coroorea nei 6 mesi

precedentibull uso recente di alcoholbull Fumo recentebull Storia di COPDbull Storia di accidente cerebrovascolare con deficit residuobull Disturbo di coscienza

Fattori di rischio per la polmonite postopinterventiDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857

bull abdominal aortic aneurysm repairbull thoracic bull neck bull upper abdominalbull peripheral vascular surgerybull neurosurgery

Am J Respir Crit Care Med 2005 Mar 1171(5)514-7 Incidence of and risk factors for pulmonary complications after nonthoracic

surgeryMcAlister FA Bertsch K Man J Bradley J Jacka M

bull Identifica come fattori di rischiondash lrsquoetagravegt65 annindash il fumo(gt 40 pacchettianno)ndash la diminuzione del FEV1ndash Diminuzione del FVC e del FEV1FVCndash la durata dellrsquoanestesia gt25 hrndash storia di COPDndash tosse produttiva giornalierandash incisione nellrsquoaddome supndash presenza di un SNG

bull Solo 4 sono indipendenti dopo una analisi multivariata etagravetest alla tosse positivopresenza periop del SNG e la durata dellrsquoanestesia

a preoperative risk index for predicting postoperative respiratory

failure (PRF)

Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National

Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS

OF SURGERY Vol 232 No 2 242ndash253bull Objectivebull To develop and validate a preoperative risk index for

predicting postoperative respiratory failure (PRF)bull prospective cohort studybull 44 Veterans Affairs Medical Centers (n 5 81719) were used to

develop the models Cases from 132 Veterans Affairs Medical Centers (n 5 99390) were used as a validation sample

bull PRF was defined as mechanical ventilation for more than 48 hours after surgery or reintubation and mechanical ventilation after postoperative extubation

bull Ventilator-dependent comatose do notresuscitate and female patients were excluded

bull respiratory care

Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac

Surgery Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Results bull PRF developed in 2746 patients (34) bull The respiratory failure risk index was developed from a simplified logistic

regression model and includedndash abdominal aortic aneurysm repairndash thoracic surgeryndash neurosurgery ndash upper abdominal surgery ndash Peripheral vascular surgery ndash neck surgeryndash emergency surgeryndash albumin level llt than 30 gL ndash blood urea nitrogen level gtthan 30 mgdL ndash dependent functional statusndash chronic obstructive pulmonary disease ndash agegt60

Indici prognostici di insuff resp postop Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the

National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF

SURGERY Vol 232 No 2 242ndash253

ndash Aneurismectomia aorta addominalendash Chir toracica ndash neurochir ndash Chir addominale maggiore ndash Chir vascolare periferica ndash Chir del collo ndash Chir in emergenza ndash Livelli di albumina lt 30 gL ndash BUN gt 30 mgdL ndash Dipendenza funzionalendash COPD (chronic obstructive pulmonary disease) ndash Etagrave gt60

Probability of PRF postoperative resp failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration

Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Classe punti probab PRFbull 1 lt=10 05 bull 2 11ndash19 22-18bull 3 20ndash27 53- 42bull 4 28ndash40 10-119 bull 5 gt40 309 -266

A comparison of risk factors for postoperative pneumonia and respiratory failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

ampAhsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDDevelopment and Validation of a Multifactorial Risk

Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ann Intern Med 2001135847-857

FINESegue lavori in dettagliohellip

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern

Med 2001135847-857bull Postoperative pulmonary complications are associatedbull with substantial morbidity and mortality It hasbull been estimated that nearly one fourth of deaths occurringbull within 6 days of surgery are related to postoperativebull pulmonary complications (1) Postoperative infectionsbull are also a major source of the morbidity and mortalitybull associated with undergoing surgery Pneumonia is thebull most serious postoperative complication that is includedbull in both of these categories Pneumonia ranks as thebull third most common postoperative infection behind urinarybull tract and wound infection (2) According to thebull National Nosocomial Infection Surveillance systembull pneumonia occurred in 18 of patients after surgerybull (3) Postoperative pneumonia occurs in 9 to 40 ofbull patients and the associated mortality rate is 30 tobull 46 depending on the type of surgery (1 4)bull Previous studies of risk factors used various definitionsbull of postoperative pulmonary complications Atelectasisbull (1 4ndash7) postoperative pneumonia (1ndash2 4ndash6bull 8ndash11) the acute respiratory distress syndrome (9 12)bull and postoperative respiratory failure (6 9 11 13) havebull been classified as postoperative pulmonary complicationsbull Although the clinical significance of each of thesebull complications varies greatly they were grouped togetherbull as a single outcome in previous studies (6) Some studiesbull were limited to examination of risk factors in patientsbull undergoing abdominal or thoracic procedures or in patientsbull with specific medical conditions such as chronicbull obstructive pulmonary disease (2 4 6 10ndash12 14)bull These studies were often based on a small sample frombull one institution and studies of independent samples didbull not validate their findings (15 16

Table 1 Definition of Postoperative PneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Patient met one of the following two criteria postoperativelybull 1 Rales or dullness to percussion on physical examination of chest AND

any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull 2 Chest radiography showing new or progressive infiltrate consolidation

cavitation or pleural effusion AND any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull Isolation of virus or detection of viral antigen in respiratory secretionsbull Diagnostic single antibody titer (IgM) or fourfold increase in paired serum

samples (IgG) for pathogenbull Histopathologic evidence of pneumonia

Postoperative pneumonia risk indexDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 10: Pulmonary complications risk

Fattori di rischio per la polmonite postoppazienteDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Somministrazione di steroidi a lungo termine bull Etagravegt60 anni bull Stato funzionale dipendentebull Perdita di peso gt 10 della massa coroorea nei 6 mesi

precedentibull uso recente di alcoholbull Fumo recentebull Storia di COPDbull Storia di accidente cerebrovascolare con deficit residuobull Disturbo di coscienza

