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Guideline Summary
Guideline Title
Evidence-based patient safety advisory: patient assessment and prevention of pulmonary side effects in surgery. Part 2 - patient and procedural risk factors.
Bibliographic Source(s)
Haeck PC, Swanson JA, Iverson RE, Lynch DJ, ASPS Patient Safety Committee. Evidence-based patient safety advisory: patient assessment and prevention of pulmonary side effects in surgery. Part 2--patient and procedural risk factors. Plast Reconstr Surg. 2009 Oct;124(4 Suppl):57S-67S. [63 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Pulmonary complications during surgery including pneumothorax, abdominoplasty, airway, and operative field fire injuries

Guideline Category
Evaluation
Management
Prevention
Risk Assessment
Clinical Specialty
Anesthesiology
Plastic Surgery
Surgery
Intended Users
Advanced Practice Nurses
Health Care Providers
Physician Assistants
Physicians
Guideline Objective(s)

To provide an overview of the preoperative steps that should be performed to ensure appropriate patient selection and patient safety with regard to pulmonary complications

Target Population

Patients undergoing surgery who are at risk for pulmonary complications

Interventions and Practices Considered

Assessment

  1. Patient selection
  2. Medical history
    • Cigarette smoking
    • Preexisting conditions/comorbidities
  3. Physical examination
    • Lung assessment
  4. Inform patient/family of pneumothorax risk
  5. Pulmonary function testing

Management

  1. Preoperative
    • Ensure access to Heimlich valve intracatheter or pigtail catheter
    • Ensure surgical team appraised of surgical plan
    • Drape positioning
    • Moistened towels (for laser treatment of face/neck)
    • Metal or laser-safe intubation tubes (in non-flammable packaging)
    • Supplemental oxygen
    • Separate suction tube for nitrous oxide/oxygen
    • Smoking cessation (counseling, behavioral intervention, nicotine replacement)
  2. Intraoperative
    • Assess area for thin or absent intercostal muscles
    • Use of small needles tangentially inserted into chest cavity (for local anesthesia infiltration)
    • Closing of fascia defects
    • Drainage tube procedures
    • Oxygen tank transition procedures
    • Avoidance of simultaneous use of potential oxidizers, ignition sources, and fuel sources
    • Placement of ignition sources on standby mode when not in use
  3. Postoperative
    • Chest radiograph
    • Assess breath sounds and oxygen saturation
    • Treatment of pneumothorax (Heimlich valve or insertion of chest tube)
    • Patient/family education for signs of pneumothorax
Major Outcomes Considered

Incidence of perioperative pulmonary complications

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

PubMed and the Cochrane Library were searched. The search terms used were: perioperative pulmonary complications, pulmonary complications, respiratory complications, patient selection, preoperative assessment, physical examination, medical history, predictors, risk factors, pneumothorax, abdominoplasty, surgical fires, American Society of Anesthesiologists (ASA) classification, smoking, young healthy athletic adult males. No limits were set on publication the dates in the searches. The papers include all types of published articles. However, articles that were critically appraised and rated for level of evidence were limited to systematic reviews, meta-analyses, randomized controlled trials (RCTs), clinical trials, comparative studies, case series and case reports.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Evidence Rating Scale for Studies Reviewed

Level of Evidence Qualifying Studies
I High-quality, multi-centered or single-centered, randomized controlled trial with adequate power; or a systematic review of these studies
II Lesser-quality, randomized controlled trial; prospective cohort study; or a systematic review of these studies
III Retrospective comparative study; case-control study; or a systematic review of these studies
IV Case series
V Expert opinion; case report or clinical example; or evidence based on physiology, bench research, or "first principles"
Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

Depending on study design and quality, each reference was assigned a corresponding level of evidence (I through V) with the American Society of Plastic Surgeons (ASPS) Evidence Rating Scales, and the evidence was synthesized into practice recommendations (see "Rating Scheme for the Strength of the Evidence").

