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

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

4. 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

5. 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

6. 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:
Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171:

7. 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:
Garibaldi R. A, et al. Risk factors for Postoperative pneumonia. American Journal of Medicine 1981; 70:

8. 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:
Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171:

9. 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:

10. 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:

11. Prevention of post-op pneumonia
Retrospective single center review of 3319 surgical cases between 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:

12. 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%)

13. Questions ?