This document discusses the development and validation of a multifactorial risk index to predict the risk of postoperative pneumonia in patients undergoing major noncardiac surgery. It describes defining postoperative pneumonia as new radiographic lung findings accompanied by changes in sputum, a positive blood culture, or isolation of a pathogen from respiratory samples. Risk factors identified for the index included age, functional status, weight loss, COPD, anesthesia type, impaired sensorium, steroid use, smoking, and medical history. The risk index stratified patients into five classes from lowest to highest risk of developing postoperative pneumonia.

1. Pulmonary complications risk:
Pneumonia,respiratory
insufficiency….

2. • Risk Assessment for and Strategies To Reduce
Perioperative Pulmonary Complications for Patients
Undergoing Noncardiothoracic Surgery: A Guideline
from the American College of Physicians
• Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Nick Fitterman, Annals of Internal medicine 18 April 2006 | Volume
144 Issue 8 | Pages 575-580

3. Relazione fra ASA PS e complicanze
polmonari

4. Strategie tese alla riduzione delle complicanze postop
• Lawrence VA, Cornell JE, Smetana GW. Strategies to reduce postoperative pulmonary
complications after noncardiothoracic surgery: systematic review for the American
College of Physicians. Ann Intern Med. 2005;144:596-608.
• Tutte le tecniche di espansione polmonare :
– spirometria incentiva
– terapia fisica
– provocazione della tosse
– drenaggio posturale
– percussione e vibrazione
– Aspirazione
– Deambulazione
– IPPB
– CPAP
• hanno dimostrato superiorità rispetto ai controlli dopo chirurgia
addominale.
• Non differenze fra le diverse modalità di espansione ,né dalla loro
combinazione.

5. decompressione nasogastrica selettiva
• effettuata nei pazienti con PONV ,incapaci di assumere nutrizione orale o con
distensione addominale
– diminuisce la frequenza di polmonite ed atelettasia
nei confronti della decompressione con sondino
routinaria ,finche cioè non ritorni la motilità
gastrointestinale.
– 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.
– Nelson R, Tse B, Edwards S. Systematic review of prophylactic nasogastric
decompression after abdominal operations. Br J Surg. 2005;92:673-80.
– Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after
abdominal surgery. Cochrane Database Syst Rev. 2005.

6. Pneumonia risk

7. Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac
Surgery Ahsan M. Arozullah, MD, MPH; Shukri F. Khuri, MD;
William G. Henderson, PhD; and Jennifer Daley, MDAnn Intern
Med. 2001;135:847-857
• Background: Pneumonia is a common postoperative complication associated with substantial morbidity and mortality.
• Objective: To develop and validate a preoperative risk index for predicting postoperative pneumonia.
• Design: Prospective cohort study with outcome assessment based on chart review.
• Setting: 100 Veterans Affairs Medical Centers performing major surgery.
• Patients: The risk index was developed by using data on 160 805 patients undergoing major noncardiac surgery bet ween 1
September 1997 and 31 August 1999 and was validated by using data on 155 266 patients undergoing surgery between 1
September 1995 and 31 August 1997. Patients with preoperative pneumonia, ventilator dependence, and pneumonia that
developed after postoperative respiratory failure were excluded.
• Measurements: Postoperative pneumonia was defined by using the Centers for Disease Control and Prevention definition
of nosocomial pneumonia.
• Results: A total of 2466 patients (1.5%) developed pneumonia, and the 30-day postoperative mortality rate was 21%. A
postoperative pneumonia risk index was developed that included type of surgery (abdominal aortic aneurysm repair,
thoracic, upper abdominal, neck, vascular, and neurosurgery), age, functional status, weight loss, chronic obstructive
pulmonary disease, general anesthesia,
• impaired sensorium, cerebral vascular accident, blood urea nitrogen level, transfusion, emergency surgery, long-term
steroid use, smoking, and alcohol use. Patients were divided into five risk classes by using risk index scores. Pneumonia
rates were 0.2% among those with 0 to 15 risk points, 1.2% for those with 16 to 25 risk points, 4.0% for those with 26 to 40
risk points, 9.4% for those with 41 to 55 risk oints, and 15.3% for those with more than 55 risk points. The C-statistic was
0.805 for the development cohort and 0.817 for the validation cohort.
• Conclusions: The postoperative pneumonia risk index identifies patients at risk for postoperative neumonia and may be
useful in guiding perioperative respiratory care.

8. Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M. Arozullah, MD,
MPH; Shukri F. Khuri, MD; William G. Henderson, PhD; and Jennifer Daley, MDAnn Intern Med.
2001;135:847-857
Risk of postop
pneumonia

9. Risk factors for postop pneumonia
Development and Validation of a Multifactorial Risk Index for Predicting Postoperative Pneumonia after Major
Noncardiac Surgery Ahsan M. Arozullah, MD, MPH; Shukri F. Khuri, MD; William G. Henderson, PhD; and Jennifer
Daley, MDAnn Intern Med. 2001;135:847-857
• Long-term steroid use
• Age older than 60 years
• dependent functional status,
• weight loss greater than 10% of body mass in the previous 6
months
• recent alcohol use.
• Recent smoking
• history of chronic obstructive pulmonary disease
• history of cerebral vascular accident with a residual
• deficit
• impaired sensorium.

10. Fattori di rischio per la polmonite postop:paziente
Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M. Arozullah, MD, MPH;
Shukri F. Khuri, MD; William G. Henderson, PhD; and Jennifer Daley, MDAnn Intern Med. 2001;135:847-857
• Somministrazione di steroidi a lungo termine
• Età>60 anni
• Stato funzionale dipendente
• Perdita di peso > 10% della massa coroorea nei 6 mesi
precedenti
• uso recente di alcohol
• Fumo recente
• Storia di COPD
• Storia di accidente cerebrovascolare con deficit residuo.
• Disturbo di coscienza

11. Fattori di rischio per la polmonite postop:interventi
Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M. Arozullah, MD, MPH;
Shukri F. Khuri, MD; William G. Henderson, PhD; and Jennifer Daley, MDAnn Intern Med. 2001;135:847-
857
• abdominal aortic aneurysm repair
• thoracic,
• neck,
• upper abdominal
• peripheral vascular surgery
• neurosurgery

12. Am J Respir Crit Care Med. 2005 Mar 1;171(5):514-7. Incidence of
and risk factors for pulmonary complications after nonthoracic
surgery.McAlister FA, Bertsch K, Man J, Bradley J, Jacka M
• Identifica come fattori di rischio:
– l’età>65 anni
– il fumo(> 40 pacchetti/anno)
– la diminuzione del FEV1
– Diminuzione del FVC e del FEV1/FVC
– la durata dell’anestesia >2.5 hr
– storia di COPD
– tosse produttiva giornaliera
– incisione nell’addome sup
– presenza di un SNG.
• Solo 4 sono indipendenti dopo una analisi
multivariata: età,test alla tosse
positivo,presenza periop del SNG e la
durata dell’anestesia.

13. a preoperative risk index for
predicting postoperative respiratory
failure (PRF).

14. Ahsan M. Arozullah, Jennifer Daley, William G. Henderson, Shukri F. Khuri, for the National
Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting
Postoperative Respiratory Failure in Men After Major Noncardiac Surgery. ANNALS
OF SURGERY Vol. 232, No. 2, 242–253
• Objective
• To develop and validate a preoperative risk index for
predicting postoperative respiratory failure (PRF).
• prospective cohort study
• 44 Veterans Affairs Medical Centers (n 5 81,719) were used to
develop the models. Cases from 132 Veterans Affairs Medical
Centers (n 5 99,390) were used as a validation sample.
• PRF was defined as mechanical ventilation for more than 48
hours after surgery or reintubation and mechanical
ventilation after postoperative extubation.
• Ventilator-dependent, comatose, do not,resuscitate, and
female patients were excluded.
• respiratory care.