Fattori di rischio per la polmonite postopinterventiDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857

bull abdominal aortic aneurysm repairbull thoracic bull neck bull upper abdominalbull peripheral vascular surgerybull neurosurgery

Am J Respir Crit Care Med 2005 Mar 1171(5)514-7 Incidence of and risk factors for pulmonary complications after nonthoracic

surgeryMcAlister FA Bertsch K Man J Bradley J Jacka M

bull Identifica come fattori di rischiondash lrsquoetagravegt65 annindash il fumo(gt 40 pacchettianno)ndash la diminuzione del FEV1ndash Diminuzione del FVC e del FEV1FVCndash la durata dellrsquoanestesia gt25 hrndash storia di COPDndash tosse produttiva giornalierandash incisione nellrsquoaddome supndash presenza di un SNG

bull Solo 4 sono indipendenti dopo una analisi multivariata etagravetest alla tosse positivopresenza periop del SNG e la durata dellrsquoanestesia

a preoperative risk index for predicting postoperative respiratory

failure (PRF)

Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National

Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS

OF SURGERY Vol 232 No 2 242ndash253bull Objectivebull To develop and validate a preoperative risk index for

predicting postoperative respiratory failure (PRF)bull prospective cohort studybull 44 Veterans Affairs Medical Centers (n 5 81719) were used to

develop the models Cases from 132 Veterans Affairs Medical Centers (n 5 99390) were used as a validation sample

bull PRF was defined as mechanical ventilation for more than 48 hours after surgery or reintubation and mechanical ventilation after postoperative extubation

bull Ventilator-dependent comatose do notresuscitate and female patients were excluded

bull respiratory care

Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac

Surgery Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Results bull PRF developed in 2746 patients (34) bull The respiratory failure risk index was developed from a simplified logistic

regression model and includedndash abdominal aortic aneurysm repairndash thoracic surgeryndash neurosurgery ndash upper abdominal surgery ndash Peripheral vascular surgery ndash neck surgeryndash emergency surgeryndash albumin level llt than 30 gL ndash blood urea nitrogen level gtthan 30 mgdL ndash dependent functional statusndash chronic obstructive pulmonary disease ndash agegt60

Indici prognostici di insuff resp postop Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the

National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF

SURGERY Vol 232 No 2 242ndash253

ndash Aneurismectomia aorta addominalendash Chir toracica ndash neurochir ndash Chir addominale maggiore ndash Chir vascolare periferica ndash Chir del collo ndash Chir in emergenza ndash Livelli di albumina lt 30 gL ndash BUN gt 30 mgdL ndash Dipendenza funzionalendash COPD (chronic obstructive pulmonary disease) ndash Etagrave gt60

Probability of PRF postoperative resp failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration

Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Classe punti probab PRFbull 1 lt=10 05 bull 2 11ndash19 22-18bull 3 20ndash27 53- 42bull 4 28ndash40 10-119 bull 5 gt40 309 -266

A comparison of risk factors for postoperative pneumonia and respiratory failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

ampAhsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDDevelopment and Validation of a Multifactorial Risk

Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ann Intern Med 2001135847-857

FINESegue lavori in dettagliohellip

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern

Med 2001135847-857bull Postoperative pulmonary complications are associatedbull with substantial morbidity and mortality It hasbull been estimated that nearly one fourth of deaths occurringbull within 6 days of surgery are related to postoperativebull pulmonary complications (1) Postoperative infectionsbull are also a major source of the morbidity and mortalitybull associated with undergoing surgery Pneumonia is thebull most serious postoperative complication that is includedbull in both of these categories Pneumonia ranks as thebull third most common postoperative infection behind urinarybull tract and wound infection (2) According to thebull National Nosocomial Infection Surveillance systembull pneumonia occurred in 18 of patients after surgerybull (3) Postoperative pneumonia occurs in 9 to 40 ofbull patients and the associated mortality rate is 30 tobull 46 depending on the type of surgery (1 4)bull Previous studies of risk factors used various definitionsbull of postoperative pulmonary complications Atelectasisbull (1 4ndash7) postoperative pneumonia (1ndash2 4ndash6bull 8ndash11) the acute respiratory distress syndrome (9 12)bull and postoperative respiratory failure (6 9 11 13) havebull been classified as postoperative pulmonary complicationsbull Although the clinical significance of each of thesebull complications varies greatly they were grouped togetherbull as a single outcome in previous studies (6) Some studiesbull were limited to examination of risk factors in patientsbull undergoing abdominal or thoracic procedures or in patientsbull with specific medical conditions such as chronicbull obstructive pulmonary disease (2 4 6 10ndash12 14)bull These studies were often based on a small sample frombull one institution and studies of independent samples didbull not validate their findings (15 16

Table 1 Definition of Postoperative PneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Patient met one of the following two criteria postoperativelybull 1 Rales or dullness to percussion on physical examination of chest AND

any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull 2 Chest radiography showing new or progressive infiltrate consolidation

cavitation or pleural effusion AND any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull Isolation of virus or detection of viral antigen in respiratory secretionsbull Diagnostic single antibody titer (IgM) or fourfold increase in paired serum

samples (IgG) for pathogenbull Histopathologic evidence of pneumonia

Postoperative pneumonia risk indexDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 11: Pulmonary complications risk

Fattori di rischio per la polmonite postopinterventiDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857

bull abdominal aortic aneurysm repairbull thoracic bull neck bull upper abdominalbull peripheral vascular surgerybull neurosurgery

Am J Respir Crit Care Med 2005 Mar 1171(5)514-7 Incidence of and risk factors for pulmonary complications after nonthoracic

surgeryMcAlister FA Bertsch K Man J Bradley J Jacka M

bull Identifica come fattori di rischiondash lrsquoetagravegt65 annindash il fumo(gt 40 pacchettianno)ndash la diminuzione del FEV1ndash Diminuzione del FVC e del FEV1FVCndash la durata dellrsquoanestesia gt25 hrndash storia di COPDndash tosse produttiva giornalierandash incisione nellrsquoaddome supndash presenza di un SNG

bull Solo 4 sono indipendenti dopo una analisi multivariata etagravetest alla tosse positivopresenza periop del SNG e la durata dellrsquoanestesia

a preoperative risk index for predicting postoperative respiratory

failure (PRF)

Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National

Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS

OF SURGERY Vol 232 No 2 242ndash253bull Objectivebull To develop and validate a preoperative risk index for

predicting postoperative respiratory failure (PRF)bull prospective cohort studybull 44 Veterans Affairs Medical Centers (n 5 81719) were used to

develop the models Cases from 132 Veterans Affairs Medical Centers (n 5 99390) were used as a validation sample

bull PRF was defined as mechanical ventilation for more than 48 hours after surgery or reintubation and mechanical ventilation after postoperative extubation

bull Ventilator-dependent comatose do notresuscitate and female patients were excluded

bull respiratory care

Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac

Surgery Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Results bull PRF developed in 2746 patients (34) bull The respiratory failure risk index was developed from a simplified logistic

regression model and includedndash abdominal aortic aneurysm repairndash thoracic surgeryndash neurosurgery ndash upper abdominal surgery ndash Peripheral vascular surgery ndash neck surgeryndash emergency surgeryndash albumin level llt than 30 gL ndash blood urea nitrogen level gtthan 30 mgdL ndash dependent functional statusndash chronic obstructive pulmonary disease ndash agegt60

Indici prognostici di insuff resp postop Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the

National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF

SURGERY Vol 232 No 2 242ndash253

ndash Aneurismectomia aorta addominalendash Chir toracica ndash neurochir ndash Chir addominale maggiore ndash Chir vascolare periferica ndash Chir del collo ndash Chir in emergenza ndash Livelli di albumina lt 30 gL ndash BUN gt 30 mgdL ndash Dipendenza funzionalendash COPD (chronic obstructive pulmonary disease) ndash Etagrave gt60

Probability of PRF postoperative resp failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration

Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Classe punti probab PRFbull 1 lt=10 05 bull 2 11ndash19 22-18bull 3 20ndash27 53- 42bull 4 28ndash40 10-119 bull 5 gt40 309 -266

A comparison of risk factors for postoperative pneumonia and respiratory failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

ampAhsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDDevelopment and Validation of a Multifactorial Risk

Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ann Intern Med 2001135847-857

FINESegue lavori in dettagliohellip

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern

Med 2001135847-857bull Postoperative pulmonary complications are associatedbull with substantial morbidity and mortality It hasbull been estimated that nearly one fourth of deaths occurringbull within 6 days of surgery are related to postoperativebull pulmonary complications (1) Postoperative infectionsbull are also a major source of the morbidity and mortalitybull associated with undergoing surgery Pneumonia is thebull most serious postoperative complication that is includedbull in both of these categories Pneumonia ranks as thebull third most common postoperative infection behind urinarybull tract and wound infection (2) According to thebull National Nosocomial Infection Surveillance systembull pneumonia occurred in 18 of patients after surgerybull (3) Postoperative pneumonia occurs in 9 to 40 ofbull patients and the associated mortality rate is 30 tobull 46 depending on the type of surgery (1 4)bull Previous studies of risk factors used various definitionsbull of postoperative pulmonary complications Atelectasisbull (1 4ndash7) postoperative pneumonia (1ndash2 4ndash6bull 8ndash11) the acute respiratory distress syndrome (9 12)bull and postoperative respiratory failure (6 9 11 13) havebull been classified as postoperative pulmonary complicationsbull Although the clinical significance of each of thesebull complications varies greatly they were grouped togetherbull as a single outcome in previous studies (6) Some studiesbull were limited to examination of risk factors in patientsbull undergoing abdominal or thoracic procedures or in patientsbull with specific medical conditions such as chronicbull obstructive pulmonary disease (2 4 6 10ndash12 14)bull These studies were often based on a small sample frombull one institution and studies of independent samples didbull not validate their findings (15 16

Table 1 Definition of Postoperative PneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Patient met one of the following two criteria postoperativelybull 1 Rales or dullness to percussion on physical examination of chest AND

any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull 2 Chest radiography showing new or progressive infiltrate consolidation

cavitation or pleural effusion AND any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull Isolation of virus or detection of viral antigen in respiratory secretionsbull Diagnostic single antibody titer (IgM) or fourfold increase in paired serum

samples (IgG) for pathogenbull Histopathologic evidence of pneumonia

Postoperative pneumonia risk indexDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 12: Pulmonary complications risk

Am J Respir Crit Care Med 2005 Mar 1171(5)514-7 Incidence of and risk factors for pulmonary complications after nonthoracic

surgeryMcAlister FA Bertsch K Man J Bradley J Jacka M

bull Identifica come fattori di rischiondash lrsquoetagravegt65 annindash il fumo(gt 40 pacchettianno)ndash la diminuzione del FEV1ndash Diminuzione del FVC e del FEV1FVCndash la durata dellrsquoanestesia gt25 hrndash storia di COPDndash tosse produttiva giornalierandash incisione nellrsquoaddome supndash presenza di un SNG

bull Solo 4 sono indipendenti dopo una analisi multivariata etagravetest alla tosse positivopresenza periop del SNG e la durata dellrsquoanestesia

a preoperative risk index for predicting postoperative respiratory

failure (PRF)

Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National

Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS

OF SURGERY Vol 232 No 2 242ndash253bull Objectivebull To develop and validate a preoperative risk index for

predicting postoperative respiratory failure (PRF)bull prospective cohort studybull 44 Veterans Affairs Medical Centers (n 5 81719) were used to

develop the models Cases from 132 Veterans Affairs Medical Centers (n 5 99390) were used as a validation sample

bull PRF was defined as mechanical ventilation for more than 48 hours after surgery or reintubation and mechanical ventilation after postoperative extubation

bull Ventilator-dependent comatose do notresuscitate and female patients were excluded

bull respiratory care

Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac

Surgery Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Results bull PRF developed in 2746 patients (34) bull The respiratory failure risk index was developed from a simplified logistic

regression model and includedndash abdominal aortic aneurysm repairndash thoracic surgeryndash neurosurgery ndash upper abdominal surgery ndash Peripheral vascular surgery ndash neck surgeryndash emergency surgeryndash albumin level llt than 30 gL ndash blood urea nitrogen level gtthan 30 mgdL ndash dependent functional statusndash chronic obstructive pulmonary disease ndash agegt60

