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*
Note: Clinical practice guidelines are “guides” only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication, or once an update has been issued.
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Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Qaseem and Snow: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Fitterman: 120 New York Avenue, Suite 3W, Huntington, NY 11743.
Dr. Hornbake: 7 Shelter Rock Road, P.O. Box 218, Hadlyme, CT 06439.
Dr. Lawrence: 7703 Floyd Curl Drive, Mail Code 7879, San Antonio, TX 78229.
Dr. Smetana: Shapiro 621D, 330 Brookline Avenue, Boston, MA 02215.
Dr. Weiss: P.O. Box 5000, Hines, IL 60141.
Dr. Owens: 117 Encina Commons, Stanford, CA 94305.
Postoperative pulmonary complications play an important role in the risk for patients undergoing noncardiothoracic surgery. Postoperative pulmonary complications are as prevalent as cardiac complications and contribute similarly to morbidity, mortality, and length of stay. Pulmonary complications may even be more likely than cardiac complications to predict long-term mortality after surgery. The purpose of this guideline is to provide guidance to clinicians on clinical and laboratory predictors of perioperative pulmonary risk before noncardiothoracic surgery. It also evaluates strategies to reduce the perioperative pulmonary risk and focuses on atelectasis, pneumonia, and respiratory failure. The target audience for this guideline is general internists or other clinicians involved in perioperative management of surgical patients. The target patient population is all adult persons undergoing noncardiothoracic surgery.
*This paper, written by 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; and Douglas K. Owens, MD, MS, was developed for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians (ACP): Douglas K. Owens, MD, MS (Chair); Mark Aronson, MD; Patricia Barry, MD, MPH; Donald E. Casey Jr., MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Nick Fitterman, MD; E. Rodney Hornbake, MD; Katherine D. Sherif, MD; and Kevin B. Weiss, MD, MPH (Immediate Past Chair). Approved by the ACP Board of Regents on 21 January 2006.
Table. American Society of Anesthesiologists Classification
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Enrique J. SÃ¡nchez-Delgado, MD
Hospital Metropolitano Vivian Pellas, Managua, Nicaragua
April 23, 2006
Inspiratory Apnea Time Index Correlates with Functional Capacity and Better ASA Class
The new Clinical Guidelines from the ACP (Annals, April 18, 2006) can be very useful for the practicing internist who does every day preoperatory evaluations and also for surgeons and anesthesiologists. Very practical recommendations, among others, are the use of the clinical judgment (history and physical examination), rather than the routine chest X ray, except for specific cases.
In the past, the inspiratory apnea time (to hold the inspiration after hyperventilation) over 40 seconds, was considered a good sign of respiratory function. Anesthesiologists need a good time in apnea for the intubation and usually ventilate and oxygenate before. Thus, enough time in apnea with a normal oxygen saturation (e.g. SpO2 over 95 % or at least 92 %) is desirable. At the other hand, the resting heart rate (RHR), increases as the SpO2 decreases. The lower the RHR, and/or the increase of RHR during apnea, the better the general cardio-respiratory condition of the patient.
I have been doing for several years a prospective observational study of patients with preoperatory evaluations, in the meantime several hundreds, in which I assess the apnea time in seconds (ideal over 50), multiplied by the average SpO2 (ideal over 92 %), and divided by the RHR (ideal under 90). Form these data I calculate an Index, which should be over 50. The higher, the better.
This Index is then compared with the global functional capacity of the patients, with special attention to symptoms like angina or dyspnea during exercise or physical efforts (and their intensity or duration). It is also compared with the ASA Class. Patients in ASA Class I and good functional capacity according to the current guidelines, usually have an Index over 50 to 80, but not under or near to 50. Patients in ASA Class II, have an Index over 50. The patients with an Index under or very close to 50, usually have an ASA Class III or over, with a poor functional capacity. Of course, the younger and physically active have the best results, but the correlation is also observed in obese or elderly patients. I recommend this Index, which is very simple and can be done by any internist, to be done in every preoperatory evaluation.
Presbyterian Healthcare Services
April 21, 2006
Risk assessment for and strategies to reduce perioperative pulmonary complications
This is in response to your current publication in the Annals of Internal Medicine April 18, 2006.
Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing non cardiothoracic surgery : A guideline from the American College of Physicians.
To the Editor,
Qaseem and colleagues in their clinical guidelines for risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing non cardiothoracic surgery have overlooked an important factor in preventing postoperative pneumonia related to acid aspiration. Pulmonary aspiration of gastric contents during the perioperative period may be associated with postoperative mortality or pulmonary morbidity (1). While acid aspiration during induction of anesthesia is rare with an incidence of 3 in 10,000, this complication causes high morbidity and mortality. Aspiration-related complications such as pneumonitis, adult respiratory distress syndrome, and laryngeal complications remain important causes of perioperative morbidity and mortality. In a study reported by Rosenstock and colleagues, 7 patients out of 60 with adverse respiratory events during anesthesia had pulmonary aspiration of gastric contents, six of whom died (2). It has also been reported that patients who attend for day surgery are more likely to have larger gastric residual volumes and a higher risk of aspiration pneumonia compared with inpatients (3) .The effects of aspiration are multiple and are thought to be attributable to the acid, chemical, and microbiological composition, as well as the volume of aspirate. Studies in animals have shown that low gastric pH is the more important determinant of aspiration induced lung injury and mortality as compared to the volume of the aspirate. Prophylaxis against aspiration pneumonia is therefore important in preanaesthetic management. These regimens include H2 antagonists, sucralfate and proton pump inhibitors.