15. Multifactorial Risk Index for Predicting Postoperative
Respiratory Failure in Men After Major Noncardiac
Surgery Ahsan M. Arozullah, Jennifer Daley, William G. Henderson, Shukri F. Khuri, for the National Veterans Administration Surgical
Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac
Surgery. ANNALS OF SURGERY Vol. 232, No. 2, 242–253
• Results
• PRF developed in 2,746 patients (3.4%).
• The respiratory failure risk index was developed from a simplified logistic
regression model and included:
– abdominal aortic aneurysm repair,
– thoracic surgery,
– neurosurgery,
– upper abdominal surgery,
– Peripheral vascular surgery,
– neck surgery
– emergency surgery,
– albumin level l< than 30 g/L,
– blood urea nitrogen level >than 30 mg/dL,
– dependent functional status,
– chronic obstructive pulmonary disease,
– age>60

16. Indici prognostici di insuff resp postop: Ahsan M. Arozullah,
MD, MPH,* Jennifer Daley, MD,† William G. Henderson, PhD,‡ and Shukri F. Khuri, MD,§ for the
National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for
Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery. ANNALS OF
SURGERY Vol. 232, No. 2, 242–253
– Aneurismectomia aorta addominale,
– Chir toracica
– neurochir,
– Chir addominale maggiore
– Chir vascolare periferica
– Chir del collo
– Chir in emergenza ,
– Livelli di albumina < 30 g/L,
– BUN > 30 mg/dL,
– Dipendenza funzionale,
– COPD (chronic obstructive pulmonary disease)
– Età >60

17. Probability of PRF, postoperative resp failure
Ahsan M. Arozullah, MD, MPH,* Jennifer Daley, MD,† William G. Henderson, PhD,‡ and Shukri F. Khuri, MD,§ for the National Veterans Administration
Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac
Surgery. ANNALS OF SURGERY Vol. 232, No. 2, 242–253
• Classe punti probab PRF
• 1 <=10 0.5%
• 2 11–19 2.2%-1.8%
• 3 20–27 5.3%- 4.2%
• 4 28–40 10%-11.9%
• 5 . >40 30.9% -26.6%

18. A comparison of risk factors for postoperative pneumonia and respiratory failure
Ahsan M. Arozullah, MD, MPH,* Jennifer Daley, MD,† William G. Henderson, PhD,‡ and Shukri F. Khuri, MD,§ for the National Veterans Administration Surgical
Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery. ANNALS OF
SURGERY Vol. 232, No. 2, 242–253
&
Ahsan M. Arozullah, MD, MPH; Shukri F. Khuri, MD; William G. Henderson, PhD; and Jennifer Daley, MD.Development and Validation of a Multifactorial Risk
Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ann Intern Med. 2001;135:847-857

19. FINE
Segue lavori in dettaglio….

20. Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac
Surgery Ahsan M. Arozullah, MD, MPH; Shukri F. Khuri, MD;
William G. Henderson, PhD; and Jennifer Daley, MDAnn Intern
Med. 2001;135:847-857 • Postoperative pulmonary complications are associated
• with substantial morbidity and mortality. It has
• been estimated that nearly one fourth of deaths occurring
• within 6 days of surgery are related to postoperative
• pulmonary complications (1). Postoperative infections
• are also a major source of the morbidity and mortality
• associated with undergoing surgery. Pneumonia is the
• most serious postoperative complication that is included
• in both of these categories. Pneumonia ranks as the
• third most common postoperative infection, behind urinary
• tract and wound infection (2). According to the
• National Nosocomial Infection Surveillance system,
• pneumonia occurred in 18% of patients after surgery
• (3). Postoperative pneumonia occurs in 9% to 40% of
• patients, and the associated mortality rate is 30% to
• 46%, depending on the type of surgery (1, 4).
• Previous studies of risk factors used various definitions
• of postoperative pulmonary complications. Atelectasis
• (1, 4–7), postoperative pneumonia (1–2, 4–6,
• 8–11), the acute respiratory distress syndrome (9, 12),
• and postoperative respiratory failure (6, 9, 11, 13) have
• been classified as postoperative pulmonary complications.
• Although the clinical significance of each of these
• complications varies greatly, they were grouped together
• as a single outcome in previous studies (6). Some studies
• were limited to examination of risk factors in patients
• undergoing abdominal or thoracic procedures or in patients
• with specific medical conditions, such as chronic
• obstructive pulmonary disease (2, 4, 6, 10–12, 14).
• These studies were often based on a small sample from
• one institution, and studies of independent samples did
• not validate their findings (15, 16

