Date post: | 01-Dec-2014 |
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POST OPERATIVE PULMONARY COMPLICATIONS
Chris Wasson St3 Anaesthesia
• PPC’s• Audit project• interventions• iCough bundle• summary• questions/discussion
What are PPCs?• Respiratory failure• Atelectasis• Acute lung injury• Pneumonia• Pneumothorax• Pneumonitis• Exacerbation COPD
Why are they important• Common; incidence of 1.2 – 10.9%• Increased mortality – 10.7%• Increased ICU stay• Increased Hospital day 8-14 days• Increased hospital costs -75%
Risk factors• Patient• Surgical• Anaesthetic
Pathophysiology
Project• Prospective cohort• January to June• 100 major cases followed up for 10 post operative days
Aims• Identify rate of PPC• Identify high risk groups
Data collected• AGE• Pre-op functional status• ASA score• BMI• OSA• Congestive heart failure hx [use NYHA if known or mild,
moderate, severe]• Cigarette use• Asthma/COPD• Diabetes [IDDM/NIDDM]
Post operative pneumonia• Temp >38.5• Wheeze• New onset purulent sputum• WCC and CRP• CXR• Anti-biotics• New nebs
Cohort• 102 patients• Male 62 Female 40• Average age 62.1ASA:
I – 11II – 41III – 47IV - 3
Patient Characteristics• 32% overweight• 20.5% obese• 21.6% smokers• 32.3% ex smokers• 21 patients with prior respiratory disease• 17 diabetics
Surgical factors• Elective – 83• Emergency – 19• Average duration of surgery 208 minutes
Speciality• General – 35• HPB – 25• Upper GI – 13• Vascular – 11• Urology – 8• Gynae – 7• Transplant – 3
Results• Rate of PPC 20.5%• Rate of post op pneumonia 14.7%
Analysis• Rate pneumonia 14.7%• Per specialty:
• 14.3 % general• 27.3% vascular• 30.8% upper GI• 14.3% gynaecology• 0% transplant
Asa• 1 – 0%• 2 – 9.8%• 3 – 21.3%• 4 – 33.3%
• Emergency - 10.2%• Elective – 15.7%• EX-smoker – 21.9%• Smoker 27%• Non-smoker – 3.8%• Overweight – 12.5%• Obese – 14.6%• Diabetes – 23.5%
analysis• Pulmonary disease – 33.3 %• Upper abdominal incision – 19.4%• Elective surgical time – 232 minutes• Epidural 45%
• 26% in epidural group• 5.4% in non epidural group• 80% post op pneumonia had epidural
At risk groups• ASA 3• Prolonged surgery (>180 minutes)• Pre existing pulmonary disease• Upper abdominal incision• Diabetics• Smoking history
What to do about it?
Bundles• Simple• Inexpensive• Implementable• Easily audited
Examples• VAP• Central line – matching Michigan• Sepsis 6 - Rivers
Interventions• “Manchester Respiratory Intervention”
• Pre operative• Peri operative• Post operative
Pre operative• Patient education• Teeth brushing• Chlorhexidine mouthwash• Pulmonary optomisation
Peri operative• Polyurethane tapered tube• Sub glottic suctioning
Post operative• iCOUGH
ICOUGH
Bundle of preventative measures for PPC's
• Boston Medical Centre USA, Aug 2010
• All general and vascular surgical patients
• Post op pneumonia 2.55% down to 1.62%
• Unplanned intubations 1.98% down to 1.16%
6 Elements
I - Incentive spirometry
C - Cough/deep breathing exercises
O - Oral Care
U - Understanding/education
G - Getting out of bed
H - Head of bed elevation
Important ICOUGH Features
• Bundle of simple nursing/physio interventions
• Basic and inexpensive• Estimated cost of PPC per patient between £4000 - £16 000• Length of hospital stay increased by 8-14days
• Effective in reducing PPCs
• Implemented through check-lists
• Easy to measure effectiveness and re-audit
ICOUGH Development
Audit of the pre-intervention practices of nurses and physios
Set up a multi-disciplinary pulmonary care working group
Development of ICOUGH bundle
Programmes of education for doctors, nurses, physios and patients
Preparation of check-list bundle
Audit of post intervention practices
Patient Audit• 50 patients over 6 week period + followed them daily• Post-op HDU following major surgery• Average duration of surgery 3h 30min
No PPC
PPC
24%
76%
PPC Incidence
Pneumonia
Atelectasis
Pnemothorax
Pleural Ef-fusion
Types of PPC
8 patients2
11
Education and MobilisationEducationWere risks of PPCs and preventative measures explained?
