Surveillance of Post-operative pneumonia Presenter: Andrew Griffiths PGY-2 Sponsor: Dr. Karen McGinnis Date: 4/13/11

Objectives Identify risk factors for post-operative pneumonia Understand NSQIP definition and criteria for post-operative pneumonia Understand recommendations for prevention of pneumonia

NSQIP definition of post-operative pneumonia Inflammation of the lungs caused primarily by bacteria, viruses and/or chemical irritants usually manifested by chills, fever, pain in the chest, cough, purulent or bloody sputum Surgery NSQIP – CICSP Enhancements 2007 Release Notes

NSQIP criteria for post-operative pneumonia Rales or dullness to percussion on physical exam of chest and New onset of purulent sputum or change in character of sputum Organism isolate from blood culture Isolation of pathogen from specimen obtained by transtracheal aspirate, bronchial brushing or biopsy. Criteria 2 Chest radiographic examination shows new or progressive infiltrate, consolidation, cavitation or pleural effusion AND New onset of purulent sputum or change in character of sputum Organism isolated from blood culture Isolation of pathogen from specimen obtained by transtracheal aspirate, bronchial brushing or biopsy Isolation of virus or detection of viral antigen in respiratory secretion Histopathologic evidence of pneumonia Surgery NSQIP – CICSP Enhancements 2007 Release Notes

Post-operative pneumonia 3rd most common infectious complication in surgical patients. Prevalence 1.5% Mortality rate 20-70% Cost $40,000 per patient Wren S. M, et al. Postoperative Pneumonia-Prevention Program for the inpatient Surgical Ward. J Am Coll Surg 2010; 210: 491-495. Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171: 388-416.

Post-operative pneumonia Risk factors/ Microbiology Low serum albumin High ASA Intubation Supine positioning Lengthy surgeries Chest and upper abdominal surgery Microbiology Staphylococcus aureus Streptococcus pneumoniae Pseudomonas sp. Acinetobacter sp. Klebsiella pneumoniae Guideline for the Management of Adults with Hospital-acquired, ventilator-associated and Healthcare-associated pneumonia. Am J Resp Crit Care Med 2005; 171: 388-416. Garibaldi R. A, et al. Risk factors for Postoperative pneumonia. American Journal of Medicine 1981; 70: 677-680.

Post-operative pneumonia Pathogenesis Entry of microbial pathogens into the lower respiratory tract followed by colonization Aspiration of oropharyngeal pathogens or leakage of bacteria around the endotracheal tube cuff is the primary route of bacterial entry into the trachea Wren S. M, et al. Postoperative Pneumonia-Prevention Program for the inpatient Surgical Ward. J Am Coll Surg 2010; 210: 491-495. Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171: 388-416.

Post-operative pneumonia Recommendations Intubation and reintubation should be avoided. (Level I) Endotracheal cuff pressure should be maintained >20cm H2O (Level II) Patients should be kept in the semi-recumbent position (30-45 degrees) [Level I] Samples of lower respiratory tract secretions should include an endotracheal aspirate, Bronchioalveolar lavage. (Level II) Guidelines for the Management of Adults with Hospital-acquired, ventilator-associated and Healthcare-associated pneumonia. Am J Resp Crit Care Med 2005; 171: 388-416.

ET tube cuffs and Pneumonia A prospective single blind RCT involving 134 who underwent Cardiothoracic surgery 67 patients were given an ET tube with a polyurethane cuff vs. 67 patients given an ET tube with a polyvinylchloride (PVC) cuff 15 patients with the Polyurethane cuff developed pneumonia vs. 28 patients with the PVC cuff. (P= 0.026) Poelaert J, et al. Polyurethan cuffed endotracheal tubes to prevent early postoperative pneumonia after cardiac surgery: A pilot study. J Thorac Cadiovasc Surg 2008; 135: 771-776.

Prevention of post-op pneumonia Retrospective single center review of 3319 surgical cases between 2006 and 2008 Pre-intervention group (1668 patients) vs. Intervention group (1651 patients) 13 post-op pneumonias diagnosed in pre-intervention group (0.78%) vs. 3 pneumonias diagnosed in intervention group (0.18%) [p=0.006] Intervention steps Education of all surgical ward nursing staff about role of pneumonia prevention Cough and deep breathing exercises with incentive spirometer Twice daily oral hygiene with chlorhexidine swabs Ambulation with good pain control Head of bed elevation to at least 30 degrees and siting up for all meals. Wren S.M, et al Postoperative pneumonia-prevention program for the inpatient surgical ward. J Am Coll Surg 2010; 210:491-495.

Bassett Post-operative pneumonia stats (2009) Surgical service No. patients NG tubes Ventilated patients General 22 11 (50%) 7 (32%) Neurosurgery 2 Orthopaedics 5 Plastic surgery 3 1 (33%) Thoracic surgery 9 8 (89%) 7(78%) Urology Vascular surgery 10 5 (50%) 4(40) Total 54 26 (48%) 19 (35%)

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