21. Table 1. Definition of Postoperative
PneumoniaDevelopment and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M. Arozullah, MD, MPH;
Shukri F. Khuri, MD; William G. Henderson, PhD; and Jennifer Daley, MDAnn Intern Med. 2001;135:847-857
• Patient met one of the following two criteria postoperatively:
• 1. Rales or dullness to percussion on physical examination of chest AND
any of the following:
• New onset of purulent sputum or change in character of sputum
• Isolation of organism from blood culture
• Isolation of pathogen from specimen obtained by transtracheal aspirate,
bronchial brushing, or biopsy
• 2. Chest radiography showing new or progressive infiltrate, consolidation,
cavitation, or pleural effusion AND any of the following:
• New onset of purulent sputum or change in character of sputum.
• Isolation of organism from blood culture.
• Isolation of pathogen from specimen obtained by transtracheal aspirate,
bronchial brushing, or biopsy
• Isolation of virus or detection of viral antigen in respiratory secretions
• Diagnostic single antibody titer (IgM) or fourfold increase in paired serum
samples (IgG) for pathogen
• Histopathologic evidence of pneumonia

23. Postoperative pneumonia risk
indexDevelopment and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M. Arozullah, MD, MPH;
Shukri F. Khuri, MD; William G. Henderson, PhD; and Jennifer Daley, MDAnn Intern Med. 2001;135:847-857

24. Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan
M. Arozullah, MD, MPH; Shukri F. Khuri, MD; William G. Henderson, PhD;
and Jennifer Daley, MDAnn Intern Med. 2001;135:847-857
• DISCUSSION
• Our results confirm several previously described risk
• factors for postoperative pneumonia, including the type
• of surgery performed. The patient-specific risk factors
• were related to general health and immune status, respiratory
• status, neurologic status, and fluid status. These
• risk factors were used to develop a preoperative risk assessment
• model for predicting postoperative pneumonia,
• the postoperative pneumonia risk index.
• We found that patients undergoing abdominal aortic
• aneurysm repair; thoracic, neck, upper abdominal, or
• peripheral vascular surgery; or neurosurgery had an increased
• likelihood of developing postoperative pneumonia.
• Previous studies focused on the increased incidence
• of postoperative pulmonary complications in patients
• undergoing these types of surgery (2, 4, 5, 8, 9, 11, 12,
• 14, 29). Impairment of normal swallowing and respiratory
• clearance mechanisms may be responsible for some
• of the increased risk in these patients.

25. Patient specific risk factor for postop pneumonia
Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M. Arozullah, MD, MPH; Shukri F.
Khuri, MD; William G. Henderson, PhD; and Jennifer Daley, MDAnn Intern Med. 2001;135:847-857
• Long-term steroid use (30)
• Age older than 60 years (2, 4, 5, 11, 12)
• dependent functional status,
• weight loss greater than 10% of body mass in the previous 6 months
• recent alcohol use.
• Further studies are needed to assess the effect of interventions, such as preoperative
optimization of nutritional status and perioperative physical therapy, in reducing the
incidence of postoperative pneumonia.
• Our definition of current smoking included patients who smoked up to 1 year before surgery.
Before 1995, the NSQIP definition for “current smoking” was smoking in the 2 weeks before
surgery. Using this definitio n,we found that smoking was not significantly associated with
postoperative mortality or overall morbidity (22, 23). On closer examination, it appeared that
sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore
being classified as nonsmokers. To capture the effect of recent smoking, the NSQIP definition
was modified in September 1995 to include patients who smoked up to 1 year before
surgery.

26. Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery
Ahsan M. Arozullah, MD, MPH; Shukri F. Khuri, MD; William G.
Henderson, PhD; and Jennifer Daley, MDAnn Intern Med. 2001;135:847-857
• Recent smoking and history of chronic obstructive
• pulmonary disease were previously found to be pulmonary
• risk factors for postoperative pneumonia (2, 4,
• 9–12, 14). Chumillas and colleagues (31) found that
• preoperative and postoperative respiratory rehabilitation
• protected against postoperative pulmonary complications
• in moderate-risk and high-risk patients undergoing
• upper abdominal surgery. Use of an incentive spirometer
• or intermittent positive-pressure breathing and control
• of pain that interferes with coughing and deep
• breathing have been recommended for preventing postoperative
• pneumonia in high-risk patients (32).

27. Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery
Ahsan M. Arozullah, MD, MPH; Shukri F. Khuri, MD; William G.
Henderson, PhD; and Jennifer Daley, MDAnn Intern Med. 2001;135:847-
857 • We found two risk factors related to neurologic status:
• history of cerebral vascular accident with a residual
• deficit and impaired sensorium. Previously identified
• neurologic risk factors for postoperative pneumonia
included
• impaired cognitive function (4). These risk factors
• are often associated with a decreased ability to protect
• one’s airway and may increase the risk for
• aspiration. Other risk factors related to aspiration in
previous
• studies included the use of nasogastric tubes and
• H2 receptor antagonists (6).

28. •APPENDIX: DEFINITIONS OF RISK FACTORS IN THE
POSTOPERATIVE PNEUMONIA RISK INDEX
Type of Surgery Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M. Arozullah, MD, MPH; Shukri F. Khuri,
MD; William G. Henderson, PhD; and Jennifer Daley, MDAnn Intern Med. 2001;135:847-857
• Abdominal aortic aneurysm repair: Surgeries to repair ruptured or unruptured aortic
aneurysm involving only abdominal incisions.
• Neck surgery: Surgeries related to the thyroid, parathyroid,and larynx; tracheostomy; cervical
and axillary lymph node excision; and cervical and axillary lymphadenectomy.
• Neurosurgery: Application of a halo, central nervous system injection, central nervous system
drainage, creation of a bur hole,craniectomy, craniotomy, arteriovenous malformation or
aneurysm repair, stereotaxis, neurostimulator placement, skull repair, and cerebral spinal
fluid shunt.
• Thoracic surgery: Esophageal resection, esophageal repair, mediastinoscopy, pleural biopsy,
pneumocentesis, chest wall excision, incision and drainage of neck and thorax, excision of
neck and thorax, repair of fractured ribs, diaphragmatic hernia repair, bronchoscopy,
catheterization of trachea, trachea repair, thoracotomy, pericardium, pacemaker placement,
heart wound repair, valve repair, thoracic or abdominothoracic aortic aneurysm repair,
• and pulmonary artery procedures.
• Upper abdominal surgery: Gastrectomy; vagotomy; intestinal surgery; partial hepatectomy;
subfascial abdominal excision; splenectomy; excision of abdominal masses; laparoscopic
appendectomy and cholecystectomy; shunt insertion; ventral, umbilical and spigelian hernia
repair; and liver, gallbladder, and pancreas surgery.
• Vascular surgery: Any surgery related to the arteries or veins except central nervous
system aneurysm or abdominal aortic aneurysm repair

29. APPENDIX: DEFINITIONS OF RISK FACTORS IN THE
POSTOPERATIVE PNEUMONIA RISK INDEX:
Functional StatusDevelopment and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M. Arozullah, MD, MPH; Shukri F. Khuri,
MD; William G. Henderson, PhD; and Jennifer Daley, MDAnn Intern Med. 2001;135:847-857
• Functional status: The level of self-care demonstrated by the patient on
admission to the hospital, reflecting his or her prehospitalization
functional status.
• Totally dependent: The patient cannot perform any activities of daily living
for himself or herself; includes patients who are totally dependent on
nursing care, such as a dependent nursing home patient.
• Partially dependent: The patient requires use of equipment or devices plus
assistance from another person for some activities of daily living. Patients
admitted from a nursing home setting who are not totally dependent
would fall into this category, as would any patient who requires kidney
dialysis or home ventilator support yet maintains some independent
function.
• Independent: The patient is independent in activities of daily living;
ncludes those who are able to function independently with a prosthesis,
equipment, or devices.

