Perioperative hypoxemia is common with horizontal positioning during general anesthesia and is associated with major adverse outcomes: a retrospective study of consecutive patients

BMC Anesthesiology

C Michael Dunham¹  Barbara M Hileman¹  Amy E Hutchinson²  Elisha A Chance¹  Gregory S Huang¹ 

[1] Trauma/Critical Services, St. Elizabeth Health Center, 1044 Belmont Avenue, Youngstown OH 44501, USA

[2] Department of Anesthesiology, St. Elizabeth Health Center, 1044 Belmont Avenue, Youngstown OH 44501, USA

关键词: Supine position;    Operating rooms;    Perioperative;    Period;    Hypoxemia;    Respiratory;    Aspiration;   

Others  :  816306
DOI  :  10.1186/1471-2253-14-43

 received in 2014-01-26, accepted in 2014-06-05,  发布年份 2014

【 摘 要 】

Background

Reported perioperative pulmonary aspiration (POPA) rates have substantial variation. Perioperative hypoxemia (POH), a manifestation of POPA, has been infrequently studied beyond the PACU, for patients undergoing a diverse array of surgical procedures.

Methods

Consecutive adult patients with ASA I-IV and pre-operative pulmonary stability who underwent a surgical procedure requiring general anesthesia were investigated. Using pulse oximetry, POH was documented in the operating room and during the 48 hours following PACU discharge. POPA was the presence of an acute pulmonary infiltrate with POH.

Results

The 500 consecutive, eligible patients had operative body-positions of prone 13%, decubitus 8%, sitting 1%, and supine/lithotomy 78%, with standard practice of horizontal recumbency. POH was found in 150 (30%) patients. Post-operative stay with POH was 3.7 ± 4.7 days and without POH was 1.7 ± 2.3 days (p < 0.0001). POH rate varied from 14% to 58% among 11 of 12 operative procedure-categories. Conditions independently associated with POH (p < 0.05) were acute trauma, BMI, ASA level, glycopyrrolate administration, and duration of surgery. POPA occurred in 24 (4.8%) patients with higher mortality (8.3%), when compared to no POPA (0.2%; p = 0.0065). Post-operative stay was greater with POPA (7.7 ± 5.7 days), when compared to no POPA (2.0 ± 2.9 days; p = 0.0001). Conditions independently associated with POPA (p < 0.05) were cranial procedure, ASA level, and duration of surgery. POPA, acute trauma, duration of surgery, and inability to extubate in the OR were independently associated with post-operative stay (p < 0.05). POH, gastric dysmotility, acute trauma, cranial procedure, emergency procedure, and duration of surgery had independent correlations with post-operative length of stay (p < 0.05).

Conclusions

Adult surgical patients undergoing general anesthesia with horizontal recumbency have substantial POH and POPA rates. Hospital mortality was greater with POPA and post-operative stay was increased for POH and POPA. POH rates were noteworthy for virtually all categories of operative procedures and POH and POPA were independent predictors of post-operative length of stay. A study is needed to determine if modest reverse-Trendelenburg positioning during general anesthesia has a relationship with reduced POH and POPA rates.

