Perioperative Management in

Anesthesia Leading to Better

Outcome

Jittiya Watcharotayangul M.D.

Department of Anesthesiology, Ramathibodi Hospital
Mahidol University
 Outline
• Incidence
• Definition
• Cause
• Management
– Pre-op
– Intra-op
– Post-op
 Incidence

• 2-40%

– Clinical setting
– Surgery type
– Definition
 Definition

• No standard in definition
 Definition
• Respiratory infection
• Respiratory failure
• Pleural effusion
• Atelectasis
• Pneumothorax
• Bronchospasm
• Aspiration pneumonitis

Canet J, Anesthesiology. 2010 Dec;113(6):1338-50

 Patient with PPC Patient without PPC
Length of hospital stay 10 days 3 days
Attendance to the ED
27% 10.6%
within 30 days
30-day readmission 21.7% 9.9%
30-day mortality 12.5% 0%

Patel K., Perioper Med (Lond). 2016 May 23;5:10

 Cause

• Patient
• Anesthetic
• Surgical
 Patient
• Heart failure
• ASA >2
• Advance age
• COPD
• Functional dependent
• Cough test

Gallart L, Best Pract Res Clin Anaesthesiol. 2015 Sep;29(3):315-30

 Anesthetic cause
• Lungs mechanic change: FRC↓ , VC ↓
(easier to develop atelectasis)
• Respiratory drive ↓
• Coordination of respiratory muscle ↓
• Immunosuppression from transfusion
• Ventilation management
 Surgical Cause
• Direct trauma
• Pain
• Phrenic nerve inhibited by visceral traction
• Immunosuppression
 Surgical Cause
• Type of surgery
• Duration
• Blood loss
• Level of aggressiveness
 Type of surgery
• Thoracic and upper abdominal
• Vascular
• Neurosurgery
• Head and neck
• Emergency surgery

Gallart L, Best Pract Res Clin Anaesthesiol. 2015 Sep;29(3):315-30

 Pre-op management
• Smoking cessation 4-6 weeks is the best
– 12-24 hr : CO and nicotine level =0
– 1 wk : airway reactivity decrease
– 2 wk : sputum volume is half of normal
Wong J, Can J Anaesth. 2012 Mar;59(3):268-79
Mills E, Am J Med. 2011 Feb;124(2):144-154
 Pre-op management
• COPD
– Pre-op bronchodilator
– Postpone elective surgery if acute exacerbation or
influenza developed

• Asthma
– β2-agonist 30 min before intubation
– Postpone elective surgery in poorly control patient
 Pre-op management
• Breathing exercise/inspiratory muscle training
– Cardiac or abdominal surgery
– Reduce pneumonia, atelectasis and LOH stay

Katsura M, Cochrane Database Syst Rev. 2015 Oct 5;(10):CD010356

 Pre-op management
• Lung expansion therapy
– Should be taught pre-operatively
 Pre-op management
• Nutrition
– Low serum albumin increase risk
– Improve nutrition might be good
– No supportive evidence
 Anesthetic technique
GA RA
30-day mortality 1 0.71 (0.53-0.94)
Pneumonia 1 0.45 (0.26-0.79)

GA GA+RA
Pneumonia 1 0.69 (0.49-0.98)

Guay J, Cochrane Database Syst Rev. 2014 Jan 25;(1):CD010108

Guay J, Anesth Analg. 2014 Sep;119(3):716-25
 Intra-op management
• Anesthetic technique
– GA VS RA
– Avoid long acting muscle relaxant eg.pancuronium
 Ventilatory management
• Protective ventilation