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations
Grade Descriptor Qualifying Evidence Implications for Practice
A Strong Recommendation Level I evidence or consistent findings from multiple studies of levels II, III, or IV Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.
B Recommendation Levels II, III, or IV evidence and findings are generally consistent Generally, clinicians should follow a recommendation but should remain alert to new information and sensitive to patient preference.
C Option Levels II, III, or IV evidence, but findings are inconsistent Clinicians should be flexible in their decision-making regarding appropriate practice, although they may set bounds on alternatives; patient preference should have a substantial influencing role.
D Option Level V; little or no systematic empirical evidence Clinicians should consider all options in their decision-making and be alert to new published evidence that clarifies the balance of benefit versus harm; patient preference should have a substantial influencing role.
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

The guideline was approved by the American Society of Plastic Surgeons Executive Committee on January 10, 2009.

Recommendations

Major Recommendations

Definitions for the levels of evidence (I–V) and the grades of the recommendations (A–D) are provided at the end of the "Major Recommendations" field.

Recommendations Supporting Evidence Grade
Pneumothorax

Patient selection

  • Medical history should include questions about cigarette smoking and preexisting conditions such as lung diseases, pneumothorax, and presence of blebs/bullae.
  • Physical examination should include lung assessment.
  • Inform patient/family of this risk.

Weissberg & Refaely, 2000; Alifano et al., 2003

D*

Preoperative

Ensure access to a Heimlich valve intracatheter or pigtail catheter for treatment of potential tension pneumothorax.

Expert opinion

D

Intraoperative

  • The use of small needles, placed tangentially to the chest cavity, should be considered for infiltration of local anesthesia into anatomical locations adjacent to the pleural space.
  • Assess area for thin or absent intercostal muscles (leaving fascia exposed).
  • If the fascia is traumatized, close small defects with purse-string or interrupted suture over a small catheter (withdraw catheter during deep inspiration delivered by positive-pressure ventilation or with a Valsalva maneuver if performed under intravenous sedation and local anesthesia).
  • If intercostal muscles are thin or absent, insertion of a drainage tube into surgical pocket may be considered to reduce pressure and prevent air dissection into pleural cavity.
  • If a change of oxygen tank is needed during surgery, the endotracheal tube should be detached from the anesthesia machine to prevent delivery of increased air pressure to the patient.

Kaye et al., 1995; Fayman, Beeton, & Potgieter, 2005

D*

Postoperative

  • If fascia/pleura was traumatized intraoperatively, a chest radiograph may be necessary.
  • If the patient complains of shortness of breath/difficulty breathing following procedure, breath sounds and oxygen saturation should be assessed before discharge.
  • If there is a suspicion of pneumothorax, a chest radiograph should be obtained.
  • If pneumothorax occurs, follow an acceptable treatment plan (e.g., inserting chest tube or Heimlich valve).
  • Patient/family should be instructed to monitor for shortness of breath and difficulty breathing after discharge.

Kaye et al., 1995; Weissberg & Refaely, 2000

D*
Abdominoplasty
  • Pulmonary function should be assessed for entire perioperative period.
  • If the patient is at increased risk for periprocedural complications (PPCs), abdominal compression garments may not be appropriate.

Jansen et al., 1999; Al-Basti et al., 2004; Hunter et al., 1983

D*
Airway and Operative Field Fires

Preoperative

  • The surgeon, anesthesia provider, and all members of the surgical staff should be apprised of the surgical plan with respect to the use of potential oxidizers, ignition sources, and fuel sources.
  • Drapes should be positioned to prevent accumulation of oxidizers under the drapes and should not be placed on patient until flammable preparations have dried.
  • Moistened towels should be placed around the face and neck if a laser is used on the face or oral region.
  • If endotracheal intubation is necessary, the use of metal or laser-safe tubes should be considered if appropriate for the procedure, or the tube should be wrapped in a nonflammable material such as aluminum foil or moistened gauze, cotton, or sponges.
  • If supplemental oxygen is required, the lowest oxygen concentration needed to provide adequate saturation should be considered.
  • If possible, nitrous oxide anesthetics should be avoided and alternatives such as intravenous sedation and localized blocks should be considered.
  • If the use of oxygen and/or nitrous oxide is unavoidable, a separate suction tube is recommended for scavenging excess gases in the oropharynx.