【 授权许可】

   
2014 Dunham et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]Cotton BR, Smith G: The lower oesophageal sphincter and anaesthesia. Br J Anaesth 1984, 56(1):37-46.
• [2]Morgan M: Control of intragastric pH and volume. Br J Anaesth 1984, 56(1):47-57.
• [3]Tiret L, Desmonts JM, Hatton F, Vourc’h G: Complications associated with anaesthesia–a prospective survey in France. Canadian Anaesthetists’ Society Journal 1986, 33(3 Pt 1):336-344.
• [4]Kozlow JH, Berenholtz SM, Garrett E, Dorman T, Pronovost PJ: Epidemiology and impact of aspiration pneumonia in patients undergoing surgery in Maryland, 1999–2000. Crit Care Med 2003, 31(7):1930-1937.
• [5]Kluger MT, Short TG: Aspiration during anaesthesia: a review of 133 cases from the Australian anaesthetic incident monitoring study (AIMS). Anaesthesia 1999, 54(1):19-26.
• [6]Blitt CD, Gutman HL, Cohen DD, Weisman H, Dillon JB: “Silent” regurgitation and aspiration during general anesthesia. Anesth Analg 1970, 49(5):707-713.
• [7]Charuluxananan S, Punjasawadwong Y, Suraseranivongse S, Srisawasdi S, Kyokong O, Chinachoti T, Chanchayanon T, Rungreungvanich M, Thienthong S, Sirinan C, et al.: The Thai anesthesia incidents study (THAI study) of anesthetic outcomes: II. anesthetic profiles and adverse events. Journal of the Medical Association of Thailand = Chotmaihet thangphaet 2005, 88(7):S14-29.
• [8]Mellin-Olsen J, Fasting S, Gisvold SE: Routine preoperative gastric emptying is seldom indicated: a study of 85,594 anaesthetics with special focus on aspiration pneumonia. Acta Anaesthesiol Scand 1996, 40(10):1184-1188.
• [9]Olsson GL, Hallen B, Hambraeus-Jonzon K: Aspiration during anaesthesia: a computer-aided study of 185,358 anaesthetics. Acta Anaesthesiol Scand 1986, 30(1):84-92.
• [10]Sakai T, Planinsic RM, Quinlan JJ, Handley LJ, Kim TY, Hilmi IA: The incidence and outcome of perioperative pulmonary aspiration in a university hospital: a 4-year retrospective analysis. Anesth Analg 2006, 103(4):941-947.
• [11]Warner MA, Warner ME, Weber JG: Clinical significance of pulmonary aspiration during the perioperative period. Anesthesiology 1993, 78(1):56-62.
• [12]Cheney FW, Posner KL, Caplan RA: Adverse respiratory events infrequently leading to malpractice suits: a closed claims analysis. Anesthesiology 1991, 75(6):932-939.
• [13]Kluger MT, Visvanathan T, Myburgh JA, Westhorpe RN: Crisis management during anaesthesia: regurgitation, vomiting, and aspiration. Quality & safety in health care 2005, 14(3):e4.
• [14]Klanarong S, Suksompong S, Hintong T, Chau-In W, Jantorn P, Werawatganon T: Perioperative pulmonary aspiration: an analysis of 28 reports from the Thai anesthesia incident monitoring study (Thai AIMS). Journal of the Medical Association of Thailand = Chotmaihet thangphaet 2011, 94(4):457-464.
• [15]Neelakanta G, Chikyarappa A: A review of patients with pulmonary aspiration of gastric contents during anesthesia reported to the departmental quality assurance committee. J Clin Anesth 2006, 18(2):102-107.
• [16]Engelhardt T, Webster NR: Pulmonary aspiration of gastric contents in anaesthesia. Br J Anaesth 1999, 83(3):453-460.
• [17]Ewig S, Torres A: Prevention and management of ventilator-associated pneumonia. Curr Opin Crit Care 2002, 8(1):58-69.
• [18]Torres A, Serra-Batlles J, Ros E, Piera C, Puig de la Bellacasa J, Cobos A, Lomena F, Rodriguez-Roisin R: Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med 1992, 116(7):540-543.
• [19]Reali-Forster C, Kolobow T, Giacomini M, Hayashi T, Horiba K, Ferrans VJ: New ultrathin-walled endotracheal tube with a novel laryngeal seal design: long-term evaluation in sheep. Anesthesiology 1996, 84(1):162-172. discussion 127A
• [20]Petring OU, Adelhoj B, Jensen BN, Pedersen NO, Lomholt N: Prevention of silent aspiration due to leaks around cuffs of endotracheal tubes. Anesth Analg 1986, 65(7):777-780.
