Risk Stratification for CABG Patients with Recent Pneumonia
Patients with recent pneumonia should delay elective CABG for at least 5-7 days after resolution of symptoms and completion of appropriate antibiotic therapy to reduce perioperative morbidity and mortality.
Preoperative Assessment
Timing of Surgery
- For patients with recent pneumonia, elective CABG should be delayed until the patient has completed appropriate antibiotic therapy and symptoms have resolved 1
- Emergency CABG should only be performed in patients with recent pneumonia if there is ongoing ischemia, threatened coronary occlusion with substantial myocardium at risk, or hemodynamic compromise 1
Risk Factors to Evaluate
- Assess for high-risk features including age >65 years, left main coronary stenosis, peripheral artery disease, history of cerebrovascular disease, hypertension, smoking, and diabetes mellitus 1
- Evaluate renal function, as preoperative renal dysfunction increases risk of complications; consider delaying surgery after coronary angiography to assess the effect of contrast on renal function 1
- Screen for methicillin-resistant Staphylococcus aureus colonization to guide appropriate antibiotic prophylaxis 1
Perioperative Management
Infection Control
- Administer appropriate preoperative antibiotics to all patients to reduce the risk of postoperative infection 1
- Use first- or second-generation cephalosporins for standard prophylaxis in patients without MRSA colonization 1
- Consider vancomycin alone or in combination with other antibiotics for patients with proven or suspected MRSA colonization 1
Respiratory Management
- Implement lung-protective ventilation strategies during surgery to reduce the risk of postoperative pneumonia 2
- Target early extubation (less than 6 hours post-surgery) when clinically appropriate to reduce pneumonia risk 2
- Avoid routine postoperative bronchodilator therapy as it has been associated with higher odds of pneumonia 2
Cardiovascular Management
- Administer beta-blockers for at least 24 hours before CABG and reinstitute as soon as possible postoperatively to reduce the risk of postoperative atrial fibrillation 1
- Maintain strict glucose control with target blood glucose ≤180 mg/dL to reduce complications 3
- Consider intra-aortic balloon pump insertion for high-risk patients (reoperation, LVEF <30%, or left main CAD) 1
Postoperative Care
Monitoring
- Implement continuous electrocardiographic monitoring for at least 48 hours after CABG to detect arrhythmias 3
- Measure biomarkers of myonecrosis (creatine kinase-MB, troponin) in the first 24 hours after CABG 1
- Monitor for signs of recurrent pneumonia or respiratory complications 4
Interventions
- Implement progressive ambulation protocols as early as possible to significantly reduce the risk of postoperative pneumonia 2
- Continue appropriate antibiotic therapy if the patient had pneumonia preoperatively 1
- Maintain aggressive blood conservation strategies to limit hemodilutional anemia and reduce the need for red blood cell transfusions, as transfusions increase pneumonia risk 5
Seasonal Considerations
- Consider influenza vaccination status, especially during fall and winter months when patients undergoing CABG have significantly increased risk of postoperative pneumonia (adjusted odds ratio = 1.15) 6
- Evaluate for increased risk of specific pathogens during winter months, including influenza, Haemophilus influenzae, and Streptococcus pneumoniae 6
Special Considerations
- Be aware that some routine features in post-CABG patients may mimic CDC criteria for pneumonia diagnosis (loss of consciousness, tachypnea, dyspnea, PaO2 < 60 mm Hg, PaO2/FiO2 < 240, and local infiltration in first 24 hours), potentially leading to over-diagnosis 4
- Consider a preoperative risk model that includes 17 variables to estimate individual patient risk of postoperative pneumonia 7
- For patients requiring urgent CABG who recently had pneumonia, carefully weigh the risks of delaying surgery against the risks of proceeding with active infection 1