Greco et al., 1995; Rohrich et al., 1997; Prasad et al., 2006; Meltzer et al., 2005; Spigelman & Swan, 2005

D*

Intraoperative

  • The surgeon, anesthesia provider, and other surgical staff should communicate effectively to avoid simultaneous use of potential oxidizers, ignition sources, and fuel sources.
  • If possible, oxygen administration should be discontinued at least 1 min before and during the use of potential ignition sources (e.g., electrocautery and electrosurgical units, lasers, and fiberoptic lights).
  • Potential ignition sources should be placed in standby mode when not in immediate use.

Greco et al., 1995; Rohrich et al., 1997; Prasad et al., 2006; Meltzer et al., 2005; Spigelman & Swan, 2005

D*
Smoking

Patient selection

  • The patient should be asked about smoking history, including number of pack-years; if the patient is not a smoker, the patient should be asked whether anyone in the household smokes.
  • The patient should be asked about comorbidities that could exacerbate the effects of smoking (e.g., airway obstruction, chronic obstructive pulmonary disease [COPD], chronic cough).

Bluman et al., 1998; Brooks-Brunn, 1997; Warner, 2005; Myles et al., 2002; Kotani et al., 2000; Nakagawa et al., 2001; Skolnick et al., 1998; Moller et al., 2002

B

Preoperative

Preoperative smoking cessation should be recommended and should depend on the patient's overall health and the surgical procedure; optimal timing of cessation has not been fully determined and varies from 24 hr before surgery to 6–8 wk before surgery.

Bluman et al., 1998; Nakagawa et al., 2001; Moller et al., 2002

B, C

The physician should discuss available options to aid in smoking cessation: counseling and behavioral interventions, nicotine replacement (i.e., gum, transdermal patch, nasal spray, inhaler, and sublingual tablets/lozenges), and drugs such as Zyban (bupropion hydrochloride) and Chantix (varenicline)

Rice & Stead, 2004, 2006; Rigotti, Munafo, & Stead, 2007; Silagy et al., 2004; Hughes, Stead, & Lancaster, 2004; Cahill, Stead, & Lancaster, 2007

A

Postoperative

Continued smoking cessation should be recommended (at least 7 days after surgery).

Expert opinion

D

*Evidence composed of level IV and V evidence.

Definitions:

Evidence Rating Scale for Therapeutic Studies

Level of Evidence Qualifying Studies
I High-quality, multi-centered or single-centered, randomized controlled trial with adequate power; or a systematic review of these studies
II Lesser-quality, randomized controlled trial; prospective cohort study; or a systematic review of these studies
III Retrospective comparative study; case-control study; or a systematic review of these studies
IV Case series
V Expert opinion; case report or clinical example; or evidence based on physiology, bench research, or "first principles"

Rating Scheme for the Strength of the Recommendations

Grade Descriptor Qualifying Evidence Implications for Practice
A Strong Recommendation Level I evidence or consistent findings from multiple studies of levels II, III, or IV Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.
B Recommendation Levels II, III, or IV evidence and findings are generally consistent Generally, clinicians should follow a recommendation but should remain alert to new information and sensitive to patient preference.
C Option Levels II, III, or IV evidence, but findings are inconsistent Clinicians should be flexible in their decision-making regarding appropriate practice, although they may set bounds on alternatives; patient preference should have a substantial influencing role.
D Option Level V; little or no systematic empirical evidence Clinicians should consider all options in their decision-making and be alert to new published evidence that clarifies the balance of benefit versus harm; patient preference should have a substantial influencing role.
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate patient selection, patient safety and prevention of pulmonary side effects in surgery

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements
  • Practice advisories are strategies for patient management, developed to assist physicians in clinical decision-making. This practice advisory, based on a thorough evaluation of the present scientific literature and relevant clinical experience, describes a range of generally acceptable approaches to diagnosis, management, or prevention of specific diseases or conditions. This practice advisory attempts to define principles of practice that should generally meet the needs of most patients in most circumstances. However, this practice advisory should not be construed as a rule, nor should it be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the appropriate results. It is anticipated that it will be necessary to approach some patients' needs in different ways. The ultimate judgment regarding the care of a particular patient must be made by the physician in light of all the circumstances presented by the patient, the diagnostic and treatment options available, and available resources.
  • This practice advisory is not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all the facts or circumstances involved in an individual case and are subject to change as scientific knowledge and technology advance, and as practice patterns evolve. This practice advisory reflects the state of knowledge current at the time of publication. Given the inevitable changes in the state of scientific information and technology, periodic review and revision will be necessary.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Staying Healthy
IOM Domain
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Haeck PC, Swanson JA, Iverson RE, Lynch DJ, ASPS Patient Safety Committee. Evidence-based patient safety advisory: patient assessment and prevention of pulmonary side effects in surgery. Part 2--patient and procedural risk factors. Plast Reconstr Surg. 2009 Oct;124(4 Suppl):57S-67S. [63 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Oct
Guideline Developer(s)
American Society of Plastic Surgeons - Medical Specialty Society
Source(s) of Funding