• [21]Seegobin RD, van Hasselt GL: Aspiration beyond endotracheal cuffs. Canadian Anaesthetists’ Society journal 1986, 33(3 Pt 1):273-279.
• [22]Kalinowski CP, Kirsch JR: Strategies for prophylaxis and treatment for aspiration. Best practice & research Clinical anaesthesiology 2004, 18(4):719-737.
• [23]Hardy JF: Large volume gastroesophageal reflux: a rationale for risk reduction in the perioperative period. Canadian journal of anaesthesia = Journal canadien d’anesthesie 1988, 35(2):162-173.
• [24]Ng A, Smith G: Gastroesophageal reflux and aspiration of gastric contents in anesthetic practice. Anesth Analg 2001, 93(2):494-513.
• [25]Illing L, Duncan PG, Yip R: Gastroesophageal reflux during anaesthesia. Canadian journal of anaesthesia = Journal canadien d’anesthesie 1992, 39(5 Pt 1):466-470.
• [26]Farman J: Acid aspiration syndrome. British journal of perioperative nursing: the journal of the National Association of Theatre Nurses 2004, 14(6):266-267. 269–270, 272–264
• [27]Asai T: Editorial II: who is at increased risk of pulmonary aspiration? Br J Anaesth 2004, 93(4):497-500.
• [28]Nagelhout JJ: AANA journal course: update for nurse anesthetists: aspiration prophylaxis: is it time for changes in our practice? AANA journal 2003, 71(4):299-303.
• [29]McIntyre JW: Evolution of 20th century attitudes to prophylaxis of pulmonary aspiration during anaesthesia. Canadian journal of anaesthesia = Journal canadien d’anesthesie 1998, 45(10):1024-1030.
• [30]Abdulla S: Pulmonary aspiration in perioperative medicine. Acta Anaesthesiol Belg 2013, 64(1):1-13.
• [31]Smith G, Ng A: Gastric reflux and pulmonary aspiration in anaesthesia. Minerva Anestesiol 2003, 69(5):402-406.
• [32]Ferrer R, Artigas A: Clinical review: non-antibiotic strategies for preventing ventilator-associated pneumonia. Critical care (London, England) 2002, 6(1):45-51. BioMed Central Full Text
• [33]Keenan SP, Heyland DK, Jacka MJ, Cook D, Dodek P: Ventilator-associated pneumonia: prevention, diagnosis, and therapy. Crit Care Clin 2002, 18(1):107-125.
• [34]Koeman M, van der Ven AJ, Ramsay G, Hoepelman IM, Bonten MJ: Ventilator-associated pneumonia: recent issues on pathogenesis, prevention and diagnosis. The Journal of Hospital Infection 2001, 49(3):155-162.
• [35]Fernandez-Crehuet R, Diaz-Molina C, de Irala J, Martinez-Concha D, Salcedo-Leal I, Masa-Calles J: Nosocomial infection in an intensive-care unit: identification of risk factors. Infection control and Hospital Epidemiology: the Official Journal of the Society of Hospital Epidemiologists of America 1997, 18(12):825-830.
• [36]Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogue S, Ferrer M: Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet 1999, 354(9193):1851-1858.
• [37]Kollef MH: Ventilator-associated pneumonia: a multivariate analysis. JAMA: the Journal of the American Medical Association 1993, 270(16):1965-1970.
• [38]IHI: Ventilator bundle: elevation of the head of the bed: institute for healthcare improvement. 2011. http://www.ihi.org/knowledge/Pages/Changes/ImplementtheVentilatorBundle.aspx; webcite Accessed 12/9/2013
• [39]McEwen DR: Intraoperative positioning of surgical patients. AORN J 1996, 63(6):1059-1063. 1066–1079; quiz 1080–1056
• [40]Adedeji R, Oragui E, Khan W, Maruthainar N: The importance of correct patient positioning in theatres and implications of mal-positioning. Journal of Perioperative Practice 2010, 20(4):143-147.
• [41]Smith KA: Positioning principles: an anatomical review. AORN J 1990, 52(6):1196-1202. 1204, 1206–1198
• [42]Raghavendran K, Nemzek J, Napolitano LM, Knight PR: Aspiration-induced lung injury. Crit Care Med 2011, 39(4):818-826.
• [43]Jones J: Risk and outcome of aspiration pneumonia in a city hospital. J Natl Med Assoc 1993, 85(7):533-536.
• [44]Vadeboncoeur TF, Davis DP, Ochs M, Poste JC, Hoyt DB, Vilke GM: The ability of paramedics to predict aspiration in patients undergoing prehospital rapid sequence intubation. The Journal of Emergency Medicine 2006, 30(2):131-136.
