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POSTOPERATIVE PNEUMONIA AND RESPIRATORY FAILURE

Background

Postoperative pneumonia and respiratory failure are two of the more common and clinically significant conditions in the large composite outcome of postoperative pulmonary complications (PPCs), which also includes atelectasis, bronchospasm, COPD exacerbation, OSA complications, acute upper airway obstruction, pleural effusion, and others. The incidence of PPCs varies between 2% and 70% because of how such events are defined and the populations in which they were studied and was 6% (or > 165,000 patients) in the NSQIP database.1 PPCs are associated with significant morbidity and mortality with 14–30% dying within 30 days of major surgery compared with 0.2–3% without PPCs.2 Hospital length of stay is also significantly increased, leading to increased cost to the patient and the healthcare system.3 Patient and surgery-specific risk factors, various online risk calculators, and preoperative measures to prevent PPCs are discussed in Chapter 15 Preop Pulm Risk.

Approach to Postoperative Pneumonia: Diagnosis and Treatment

Postoperative pneumonia is usually seen within 5 days of surgery. The approach to diagnosis and treatment is similar to that of other hospital or ventilator acquired pneumonia (HAP/VAP). Presenting features and diagnostic criteria are listed in Table 38-1. The differential diagnosis includes atelectasis, pulmonary edema, pulmonary embolism, and acute lung injury. The most common pathogens cultured include gram negative bacteria (GNB) and Staphylococcus aureus but it may be polymicrobial. Causative organisms and risk factors associated with them are listed in Table 38-2. Initial management consist of collecting respiratory specimens for analysis, initiating empiric antibiotic treatment, and based on culture results, tailoring the antibiotic regimen.

TABLE 38-1Definitions of Complications2,4,5
TABLE 38-2Common Pathogens and Association with Medical and Surgical Factors

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