Articles20 November 2001
    Author, Article, and Disclosure Information



    Pneumonia is a common postoperative complication associated with substantial morbidity and mortality.


    To develop and validate a preoperative risk index for predicting postoperative pneumonia.


    Prospective cohort study with outcome assessment based on chart review.


    100 Veterans Affairs Medical Centers performing major surgery.


    The risk index was developed by using data on 160 805 patients undergoing major noncardiac surgery between 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.


    Postoperative pneumonia was defined by using the Centers for Disease Control and Prevention definition of nosocomial pneumonia.


    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 points, 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.


    The postoperative pneumonia risk index identifies patients at risk for postoperative pneumonia and may be useful in guiding perioperative respiratory care.


    • 1. Brooks-Brunn JAPostoperative atelectasis and pneumonia. Heart Lung1995;24:94-115. [PMID: 7759282] CrossrefMedlineGoogle Scholar
    • 2. Garibaldi RABritt MRColeman MLReading JCPace NLRisk factors for postoperative pneumonia. Am J Med1981;70:677-80. [PMID: 7211900] CrossrefMedlineGoogle Scholar
    • 3. Craven DESteger KABarber TWPreventing nosocomial pneumonia: state of the art and perspectives for the 1990s. Am J Med1991;91:44S-53S. [PMID: 1928191] CrossrefMedlineGoogle Scholar
    • 4. Brooks-Brunn JAPredictors of postoperative pulmonary complications following abdominal surgery. Chest1997;111:564-71. [PMID: 9118688] CrossrefMedlineGoogle Scholar
    • 5. Fujita TSakurai KMultivariate analysis of risk factors for postoperative pneumonia. Am J Surg1995;169:304-7. [PMID: 7879831] CrossrefMedlineGoogle Scholar
    • 6. Mitchell CKSmoger SHPfeifer MPVogel RLPandit MKDonnelly PJet al Multivariate analysis of factors associated with postoperative pulmonary complications following general elective surgery. Arch Surg1998;133:194-8. [PMID: 9484734] CrossrefMedlineGoogle Scholar
    • 7. Dales REDionne GLeech JALunau MSchweitzer IPreoperative prediction of pulmonary complications following thoracic surgery. Chest1993;104:155-9. [PMID: 8325061] CrossrefMedlineGoogle Scholar
    • 8. Iwamoto KIchiyama SShimokata KNakashima NPostoperative pneumonia in elderly patients: incidence and mortality in comparison with younger patients. Intern Med1993;32:274-7. [PMID: 8358115] CrossrefMedlineGoogle Scholar
    • 9. McCulloch TMJensen NFGirod DATsue TTWeymuller EARisk factors for pulmonary complications in the postoperative head and neck surgery patient. Head Neck1997;19:372-7. [PMID: 9243263] CrossrefMedlineGoogle Scholar
    • 10. Wong DHWeber ECSchell MJWong ABAnderson CTBarker SJFactors associated with postoperative pulmonary complications in patients with severe chronic obstructive pulmonary disease. Anesth Analg1995;80:276-84. [PMID: 7818113] MedlineGoogle Scholar
    • 11. Calligaro KDAzurin DJDougherty MJDandora RBajgier SMSimper Set al Pulmonary risk factors of elective abdominal aortic surgery. J Vasc Surg1993;18:914-20; discussion 920-1. [PMID: 8264047] CrossrefMedlineGoogle Scholar
    • 12. Ondrula DPNelson RLPrasad MLCoyle BWAbcarian HMultifactorial index of preoperative risk factors in colon resections. Dis Colon Rectum1992;35:117-22. [PMID: 1735312] CrossrefMedlineGoogle Scholar
    • 13. Arozullah AMDaley JHenderson WGKhuri SFMultifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. The National Veterans Administration Surgical Quality Improvement Program. Ann Surg2000;232:242-53. [PMID: 10903604] CrossrefMedlineGoogle Scholar
    • 14. Kroenke KLawrence VATheroux JFTuley MRHilsenbeck SPostoperative complications after thoracic and major abdominal surgery in patients with and without obstructive lung disease. Chest1993;104:1445-51. [PMID: 8222804] CrossrefMedlineGoogle Scholar
    • 15. Brooks-Brunn JAValidation of a predictive model for postoperative pulmonary complications. Heart Lung1998;27:151-8. [PMID: 9622401] CrossrefMedlineGoogle Scholar
    • 16. Melendez JACarlon VACardiopulmonary risk index does not predict complications after thoracic surgery. Chest1998;114:69-75. [PMID: 9674449] CrossrefMedlineGoogle Scholar
    • 17. Goldman LCaldera DLNussbaum SRSouthwick FSKrogstad DMurray Bet al Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med1977;297:845-50. [PMID: 904659] CrossrefMedlineGoogle Scholar
    • 18. Smetana GWPreoperative pulmonary evaluation. N Engl J Med1999;340:937-44. [PMID: 10089188] CrossrefMedlineGoogle Scholar
    • 19. Palda VADetsky ASPerioperative assessment and management of risk from coronary artery disease. Ann Intern Med1997;127:313-28. [PMID: 9265434] LinkGoogle Scholar
    • 20. Eagle KABrundage BHChaitman BREwy GAFleisher LAHertzer NRet al Guidelines for perioperative cardiovascular evaluation for noncardiac surgery: an abridged version of the report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Mayo Clin Proc1997;72:524-31. [PMID: 9179136] CrossrefMedlineGoogle Scholar
    • 21. Khuri SFDaley JHenderson WBarbour GLowry PIrvin Get al The National Veterans Administration Surgical Risk Study: risk adjustment for the comparative assessment of the quality of surgical care. J Am Coll Surg1995;180:519-31. [PMID: 7749526] MedlineGoogle Scholar
    • 22. Khuri SFDaley JHenderson WHur KGibbs JOBarbour Get al Risk adjustment of the postoperative mortality rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study. J Am Coll Surg1997;185:315-27. [PMID: 9328380] MedlineGoogle Scholar
    • 23. Daley JKhuri SFHenderson WHur KGibbs JOBarbour Get al Risk adjustment of the postoperative morbidity rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study. J Am Coll Surg1997;185:328-40. [PMID: 9328381] MedlineGoogle Scholar
    • 24. Garner JSJarvis WREmori TGHoran TCHughes JMCDC definitions for nosocomial infections, 1988. Am J Infect Control1988;16:128-40. [PMID: 2841893] CrossrefMedlineGoogle Scholar
    • 25. Stata User's GuideStata Statistical Software: Release 7.0. College Station, TX: Stata Pr 2001. Google Scholar
    • 26. Le Gall JRLemeshow SSaulnier FA new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA1993;270:2957-63. [PMID: 8254858] CrossrefMedlineGoogle Scholar
    • 27. Hosmer DWLemeshow SApplied Logistic Regression. New York: Wiley; 1989. Google Scholar
    • 28. Harrell FELee KLMatchar DBReichert TARegression models for prognostic prediction: advantages, problems, and suggested solutions. Cancer Treat Rep1985;69:1071-7. [PMID: 4042087] MedlineGoogle Scholar
    • 29. Lawrence VADhanda RHilsenbeck SGPage CPRisk of pulmonary complications after elective abdominal surgery. Chest1996;110:744-50. [PMID: 8797421] CrossrefMedlineGoogle Scholar
    • 30. Dal Nogare ARNosocomial pneumonia in the medical and surgical patient. Risk factors and primary management. Med Clin North Am1994;78:1081-90. [PMID: 8078370] CrossrefMedlineGoogle Scholar
    • 31. Chumillas SPonce JLDelgado FViciano VMateu MPrevention of postoperative pulmonary complications through respiratory rehabilitation: a controlled clinical study. Arch Phys Med Rehabil1998;79:5-9. [PMID: 9440408] CrossrefMedlineGoogle Scholar
    • 32. Guidelines for prevention of nosocomial pneumonia. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep1997;46:1-79. [PMID: 9036304] MedlineGoogle Scholar
    • 33. Delgado-Rodríguez MMedina-Cuadros MMartínez-Gallego GSillero-Arenas MUsefulness of intrinsic surgical wound infection risk indices as predictors of postoperative pneumonia risk. J Hosp Infect1997;35:269-76. [PMID: 9152819] CrossrefMedlineGoogle Scholar