Indici prognostici di insuff resp postop Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the

National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF

SURGERY Vol 232 No 2 242ndash253

ndash Aneurismectomia aorta addominalendash Chir toracica ndash neurochir ndash Chir addominale maggiore ndash Chir vascolare periferica ndash Chir del collo ndash Chir in emergenza ndash Livelli di albumina lt 30 gL ndash BUN gt 30 mgdL ndash Dipendenza funzionalendash COPD (chronic obstructive pulmonary disease) ndash Etagrave gt60

Probability of PRF postoperative resp failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration

Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Classe punti probab PRFbull 1 lt=10 05 bull 2 11ndash19 22-18bull 3 20ndash27 53- 42bull 4 28ndash40 10-119 bull 5 gt40 309 -266

A comparison of risk factors for postoperative pneumonia and respiratory failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

ampAhsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDDevelopment and Validation of a Multifactorial Risk

Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ann Intern Med 2001135847-857

FINESegue lavori in dettagliohellip

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern

Med 2001135847-857bull Postoperative pulmonary complications are associatedbull with substantial morbidity and mortality It hasbull been estimated that nearly one fourth of deaths occurringbull within 6 days of surgery are related to postoperativebull pulmonary complications (1) Postoperative infectionsbull are also a major source of the morbidity and mortalitybull associated with undergoing surgery Pneumonia is thebull most serious postoperative complication that is includedbull in both of these categories Pneumonia ranks as thebull third most common postoperative infection behind urinarybull tract and wound infection (2) According to thebull National Nosocomial Infection Surveillance systembull pneumonia occurred in 18 of patients after surgerybull (3) Postoperative pneumonia occurs in 9 to 40 ofbull patients and the associated mortality rate is 30 tobull 46 depending on the type of surgery (1 4)bull Previous studies of risk factors used various definitionsbull of postoperative pulmonary complications Atelectasisbull (1 4ndash7) postoperative pneumonia (1ndash2 4ndash6bull 8ndash11) the acute respiratory distress syndrome (9 12)bull and postoperative respiratory failure (6 9 11 13) havebull been classified as postoperative pulmonary complicationsbull Although the clinical significance of each of thesebull complications varies greatly they were grouped togetherbull as a single outcome in previous studies (6) Some studiesbull were limited to examination of risk factors in patientsbull undergoing abdominal or thoracic procedures or in patientsbull with specific medical conditions such as chronicbull obstructive pulmonary disease (2 4 6 10ndash12 14)bull These studies were often based on a small sample frombull one institution and studies of independent samples didbull not validate their findings (15 16

Table 1 Definition of Postoperative PneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Patient met one of the following two criteria postoperativelybull 1 Rales or dullness to percussion on physical examination of chest AND

any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull 2 Chest radiography showing new or progressive infiltrate consolidation

cavitation or pleural effusion AND any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull Isolation of virus or detection of viral antigen in respiratory secretionsbull Diagnostic single antibody titer (IgM) or fourfold increase in paired serum

samples (IgG) for pathogenbull Histopathologic evidence of pneumonia

Postoperative pneumonia risk indexDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 13: Pulmonary complications risk

a preoperative risk index for predicting postoperative respiratory

failure (PRF)

Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National

Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS

OF SURGERY Vol 232 No 2 242ndash253bull Objectivebull To develop and validate a preoperative risk index for

predicting postoperative respiratory failure (PRF)bull prospective cohort studybull 44 Veterans Affairs Medical Centers (n 5 81719) were used to

develop the models Cases from 132 Veterans Affairs Medical Centers (n 5 99390) were used as a validation sample

bull PRF was defined as mechanical ventilation for more than 48 hours after surgery or reintubation and mechanical ventilation after postoperative extubation

bull Ventilator-dependent comatose do notresuscitate and female patients were excluded

bull respiratory care

Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac

Surgery Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Results bull PRF developed in 2746 patients (34) bull The respiratory failure risk index was developed from a simplified logistic

regression model and includedndash abdominal aortic aneurysm repairndash thoracic surgeryndash neurosurgery ndash upper abdominal surgery ndash Peripheral vascular surgery ndash neck surgeryndash emergency surgeryndash albumin level llt than 30 gL ndash blood urea nitrogen level gtthan 30 mgdL ndash dependent functional statusndash chronic obstructive pulmonary disease ndash agegt60

Indici prognostici di insuff resp postop Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the

National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF

SURGERY Vol 232 No 2 242ndash253

ndash Aneurismectomia aorta addominalendash Chir toracica ndash neurochir ndash Chir addominale maggiore ndash Chir vascolare periferica ndash Chir del collo ndash Chir in emergenza ndash Livelli di albumina lt 30 gL ndash BUN gt 30 mgdL ndash Dipendenza funzionalendash COPD (chronic obstructive pulmonary disease) ndash Etagrave gt60

Probability of PRF postoperative resp failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration

Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Classe punti probab PRFbull 1 lt=10 05 bull 2 11ndash19 22-18bull 3 20ndash27 53- 42bull 4 28ndash40 10-119 bull 5 gt40 309 -266

A comparison of risk factors for postoperative pneumonia and respiratory failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

ampAhsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDDevelopment and Validation of a Multifactorial Risk

Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ann Intern Med 2001135847-857