American Society of Plastic Surgeons

Guideline Committee

American Society of Plastic Surgeons Patient Safety Committee

Composition of Group That Authored the Guideline

Committee Members: Phillip C. Haeck, M.D. (Chairman); Stephen B. Baker, M.D., D.D.S., Georgetown University Hospital, Washington, D.C.; Charles W. Bailey, Jr., M.D., J.D., Austin, Texas; C. Bob Basu, M.D., M.P.H., Center for Advanced Breast Restoration and Basu Plastic Surgery, Houston, Texas; Lynn A. Damitz, M.D., University of North Carolina, Chapel Hill, North Carolina; Felmont F. Eaves, III, M.D., Charlotte Plastic Surgery, Charlotte, North Carolina; Paul D. Faringer, M.D., Kaiser Permanente, Honolulu, Hawaii; Scot Bradley Glasberg, M.D., Lenox Hill Hospital and Manhattan Eye Ear and Throat Hospital, New York, New York; Lawrence S. Glassman, M.D., Nyack Hospital, Nyack, New York; Karol A. Gutowski, M.D., North Shore University Health System and University of Chicago, Evanston, Illinois; Elizabeth J. Hall-Findlay, M.D., private practice, Banff, Alberta, Canada; Ronald E. Iverson, M.D., Stanford University Medical School, Palo Alto, California; Linda J. Leffel, M.D., Bend, Oregon; Dennis J. Lynch, M.D., retired, Scott and White Healthcare, Texas A&M University, Temple, Texas; Noel B. McDevitt, M.D., Pinehurst Surgical, Pinehurst, North Carolina; Michael F. McGuire, M.D., David Geffen UCLA School of Medicine, Los Angeles, California; Patrick J. O'Neill, M.D., Medical University of South Carolina, Charleston, South Carolina; Neal R. Reisman, M.D., J.D., St. Luke's Episcopal Hospital and Baylor College of Medicine, Houston, Texas; Gary F. Rogers, M.D., Children’s Hospital Boston, Boston, Massachusetts; Loren S. Schechter, M.D., Morton Grove, Illinois; Maria Siemionow, M.D., Ph.D., D.Sc., Cleveland Clinic, Cleveland, Ohio; Robert Singer, M.D., University of California, San Diego, La Jolla, California; Gary A. Smotrich, M.D., Lawrenceville Plastic Surgery, Lawrenceville, New Jersey; Rebecca S. Twersky, M.D., M.P.H., SUNY Downstate Medical Center, Brooklyn, New York; Amy G. Wandel, M.D., Mercy Medical Group, Sacramento, California; Ronald H. Wender, M.D., Cedars-Sinai Medical Center, Los Angeles, California; and James A. Yates, M.D., Grandview Surgery Center, Vista Surgery Center, Plastic Surgery Center, and Holy Spirit Hospital, Camp Hill, Pennsylvania

Financial Disclosures/Conflicts of Interest

The authors have no financial interests related to this article.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the American Society of Plastic Surgeons Web site External Web Site Policy.

Print copies: Available from the American Society of Plastic Surgeons, 444 East Algonquin Road, Arlington Heights, IL 60005-4664

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on January 16, 2010. The information was verified by the guideline developer on August 31, 2010. This summary was updated by ECRI Institute on July 15, 2011 following the U.S. Food and Drug Administration advisory on Chantix (varenicline). This summary was updated by ECRI Institute on January 14, 2013 following the revised U.S. Food and Drug Administration advisory on Chantix (varenicline).

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Copyright ©2009 by the American Society of Plastic Surgeons

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