Serpa A, Best Pract Res Clin Anaesthesiol. 2015 Sep;29(3):331-40

 Protective ventilation

• Low TV
• PEEP
• Recruitment

Serpa A, Best Pract Res Clin Anaesthesiol. 2015 Sep;29(3):331-40

Tidal volume

Serpa A, Anesthesiology. 2015 Jul;123(1):66-78

 PROVHILO trial
(International multicenter RCT)
TV 8 cc/kg PBW

• PEEP 0-2 cmH2O • PEEP 12 cmH2O

without RM with RM

– PPC 39% – PPC 40%

– ↑hypotension
– ↑vasoactive drugs

PROVE Network Investigators, Lancet. 2014 Aug 9;384(9942):495-503

• Observational study
• 29,343 patients
• Median PEEP 4 cmH2O

Levin MA, Br J Anaesth. 2014 Jul;113(1):97-108

 6-8 cc/kg PBW 8-10 cc/kg PBW

30 days mortality 1.61 (1.2-2.1) 1

LOS 1.15 (1.05-1.26) 1

Levin MA, Br J Anaesth. 2014 Jul;113(1):97-108

PEEP

Serpa A, Anesthesiology. 2015 Jul;123(1):66-78

 PEEP

• PEEP 6 cmH2O if BMI < 25

• PEEP 8 cmH2O if BMI 25-30
• PEEP > 8 cmH2O if BMI > 30

Hedenstierna G, Best Pract Res Clin Anaesthesiol. 2015 Sep;29(3):273-84

 Recruitment

• Increase PEEP stepwise

• Increase TV stepwise
• Apply CPAP
Recruitment

Johnson D, Can J Anaesth. 2004 Aug-Sep;51(7):649-53

 Protective ventilation

• TV 6-8 cc/kg PBW

• PEEP 6-8 cmH2O

• Recruitment

Serpa A, Best Pract Res Clin Anaesthesiol. 2015 Sep;29(3):331-40

Lung protection in specific diseases
 COPD
• Titrate PEEP carefully

– Overinflation
– Beneficial
 Pulmonary HT
• Avoid
– Hypoxia
– Hypercarbia
– Acidosis

• TV
– 6 cc/kg PBW may cause hypercarbia
– Prefer 8 cc/kg PBW
 Pulmonary HT
• PEEP
– Low PEEP ↓venous return, ↓ RV preload
– High PEEP ↑ RV afterload
– Recommend low PEEP toward lower inflection
point
• Recruitment
– Very cautious approach
 Patient with cardiac disease
• Recruitment
– Hypotension

• Hypercarbia / Acidosis
• Arrhythmia / VF
• ↑ Pacemaker threshold
 Neurological patient
• Hypercarbia / recruitment
–  ICP

• ARDS with intracranial lesion

– High PEEP with low TV
– 2/11 patient need treatment for  ICP
 Neurological patient

• Normal lungs with intracranial lesion

– Lung protection
– Monitor ICP
– No clear evidence for benefit
 Organ doner
• Conventional • Protective
– 10-12 cc/kg – 6-8 cc/kg
– PEEP 3-5 cmH2O – PEEP 8-10 cmH2O

– More lungs were – Shorter ICU stay

eligible to harvest – Lower mortality
(recipient)

Mascia L, JAMA. 2010 Dec 15;304(23):2620-7

 Intra-op management

• Surgical management
– Avoid prolong surgery
– Minimally invasive surgery
 Intra-op management

• Fluid therapy
– Fluid overload might increase risk
 Post-op management

• Analgesia
– Adequate analgesia
– Epidural or PNB seems to be better than IV
opioids
 Post-op management
• Incentive spirometry
• IPPB
• CPAP(1)
– ↓atelectasis
– ↓pneumonia
– ↓reintubation
• Chest physical therapy(2)
– Worsen atelectasis
1.Ireland CJCochrane Database Syst Rev. 2014 Aug 1;(8):CD008930
2.Branson RD, Respir Care. 2013 Nov;58(11):1974-84
 Post-op management
• I COUGH
– Incentive spirometry
– Coughing and deep breathing exercise
– Oral care
– Understanding (Patient and family education)
– Getting out of bed
– Head elevation

Cassidy MR, JAMA Surg. 2013 Aug;148(8):740-5

 Post-op management

Before I COUGH After I COUGH

Pneumonia 2.6% 1.6%

Unplanned intubation 2.0% 1.2%

Cassidy MR, JAMA Surg. 2013 Aug;148(8):740-5

 Summary

• Identify high risk patient/procedure

• Stop smoking
• Respiratory muscle training before surgery
• Optimum bronchodilator in COPD/asthma
 Summary

• Avoid long acting relaxant

• Use low TV with PEEP and recruitment

• I COUGH post-operatively