FINESegue lavori in dettagliohellip

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern

Med 2001135847-857bull Postoperative pulmonary complications are associatedbull with substantial morbidity and mortality It hasbull been estimated that nearly one fourth of deaths occurringbull within 6 days of surgery are related to postoperativebull pulmonary complications (1) Postoperative infectionsbull are also a major source of the morbidity and mortalitybull associated with undergoing surgery Pneumonia is thebull most serious postoperative complication that is includedbull in both of these categories Pneumonia ranks as thebull third most common postoperative infection behind urinarybull tract and wound infection (2) According to thebull National Nosocomial Infection Surveillance systembull pneumonia occurred in 18 of patients after surgerybull (3) Postoperative pneumonia occurs in 9 to 40 ofbull patients and the associated mortality rate is 30 tobull 46 depending on the type of surgery (1 4)bull Previous studies of risk factors used various definitionsbull of postoperative pulmonary complications Atelectasisbull (1 4ndash7) postoperative pneumonia (1ndash2 4ndash6bull 8ndash11) the acute respiratory distress syndrome (9 12)bull and postoperative respiratory failure (6 9 11 13) havebull been classified as postoperative pulmonary complicationsbull Although the clinical significance of each of thesebull complications varies greatly they were grouped togetherbull as a single outcome in previous studies (6) Some studiesbull were limited to examination of risk factors in patientsbull undergoing abdominal or thoracic procedures or in patientsbull with specific medical conditions such as chronicbull obstructive pulmonary disease (2 4 6 10ndash12 14)bull These studies were often based on a small sample frombull one institution and studies of independent samples didbull not validate their findings (15 16

Table 1 Definition of Postoperative PneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Patient met one of the following two criteria postoperativelybull 1 Rales or dullness to percussion on physical examination of chest AND

any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull 2 Chest radiography showing new or progressive infiltrate consolidation

cavitation or pleural effusion AND any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull Isolation of virus or detection of viral antigen in respiratory secretionsbull Diagnostic single antibody titer (IgM) or fourfold increase in paired serum

samples (IgG) for pathogenbull Histopathologic evidence of pneumonia

Postoperative pneumonia risk indexDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 14: Pulmonary complications risk

Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National

Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS

OF SURGERY Vol 232 No 2 242ndash253bull Objectivebull To develop and validate a preoperative risk index for

predicting postoperative respiratory failure (PRF)bull prospective cohort studybull 44 Veterans Affairs Medical Centers (n 5 81719) were used to

develop the models Cases from 132 Veterans Affairs Medical Centers (n 5 99390) were used as a validation sample

bull PRF was defined as mechanical ventilation for more than 48 hours after surgery or reintubation and mechanical ventilation after postoperative extubation

bull Ventilator-dependent comatose do notresuscitate and female patients were excluded

bull respiratory care

Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac

Surgery Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Results bull PRF developed in 2746 patients (34) bull The respiratory failure risk index was developed from a simplified logistic

regression model and includedndash abdominal aortic aneurysm repairndash thoracic surgeryndash neurosurgery ndash upper abdominal surgery ndash Peripheral vascular surgery ndash neck surgeryndash emergency surgeryndash albumin level llt than 30 gL ndash blood urea nitrogen level gtthan 30 mgdL ndash dependent functional statusndash chronic obstructive pulmonary disease ndash agegt60

Indici prognostici di insuff resp postop Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the

National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF

SURGERY Vol 232 No 2 242ndash253

ndash Aneurismectomia aorta addominalendash Chir toracica ndash neurochir ndash Chir addominale maggiore ndash Chir vascolare periferica ndash Chir del collo ndash Chir in emergenza ndash Livelli di albumina lt 30 gL ndash BUN gt 30 mgdL ndash Dipendenza funzionalendash COPD (chronic obstructive pulmonary disease) ndash Etagrave gt60

Probability of PRF postoperative resp failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration

Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Classe punti probab PRFbull 1 lt=10 05 bull 2 11ndash19 22-18bull 3 20ndash27 53- 42bull 4 28ndash40 10-119 bull 5 gt40 309 -266

A comparison of risk factors for postoperative pneumonia and respiratory failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

ampAhsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDDevelopment and Validation of a Multifactorial Risk

Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ann Intern Med 2001135847-857

FINESegue lavori in dettagliohellip

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern

Med 2001135847-857bull Postoperative pulmonary complications are associatedbull with substantial morbidity and mortality It hasbull been estimated that nearly one fourth of deaths occurringbull within 6 days of surgery are related to postoperativebull pulmonary complications (1) Postoperative infectionsbull are also a major source of the morbidity and mortalitybull associated with undergoing surgery Pneumonia is thebull most serious postoperative complication that is includedbull in both of these categories Pneumonia ranks as thebull third most common postoperative infection behind urinarybull tract and wound infection (2) According to thebull National Nosocomial Infection Surveillance systembull pneumonia occurred in 18 of patients after surgerybull (3) Postoperative pneumonia occurs in 9 to 40 ofbull patients and the associated mortality rate is 30 tobull 46 depending on the type of surgery (1 4)bull Previous studies of risk factors used various definitionsbull of postoperative pulmonary complications Atelectasisbull (1 4ndash7) postoperative pneumonia (1ndash2 4ndash6bull 8ndash11) the acute respiratory distress syndrome (9 12)bull and postoperative respiratory failure (6 9 11 13) havebull been classified as postoperative pulmonary complicationsbull Although the clinical significance of each of thesebull complications varies greatly they were grouped togetherbull as a single outcome in previous studies (6) Some studiesbull were limited to examination of risk factors in patientsbull undergoing abdominal or thoracic procedures or in patientsbull with specific medical conditions such as chronicbull obstructive pulmonary disease (2 4 6 10ndash12 14)bull These studies were often based on a small sample frombull one institution and studies of independent samples didbull not validate their findings (15 16