Yes - 36%
No or couldn’t remember - 64%
ACTION : Educate all patients on risks or and measures to prevent PPCs
Mobilisation
Good early mobilisation – 22%
Partial mobilisation – 40%
Little or no early mobilisation – 38%
ACTION: Promote early and regular mobilisation (chair and/or walking)
Oral Hygiene and Deep Breathing
Oral Hygiene
Tooth brushing ≥ 2/day - 70%
Tooth brushing < 2/day - 24%
Data not available - 6%
ACTION: Implement consistent oral hygiene regime for all patients
Deep breathing
≥ once every 2h - 56%
< once every 2h - 40%
Data not available - 4%
ACTION: To standardise the deep breathing regimes for patients and
to regularly prompt patients
Incentive Spirometer and Position
Incentive Spirometer
Only 20% of patients received an incentive spirometer
and instructions on how to use it
ACTION: To issue incentive spirometers before surgery and
educate patients in their use and benefits
Position
The head of the bed was elevated by 30 degrees or more
for all patients for which is was appropriate
ACTION: None
Other ICOUGH Research
Vancouver General Hospital, Nov 2012
The results for their "ICOUGH" compliance were: Measure % patients Vancouver % patients MRI Incentive spirometry 17% 20% Deep Breathing (≥1/2h) 52% 56% Oral Care 60% 70% Understanding/education 21% 36% Get out of bed 17% into a chair 62% 76% walking Head of bed elevation 48% 100%
What Should Happen Next? 1. Decide on whether to implement ICOUGH
2. If yes - Create an implementation plan
3. Identify any obstacles and involve all staff in addressing these
4. Regularly monitor the PPC incidence
5. Review the handover from HDU to wards
Potential Barriers to Implementation
Examples of Potential Barriers
• Work load on the nursing staff • Lack of chairs/space for chairs• Mobilisation of patients with attachments • Need for help in manual handling of patients
Manchester Respiratory Intervention
Preoperative
• Lung optimisation
• Patient Education
• Oral Decontamination
Intraoperative
• Prevent aspiration
• Endotracheal tube design
• Cuff pressure monitoring
Postoperative
• HDU ICOUGH + fluid limitation
• Critical care surgical pathway
• Surgical ward ICOUGH
Thank You
Other PPC Prevention Bundles
• NICE (UK) 2008
• British Society of Antimicrobial Chemotherapy 2008
• Scottish Intensive Care Society 2008
• European HAP Working Group 2008
• Canadian Clinical Trials Group 2008
• American Society for Critical Care 2008
• Institute for Healthcare Improvement (US) 2006
• American Thoracic Society 2005
• Center for Disease Control (US) 2003
References• Peri-operative Respiratory Complications and the
Post-operative Consequences – Atelectasis and Risk Factors Paolo Pelosi and Cesare Gregoretti
• Polyurethane cuffed endotracheal tubes to prevent early postoperative pneumonia after cardiac surgery: A pilot study Stijn Blot Jan Poelaert, Pieter Depuydt, Annick De Wolf, Stijn Van de Velde, Ingrid Herck J Thorac Cardiovasc Surg 2008;135:771-776
What’s new in the prevention of ventilator-associated pneumonia?
Stijn Blot1, Jordi Rello2, and Dirk Vogelaers1