• [45]Lampe GH, Wauk LZ, Whitendale P, Way WL, Kozmary SV, Donegan JH, Eger EI 2nd: Postoperative hypoxemia after nonabdominal surgery: a frequent event not caused by nitrous oxide. Anesth Analg 1990, 71(6):597-601.
• [46]Ehrenfeld JM, Funk LM, Van Schalkwyk J, Merry AF, Sandberg WS, Gawande A: The incidence of hypoxemia during surgery: evidence from two institutions. Canadian Journal of Anaesthesia = Journal canadien d’anesthesie 2010, 57(10):888-897.
• [47]Canet J, Ricos M, Vidal F: Early postoperative arterial oxygen desaturation: determining factors and response to oxygen therapy. Anesth Analg 1989, 69(2):207-212.
• [48]Daley MD, Norman PH, Colmenares ME, Sandler AN: Hypoxaemia in adults in the post-anaesthesia care unit. Canadian Journal of anaesthesia = Journal canadien d’anesthesie 1991, 38(6):740-746.
• [49]Morris RW, Buschman A, Warren DL, Philip JH, Raemer DB: The prevalence of hypoxemia detected by pulse oximetry during recovery from anesthesia. J Clin Monit 1988, 4(1):16-20.
• [50]Tyler IL, Tantisira B, Winter PM, Motoyama EK: Continuous monitoring of arterial oxygen saturation with pulse oximetry during transfer to the recovery room. Anesth Analg 1985, 64(11):1108-1112.
• [51]Moller JT: Anesthesia related hypoxemia: the effect of pulse oximetry monitoring on perioperative events and postoperative complications. Dan Med Bull 1994, 41(5):489-500.
• [52]Xue FS, Li BW, Zhang GS, Liao X, Zhang YM, Liu JH, An G, Luo LK: The influence of surgical sites on early postoperative hypoxemia in adults undergoing elective surgery. Anesth Analg 1999, 88(1):213-219.
• [53]Drummond GB, Stedul K, Kingshott R, Rees K, Nimmo AF, Wraith P, Douglas NJ: Automatic CPAP compared with conventional treatment for episodic hypoxemia and sleep disturbance after major abdominal surgery. Anesthesiology 2002, 96(4):817-826.
• [54]Rosenberg J, Oturai P, Erichsen CJ, Pedersen MH, Kehlet H: Effect of general anesthesia and major versus minor surgery on late postoperative episodic and constant hypoxemia. J Clin Anesth 1994, 6(3):212-216.
• [55]Reeder MK, Goldman MD, Loh L, Muir AD, Foex P, Casey KR, McKenzie PJ: Postoperative hypoxaemia after major abdominal vascular surgery. Br J Anaesth 1992, 68(1):23-26.
• [56]Clayer M, Bruckner J: Occult hypoxia after femoral neck fracture and elective hip surgery. Clin Orthop Relat Res 2000, 370:265-271.
• [57]Bernstein CA, Waters JH, Torjman MC, Ritter D: Preoperative glycopyrrolate: oral, intramuscular, or intravenous administration. J Clin Anesth 1996, 8(6):515-518.
• [58]Ali-Melkkila T, Kanto J, Iisalo E: Pharmacokinetics and related pharmacodynamics of anticholinergic drugs. Acta Anaesthesiol Scand 1993, 37(7):633-642.
• [59]Mirakhur RK, Dundee JW: Glycopyrrolate: pharmacology and clinical use. Anaesthesia 1983, 38(12):1195-1204.
• [60]Malik JA, Gupta D, Agarwal AN, Jindal SK: Anticholinergic premedication for flexible bronchoscopy: a randomized, double-blind, placebo-controlled study of atropine and glycopyrrolate. Chest 2009, 136(2):347-354.
• [61]ASA: Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American society of anesthesiologists committee on standards and practice parameters. Anesthesiology 2011, 114(3):495-511.
• [62]Mirakhur RK: Preanaesthetic medication: a survey of current usage. J R Soc Med 1991, 84(8):481-483.
• [63]Suraseranivongse S, Valairucha S, Chanchayanon T, Mankong N, Veerawatakanon T, Rungreungvanich M: The Thai anesthesia incidents study (THAI study) of pulmonary aspiration: a qualitative analysis. Journal of the Medical Association of Thailand = Chotmaihet thangphaet 2005, 88(7):S76-83.
• [64]Mulier JP, Dillemans B, Van Cauwenberge S: Impact of the patient’s body position on the intraabdominal workspace during laparoscopic surgery. Surg Endosc 2010, 24(6):1398-1402.