Table 1 Definition of Postoperative PneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Patient met one of the following two criteria postoperativelybull 1 Rales or dullness to percussion on physical examination of chest AND

any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull 2 Chest radiography showing new or progressive infiltrate consolidation

cavitation or pleural effusion AND any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull Isolation of virus or detection of viral antigen in respiratory secretionsbull Diagnostic single antibody titer (IgM) or fourfold increase in paired serum

samples (IgG) for pathogenbull Histopathologic evidence of pneumonia

Postoperative pneumonia risk indexDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 15: Pulmonary complications risk

Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac

Surgery Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Results bull PRF developed in 2746 patients (34) bull The respiratory failure risk index was developed from a simplified logistic

regression model and includedndash abdominal aortic aneurysm repairndash thoracic surgeryndash neurosurgery ndash upper abdominal surgery ndash Peripheral vascular surgery ndash neck surgeryndash emergency surgeryndash albumin level llt than 30 gL ndash blood urea nitrogen level gtthan 30 mgdL ndash dependent functional statusndash chronic obstructive pulmonary disease ndash agegt60

Indici prognostici di insuff resp postop Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the

National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF

SURGERY Vol 232 No 2 242ndash253

ndash Aneurismectomia aorta addominalendash Chir toracica ndash neurochir ndash Chir addominale maggiore ndash Chir vascolare periferica ndash Chir del collo ndash Chir in emergenza ndash Livelli di albumina lt 30 gL ndash BUN gt 30 mgdL ndash Dipendenza funzionalendash COPD (chronic obstructive pulmonary disease) ndash Etagrave gt60

Probability of PRF postoperative resp failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration

Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Classe punti probab PRFbull 1 lt=10 05 bull 2 11ndash19 22-18bull 3 20ndash27 53- 42bull 4 28ndash40 10-119 bull 5 gt40 309 -266

A comparison of risk factors for postoperative pneumonia and respiratory failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

ampAhsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDDevelopment and Validation of a Multifactorial Risk

Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ann Intern Med 2001135847-857

FINESegue lavori in dettagliohellip

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern

Med 2001135847-857bull Postoperative pulmonary complications are associatedbull with substantial morbidity and mortality It hasbull been estimated that nearly one fourth of deaths occurringbull within 6 days of surgery are related to postoperativebull pulmonary complications (1) Postoperative infectionsbull are also a major source of the morbidity and mortalitybull associated with undergoing surgery Pneumonia is thebull most serious postoperative complication that is includedbull in both of these categories Pneumonia ranks as thebull third most common postoperative infection behind urinarybull tract and wound infection (2) According to thebull National Nosocomial Infection Surveillance systembull pneumonia occurred in 18 of patients after surgerybull (3) Postoperative pneumonia occurs in 9 to 40 ofbull patients and the associated mortality rate is 30 tobull 46 depending on the type of surgery (1 4)bull Previous studies of risk factors used various definitionsbull of postoperative pulmonary complications Atelectasisbull (1 4ndash7) postoperative pneumonia (1ndash2 4ndash6bull 8ndash11) the acute respiratory distress syndrome (9 12)bull and postoperative respiratory failure (6 9 11 13) havebull been classified as postoperative pulmonary complicationsbull Although the clinical significance of each of thesebull complications varies greatly they were grouped togetherbull as a single outcome in previous studies (6) Some studiesbull were limited to examination of risk factors in patientsbull undergoing abdominal or thoracic procedures or in patientsbull with specific medical conditions such as chronicbull obstructive pulmonary disease (2 4 6 10ndash12 14)bull These studies were often based on a small sample frombull one institution and studies of independent samples didbull not validate their findings (15 16

Table 1 Definition of Postoperative PneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Patient met one of the following two criteria postoperativelybull 1 Rales or dullness to percussion on physical examination of chest AND

any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull 2 Chest radiography showing new or progressive infiltrate consolidation

cavitation or pleural effusion AND any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull Isolation of virus or detection of viral antigen in respiratory secretionsbull Diagnostic single antibody titer (IgM) or fourfold increase in paired serum

samples (IgG) for pathogenbull Histopathologic evidence of pneumonia

Postoperative pneumonia risk indexDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 16: Pulmonary complications risk

Indici prognostici di insuff resp postop Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the

National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF

SURGERY Vol 232 No 2 242ndash253

ndash Aneurismectomia aorta addominalendash Chir toracica ndash neurochir ndash Chir addominale maggiore ndash Chir vascolare periferica ndash Chir del collo ndash Chir in emergenza ndash Livelli di albumina lt 30 gL ndash BUN gt 30 mgdL ndash Dipendenza funzionalendash COPD (chronic obstructive pulmonary disease) ndash Etagrave gt60

Probability of PRF postoperative resp failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration

Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Classe punti probab PRFbull 1 lt=10 05 bull 2 11ndash19 22-18bull 3 20ndash27 53- 42bull 4 28ndash40 10-119 bull 5 gt40 309 -266

A comparison of risk factors for postoperative pneumonia and respiratory failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

ampAhsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDDevelopment and Validation of a Multifactorial Risk

Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ann Intern Med 2001135847-857

FINESegue lavori in dettagliohellip

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern

Med 2001135847-857bull Postoperative pulmonary complications are associatedbull with substantial morbidity and mortality It hasbull been estimated that nearly one fourth of deaths occurringbull within 6 days of surgery are related to postoperativebull pulmonary complications (1) Postoperative infectionsbull are also a major source of the morbidity and mortalitybull associated with undergoing surgery Pneumonia is thebull most serious postoperative complication that is includedbull in both of these categories Pneumonia ranks as thebull third most common postoperative infection behind urinarybull tract and wound infection (2) According to thebull National Nosocomial Infection Surveillance systembull pneumonia occurred in 18 of patients after surgerybull (3) Postoperative pneumonia occurs in 9 to 40 ofbull patients and the associated mortality rate is 30 tobull 46 depending on the type of surgery (1 4)bull Previous studies of risk factors used various definitionsbull of postoperative pulmonary complications Atelectasisbull (1 4ndash7) postoperative pneumonia (1ndash2 4ndash6bull 8ndash11) the acute respiratory distress syndrome (9 12)bull and postoperative respiratory failure (6 9 11 13) havebull been classified as postoperative pulmonary complicationsbull Although the clinical significance of each of thesebull complications varies greatly they were grouped togetherbull as a single outcome in previous studies (6) Some studiesbull were limited to examination of risk factors in patientsbull undergoing abdominal or thoracic procedures or in patientsbull with specific medical conditions such as chronicbull obstructive pulmonary disease (2 4 6 10ndash12 14)bull These studies were often based on a small sample frombull one institution and studies of independent samples didbull not validate their findings (15 16