30. APPENDIX: DEFINITIONS OF RISK FACTORS IN THE
POSTOPERATIVE PNEUMONIA RISK INDEX:
Other…..
Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M. Arozullah, MD, MPH; Shukri F. Khuri,
MD; William G. Henderson, PhD; and Jennifer Daley, MDAnn Intern Med. 2001;135:847-857
• History of chronic obstructive pulmonary disease: The patient has chronic obstructive
pulmonary disease resulting in functional disability, hospitalization in the past to treat
chronic obstructive pulmonary disease, need for bronchodilator therapy with oral or
inhaled agents, or FEV1 of less than 75% of predicted value.
• Patients excluded from this category were those in whom the only pulmonary disease was
acute asthma, an acute and chronic inflammatory disease of the airways resulting in
bronchospasm.
• History of cerebrovascular accident: The patient has a history of cerebrovascular accident
(embolic, thrombotic, or hemorrhagic) with persistent motor, sensory, or cognitive
dysfunction.
• Impaired sensorium: The patient is acutely confused or delirious and responds to verbal or
mild tactile stimulation; patient with mental status changes or delirium in the context of
the current illness. Patients with chronic mental status changes secondary to chronic
mental illness or chronic dementing llnesses were excluded from this category.
• Steroid use for chronic condition: The patient has required the regular administration of
parenteral or oral corticosteroid medication in the month before admission. Patients using
only topical, rectal, or inhalational corticosteroids were excluded from this category.

31. Ahsan M. Arozullah, MD, MPH,* Jennifer Daley, MD,† William G. Henderson, PhD,‡ and Shukri F. Khuri, MD,§ for the National Veterans
Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After
Major Noncardiac Surgery. ANNALS OF SURGERY Vol. 232, No. 2, 242–253

32. Ahsan M. Arozullah, MD, MPH,* Jennifer Daley, MD,† William G. Henderson, PhD,‡ and Shukri F. Khuri, MD,§ for the National Veterans
Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After
Major Noncardiac Surgery. ANNALS OF SURGERY Vol. 232, No. 2, 242–253

33. Ahsan M. Arozullah, MD, MPH,* Jennifer Daley, MD,† William G. Henderson, PhD,‡ and Shukri F.
Khuri, MD,§ for the National Veterans Administration Surgical Quality Improvement Program
Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major
Noncardiac Surgery. ANNALS OF SURGERY Vol. 232, No. 2, 242–253
• The most common postoperative complications in phase I were
postoperative pneumonia (3.6%), urinary tract infection (3.5%), and
respiratory failure (3.4%). Notably, two of the top three postoperative
complications were pulmonary complications.
• The 30-day death rate for patients with PRF was 27% versus 1% for
patients without PRF.
• In contrast, cardiac arrest requiring cardiopulmonary resuscitation
occurred in 1.5% of total patients; myocardial infarction occurred in only
0.7% of patients.
• Thirty-seven percent of patients with PRF had the inability to be
extubated, 29% had unplanned intubation, and 34% had both.
• For all three groups, the most commonly associated postoperative
complications were pneumonia, pulmonary edema, systemic sepsis, and
cardiac arrest.
• The 30-day death rate was 31% for reintubation patients and 23% for
patients with the inability to be extubated.

34. Ahsan M. Arozullah, MD, MPH,* Jennifer Daley, MD,† William G. Henderson, PhD,‡ and Shukri F.
Khuri, MD,§ for the National Veterans Administration Surgical Quality Improvement Program
Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major
Noncardiac Surgery. ANNALS OF SURGERY Vol. 232, No. 2, 242–253
• Despite these limitations, the respiratory failure risk index may be helpful to
clinicians and researchers in targeting perioperative testing and respiratory care to
high-risk patients.
• Prior studies have been limited to patients undergoing specific types of
operations2–7,9,10 or patients with particular risk factors.1,10
• The respiratory failure risk index is unique in that it includes several patient-specific
and operation- specific risk factors simultaneously, allowing for an
accurate assessment of the preoperative risk of PRF associated with each
individual risk factor.
• We found that the type of surgery performed has the highest associated risk for
developing PRF and that the major patient-specific risk factors are related to
general health status, renal and fluid status, and respiratory status.
• We hope that an increased awareness of the importance of postoperative
pulmonary complications will develop through the clinical use of the respiratory
failure risk index. We also hope that by using the models developed in this study,
researchers will be able to evaluate future interventions aimed at reducing the
rate of PRF.