Postoperative Pulmonary Complications: Experience with an Outpatient Preoperative Assessment Program

• Objective: To assess outcomes of patients referred to an internal medicine preoperative assessment program for evaluation preceding noncardiac surgery. • Design: Prospective cohort study. • Patients and setting: The study cohort was a convenience sample of patients undergoing major noncardiac surgery at an academic tertiary care medical center who were referred to the IMPACT (Internal Medicine Preoperative Assessment Consultation and Treatment) Center. A standardized preoperative evaluation was performed, including assessment by various instruments (including the Charlson’s Comorbidity and Goldman’s Cardiac Risk indices, the Surgical Risk Index classification, and the American Society of Anesthesiologists score). Preoperative laboratory testing and spirometry were performed on all patients. Algorithms for managing common preoperative issues (eg, bronchospasm, bleeding risk) were used. • Measures: A separate postoperative assessment team assessed the occurrence of explicitly defined postoperative pulmonary complications (PPCs), which included death due to all causes, death due to pulmonary causes, unanticipated intubation, refractory hypoxemia, unanticipated intensive care unit admission, and pneumonia. • Results: The study sample included 510 patients (mean age, 65.3 years; 53% men). Fourteen patients (2.7%; 95% confidence interval, 1.6%–4.6%) developed 19 PPCs, including death (3), unanticipated intensive care unit admission (5), nosocomial pneumonia (5), refractory bronchospasm (3), and reintubation (3). Compared with patients without PPCs, those with PPCs had longer anesthesia time (median, 363 versus 210 min; P < 0.001), were more likely to be current smokers (43% versus 13%; P = 0.006), and were more likely to have undergone general anesthesia (100% versus 59%; P = 0.001). Median length of stay was longer in those with PPCs (6 versus 3 days; P = 0.004), as were total hospital costs ($20,181 versus $9646; P < 0.001). • Conclusion: The overall frequency of PPCs in this cohort was low. Although we did not include a control group, our results suggest that an organized preoperative assessment in an internal medicine preoperative clinic is a practical way to care for preoperative patients and is associated with a low rate of pulmonary morbidity. This study also confirms an association between anesthesia route and duration and tobacco use and the occurrence of PPCs. Despite advances in surgical and anesthetic techniques, postoperative pulmonary complications (PPCs) remain a leading cause of hospital morbidity and mortality and contribute to prolonged hospital stay [1,2]. There is a large variation in the frequency estimates for PPCs in the available series, ranging from 2% to 70%. This likely reflects differences in patient selection and variation in the definitions of PPCs. Previous reports have identified several preand intraoperative risk factors for PPCs, including the presence of chronic lung disease, smoking, higher age, obesity, poorer general health status, operative site, longer duration of surgery, and the use of general anesthesia [3–12]. In the context of our forming an outpatient unit to assess and manage patients being considered for surgery, the 2 purposes of the current study were (1) to prospectively assess the frequency of PPCs in a cohort referred to this preoperative assessment program at the Internal Medicine Preoperative Consultation and Treatment (IMPACT) Center, and (2) to assess features associated with the development of clinically important PPCs. From the Internal Medicine Preoperative Assessment, Consultation, and Treatment Center, The Cleveland Clinic Foundation, Cleveland, OH.