Table 1 Definition of Postoperative PneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Patient met one of the following two criteria postoperativelybull 1 Rales or dullness to percussion on physical examination of chest AND

any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull 2 Chest radiography showing new or progressive infiltrate consolidation

cavitation or pleural effusion AND any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull Isolation of virus or detection of viral antigen in respiratory secretionsbull Diagnostic single antibody titer (IgM) or fourfold increase in paired serum

samples (IgG) for pathogenbull Histopathologic evidence of pneumonia

Postoperative pneumonia risk indexDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 17: Pulmonary complications risk

Probability of PRF postoperative resp failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration

Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Classe punti probab PRFbull 1 lt=10 05 bull 2 11ndash19 22-18bull 3 20ndash27 53- 42bull 4 28ndash40 10-119 bull 5 gt40 309 -266

A comparison of risk factors for postoperative pneumonia and respiratory failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

ampAhsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDDevelopment and Validation of a Multifactorial Risk

Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ann Intern Med 2001135847-857

FINESegue lavori in dettagliohellip

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern

Med 2001135847-857bull Postoperative pulmonary complications are associatedbull with substantial morbidity and mortality It hasbull been estimated that nearly one fourth of deaths occurringbull within 6 days of surgery are related to postoperativebull pulmonary complications (1) Postoperative infectionsbull are also a major source of the morbidity and mortalitybull associated with undergoing surgery Pneumonia is thebull most serious postoperative complication that is includedbull in both of these categories Pneumonia ranks as thebull third most common postoperative infection behind urinarybull tract and wound infection (2) According to thebull National Nosocomial Infection Surveillance systembull pneumonia occurred in 18 of patients after surgerybull (3) Postoperative pneumonia occurs in 9 to 40 ofbull patients and the associated mortality rate is 30 tobull 46 depending on the type of surgery (1 4)bull Previous studies of risk factors used various definitionsbull of postoperative pulmonary complications Atelectasisbull (1 4ndash7) postoperative pneumonia (1ndash2 4ndash6bull 8ndash11) the acute respiratory distress syndrome (9 12)bull and postoperative respiratory failure (6 9 11 13) havebull been classified as postoperative pulmonary complicationsbull Although the clinical significance of each of thesebull complications varies greatly they were grouped togetherbull as a single outcome in previous studies (6) Some studiesbull were limited to examination of risk factors in patientsbull undergoing abdominal or thoracic procedures or in patientsbull with specific medical conditions such as chronicbull obstructive pulmonary disease (2 4 6 10ndash12 14)bull These studies were often based on a small sample frombull one institution and studies of independent samples didbull not validate their findings (15 16

Table 1 Definition of Postoperative PneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Patient met one of the following two criteria postoperativelybull 1 Rales or dullness to percussion on physical examination of chest AND

any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull 2 Chest radiography showing new or progressive infiltrate consolidation

cavitation or pleural effusion AND any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull Isolation of virus or detection of viral antigen in respiratory secretionsbull Diagnostic single antibody titer (IgM) or fourfold increase in paired serum

samples (IgG) for pathogenbull Histopathologic evidence of pneumonia

Postoperative pneumonia risk indexDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 18: Pulmonary complications risk

A comparison of risk factors for postoperative pneumonia and respiratory failure Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

ampAhsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDDevelopment and Validation of a Multifactorial Risk

Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ann Intern Med 2001135847-857

FINESegue lavori in dettagliohellip

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern

Med 2001135847-857bull Postoperative pulmonary complications are associatedbull with substantial morbidity and mortality It hasbull been estimated that nearly one fourth of deaths occurringbull within 6 days of surgery are related to postoperativebull pulmonary complications (1) Postoperative infectionsbull are also a major source of the morbidity and mortalitybull associated with undergoing surgery Pneumonia is thebull most serious postoperative complication that is includedbull in both of these categories Pneumonia ranks as thebull third most common postoperative infection behind urinarybull tract and wound infection (2) According to thebull National Nosocomial Infection Surveillance systembull pneumonia occurred in 18 of patients after surgerybull (3) Postoperative pneumonia occurs in 9 to 40 ofbull patients and the associated mortality rate is 30 tobull 46 depending on the type of surgery (1 4)bull Previous studies of risk factors used various definitionsbull of postoperative pulmonary complications Atelectasisbull (1 4ndash7) postoperative pneumonia (1ndash2 4ndash6bull 8ndash11) the acute respiratory distress syndrome (9 12)bull and postoperative respiratory failure (6 9 11 13) havebull been classified as postoperative pulmonary complicationsbull Although the clinical significance of each of thesebull complications varies greatly they were grouped togetherbull as a single outcome in previous studies (6) Some studiesbull were limited to examination of risk factors in patientsbull undergoing abdominal or thoracic procedures or in patientsbull with specific medical conditions such as chronicbull obstructive pulmonary disease (2 4 6 10ndash12 14)bull These studies were often based on a small sample frombull one institution and studies of independent samples didbull not validate their findings (15 16

Table 1 Definition of Postoperative PneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Patient met one of the following two criteria postoperativelybull 1 Rales or dullness to percussion on physical examination of chest AND

any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull 2 Chest radiography showing new or progressive infiltrate consolidation

cavitation or pleural effusion AND any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull Isolation of virus or detection of viral antigen in respiratory secretionsbull Diagnostic single antibody titer (IgM) or fourfold increase in paired serum

samples (IgG) for pathogenbull Histopathologic evidence of pneumonia

Postoperative pneumonia risk indexDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 19: Pulmonary complications risk

