The Mystery of The Mystery of Surgical Clearance Surgical Clearance Shane Hull, D.O. Edmond Pulmonology
Mar 26, 2015
The Mystery of Surgical The Mystery of Surgical ClearanceClearance
Shane Hull, D.O.Edmond Pulmonology
"It is what we think we know alreadythat often prevents us from learning."
Claude Bernard
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
To identify, stratify, and minimize post-operative and peri-operative
complications
Purpose:
Risk Factors
• Pre-operative– COPD– Age– Inhaled tobacco use– OSA– Nutritional Status– Health Status– Obesity– ETOH use
Risk Factors
• Intra-operative– Surgical site– Anesthesia– Duration of surgery– Use of paralytic– Emergency surgery
• Post-operative– Pain– Immobility– Aspiration
Evaluation
• History and Physical• Chest X-ray• PFT’s/Spirometry• Polysomnogram• Exercise testing• Chemistry• EKG• ABG
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
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
What do you do?
Chest X-ray- Reduced PPC by 3%
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
Post operative prevention
• Volume expansion therapy– Incentive spirometry– EZ-Pap/ IPPB– CPAP
• Pain control- PCA• DVT prophylaxis• Aspiration prophylaxis
Bapoje, S. R. et al. Chest 2007;132:1637-1645
Stepwise approach to preoperative pulmonary assessment
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
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