Various prophylactic regimens have been investigated and H2 antagonists being shown to be the effective agents for increasing gastric pH and decreasing gastric fluid volume (4). However, rapid development of tolerance to their antisecretory effects has led to studies with proton inhibitors, which are now considered suitable alternatives for increasing gastric pH and decreasing gastric volume.
As the majority of evidence supports the preoperative administration of H2 antagonists or proton pump inhibitors in most patients and certainly in those who are pre-operatively assessed to be at increased risk for aspiration (5), we recommend that either proton pump inhibitors or H2 blockers should be given as pre-anesthetic medicine to reduce gastric volume and acidity. This combined with selective use of naso-gastric decompression after abdominal surgery, as advocated by Qaseem and colleagues can effectively reduce the risk of gastric content aspiration and postoperative pneumonias.
Tahir Qaseem, MD, FACP Presbyterian Healthcare Services Albuquerque, New Mexico
1. Warner MA, Warner ME, Weber JG. Clinical significance of pulmonary aspiration during the perioperative period. Anesthesiology 1993; 78: 56"“62
2. Rosenstock C, MÃ¸ller J, Hauberg A. Complaints related to respiratory events in anaesthesia and intensive care medicine from 1994 to 1998 in Denmark. Acta Anaesthesiol Scand 2001; 45: 53"“8
3. Ong BY, Palahniuk RJ, Cumming M. Gastric volume and pH in out- patients. Can Anaesth Soc J 1978; 25: 36"“9
4. Talke PO, Solanki DR. Dose-response study of oral famotidine for reduction of gastric acidity and volume in outpatients and inpatients. Anesth Analg 1993; 77: 1143"“8
5. Kalinowski CPH, Kirsch JR. Strategies for prophylaxis and treatment fro aspiration. Best Pract Res Clin Anesth. 2004;18:719-737.
American College of Physicians
June 9, 2006
Response to Tahir Qaseem, MD, FACP comments
We appreciate the comments of Dr Qaseem and he makes an important point in acid suppression prophylaxis in a subset of patients at increased risk of pulmonary aspiration of gastric contents during surgery. While we agree with Dr Qaseem, the use of acid suppression is widely used for GI prophylaxis. As pointed out by Dr Qaseem that even though the acid aspiration syndrome is a critical perioperative complication, it is limited to a very small subset of patients and the use of acid suppression solely as a preventive strategy for pulmonary complications was excluded from our review. These patients need to be individually evaluated and managed as appropriate.
Tiago David Fernnades
Hospital Pedro Hispano, Matosinhos PORTUGAL
June 27, 2006
Anesthesia and Analgesia
Under this item (A & A), in the last sentence of the first paragraph, when you state "... shorter-acting neuromuscular blocking agents may prevent postoperative pulmonary complications.", don't you mean "neuroaxial blockade may prevent..."?
Otherwise the sentence doesn't seem to relate to the paragraph or item and there is no conclusion over the general anesthesia versus neuraxial anesthesia debate.
New York Hospital Queens - Department of Surgery
November 7, 2006
In regards to nasogastric decompression after abdominal surgery, the authors found that "patients receiving selective nasogastric decompression had a significantly lower rate of pneumonia and atelectasis." And concluded that, "All patients who are found to be at higher risk for postoperative pulmonary complications should receive selective use of a nasogastric tube."
However, both of the papers that the authors referenced reported an "insignificant trend toward a decrease in pulmonary complications (p=0.07)" and "significantly fewer pulmonary complications' with selective nasogastric tube decompression."
Can you please clarify?
References 31. Cheatham ML, Chapman WC, Key SP, Sawyers JL. A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg. 1995;221:469-76.
32. Nelson R, Tse B, Edwards S. Systematic review of prophylactic nasogastric decompression after abdominal operations. Br J Surg. 2005;92:673-80.
Qaseem A, Snow V, Fitterman N, Hornbake ER, Lawrence VA, Smetana GW, et al. Risk Assessment for and Strategies To Reduce Perioperative Pulmonary Complications for Patients Undergoing Noncardiothoracic Surgery: A Guideline from the American College of Physicians. Ann Intern Med. 2006;144:575-580. doi: 10.7326/0003-4819-144-8-200604180-00008
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Published: Ann Intern Med. 2006;144(8):575-580.
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