FINESegue lavori in dettagliohellip

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern

Med 2001135847-857bull Postoperative pulmonary complications are associatedbull with substantial morbidity and mortality It hasbull been estimated that nearly one fourth of deaths occurringbull within 6 days of surgery are related to postoperativebull pulmonary complications (1) Postoperative infectionsbull are also a major source of the morbidity and mortalitybull associated with undergoing surgery Pneumonia is thebull most serious postoperative complication that is includedbull in both of these categories Pneumonia ranks as thebull third most common postoperative infection behind urinarybull tract and wound infection (2) According to thebull National Nosocomial Infection Surveillance systembull pneumonia occurred in 18 of patients after surgerybull (3) Postoperative pneumonia occurs in 9 to 40 ofbull patients and the associated mortality rate is 30 tobull 46 depending on the type of surgery (1 4)bull Previous studies of risk factors used various definitionsbull of postoperative pulmonary complications Atelectasisbull (1 4ndash7) postoperative pneumonia (1ndash2 4ndash6bull 8ndash11) the acute respiratory distress syndrome (9 12)bull and postoperative respiratory failure (6 9 11 13) havebull been classified as postoperative pulmonary complicationsbull Although the clinical significance of each of thesebull complications varies greatly they were grouped togetherbull as a single outcome in previous studies (6) Some studiesbull were limited to examination of risk factors in patientsbull undergoing abdominal or thoracic procedures or in patientsbull with specific medical conditions such as chronicbull obstructive pulmonary disease (2 4 6 10ndash12 14)bull These studies were often based on a small sample frombull one institution and studies of independent samples didbull not validate their findings (15 16

Table 1 Definition of Postoperative PneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Patient met one of the following two criteria postoperativelybull 1 Rales or dullness to percussion on physical examination of chest AND

any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull 2 Chest radiography showing new or progressive infiltrate consolidation

cavitation or pleural effusion AND any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull Isolation of virus or detection of viral antigen in respiratory secretionsbull Diagnostic single antibody titer (IgM) or fourfold increase in paired serum

samples (IgG) for pathogenbull Histopathologic evidence of pneumonia

Postoperative pneumonia risk indexDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 20: Pulmonary complications risk

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern

Med 2001135847-857bull Postoperative pulmonary complications are associatedbull with substantial morbidity and mortality It hasbull been estimated that nearly one fourth of deaths occurringbull within 6 days of surgery are related to postoperativebull pulmonary complications (1) Postoperative infectionsbull are also a major source of the morbidity and mortalitybull associated with undergoing surgery Pneumonia is thebull most serious postoperative complication that is includedbull in both of these categories Pneumonia ranks as thebull third most common postoperative infection behind urinarybull tract and wound infection (2) According to thebull National Nosocomial Infection Surveillance systembull pneumonia occurred in 18 of patients after surgerybull (3) Postoperative pneumonia occurs in 9 to 40 ofbull patients and the associated mortality rate is 30 tobull 46 depending on the type of surgery (1 4)bull Previous studies of risk factors used various definitionsbull of postoperative pulmonary complications Atelectasisbull (1 4ndash7) postoperative pneumonia (1ndash2 4ndash6bull 8ndash11) the acute respiratory distress syndrome (9 12)bull and postoperative respiratory failure (6 9 11 13) havebull been classified as postoperative pulmonary complicationsbull Although the clinical significance of each of thesebull complications varies greatly they were grouped togetherbull as a single outcome in previous studies (6) Some studiesbull were limited to examination of risk factors in patientsbull undergoing abdominal or thoracic procedures or in patientsbull with specific medical conditions such as chronicbull obstructive pulmonary disease (2 4 6 10ndash12 14)bull These studies were often based on a small sample frombull one institution and studies of independent samples didbull not validate their findings (15 16

Table 1 Definition of Postoperative PneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Patient met one of the following two criteria postoperativelybull 1 Rales or dullness to percussion on physical examination of chest AND

any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull 2 Chest radiography showing new or progressive infiltrate consolidation

cavitation or pleural effusion AND any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull Isolation of virus or detection of viral antigen in respiratory secretionsbull Diagnostic single antibody titer (IgM) or fourfold increase in paired serum

samples (IgG) for pathogenbull Histopathologic evidence of pneumonia

Postoperative pneumonia risk indexDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 21: Pulmonary complications risk

Table 1 Definition of Postoperative PneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Patient met one of the following two criteria postoperativelybull 1 Rales or dullness to percussion on physical examination of chest AND

any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull 2 Chest radiography showing new or progressive infiltrate consolidation

cavitation or pleural effusion AND any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull Isolation of virus or detection of viral antigen in respiratory secretionsbull Diagnostic single antibody titer (IgM) or fourfold increase in paired serum

samples (IgG) for pathogenbull Histopathologic evidence of pneumonia

Postoperative pneumonia risk indexDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 22: Pulmonary complications risk

Postoperative pneumonia risk indexDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 23: Pulmonary complications risk

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD

and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 24: Pulmonary complications risk

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Long-term steroid use (30) bull Age older than 60 years (2 4 5 11 12)bull dependent functional status bull weight loss greater than 10 of body mass in the previous 6 monthsbull recent alcohol use bull Further studies are needed to assess the effect of interventions such as preoperative

optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 25: Pulmonary complications risk

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 26: Pulmonary complications risk

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 27: Pulmonary complications risk

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervous system aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 28: Pulmonary complications risk

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857 bull Functional status The level of self-care demonstrated by the patient on

admission to the hospital reflecting his or her prehospitalization functional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 29: Pulmonary complications risk

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Otherhellip Development and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 30: Pulmonary complications risk

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 31: Pulmonary complications risk

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 32: Pulmonary complications risk

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

Page 33: Pulmonary complications risk

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF