the mystery of surgical clearance shane hull, d.o. edmond pulmonology
TRANSCRIPT
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The Mystery of Surgical The Mystery of Surgical ClearanceClearance
Shane Hull, D.O.Edmond Pulmonology
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"It is what we think we know alreadythat often prevents us from learning."
Claude Bernard
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ObjectivesObjectives• Define the purpose of the pre-
operative assessement• List the major risk factors for post-
operative complications• Review some strategies for
postoperative risk reduction
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To identify, stratify, and minimize post-operative and peri-operative
complications
Purpose:
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Risk Factors
• Pre-operative– COPD– Age– Inhaled tobacco use– OSA– Nutritional Status– Health Status– Obesity– ETOH use
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Risk Factors
• Intra-operative– Surgical site– Anesthesia– Duration of surgery– Use of paralytic– Emergency surgery
• Post-operative– Pain– Immobility– Aspiration
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Evaluation
• History and Physical• Chest X-ray• PFT’s/Spirometry• Polysomnogram• Exercise testing• Chemistry• EKG• ABG
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Class DefinitionRates of PPCs
by Class, %
I A normally healthy patient 1.2
II A patient with mild systemic disease 5.4
IIIA patient with severe systemic disease that is not
incapacitating 11.4
IVA patient with an incapacitating systemic disease that is
a constant threat to life 10.9
VA moribund patient who is not expected to survive for 24
h with or without operation NA
VIA declared brain-dead patient whose organs are being
removed for donor purposes NA
ASA Physical Status Classification
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Case
• 57 y/o female presents for pre-operative pulmonary evaluation for right total hip replacement– OSA – noncompliant– 32 pack years– Arthritis of right hip– DM– Morbid Obesity – BMI 40.4 Kg/m2
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What do you do?
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Chest X-ray- Reduced PPC by 3%
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Fletcher CM, Peto R. BMJ. 1977;1:1645-1648.
Smoked regularly and
susceptible to effects of smoke
Never smoked or not susceptible to smoke
Stopped smoking at 45 (mild COPD)
Stopped smoking at 65 (severe COPD)
Disability
Death
FEV 1 (%
of v
alue
at a
ge 2
5)
25
50
75
100
0
Age (years)25 50 75
COPD Risk and Smoking Cessation
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Post operative prevention
• Volume expansion therapy– Incentive spirometry– EZ-Pap/ IPPB– CPAP
• Pain control- PCA• DVT prophylaxis• Aspiration prophylaxis
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Bapoje, S. R. et al. Chest 2007;132:1637-1645
Stepwise approach to preoperative pulmonary assessment
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Summary
• Inform patient of pulmonary risk– Assess post-op pulmonary function
• Optimize medical therapy• Smoking Cessation• Pre-operative incentive spirometry• DVT prophylaxis• Aspiration prophylaxis• Early mobilization
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References
• Smetana, G.W. Preoperative Pulmonary Evaluation: Identifying and reducing risks for pulmonary complications. Clev Clin J Med 2006; 73:536-41.
• Bapoje SR, Whitaker JF, Chu ES. Preoperative evaluation of the Patient with pulmonary disease. Chest 2007; 132:1637-45
• Khan MA, Hussain SF. Pre-operative pulmonary evaluation. J Ayub Med Coll 2005; 17