The Mystery of
Surgical Clearance
Shane Hull, D.O.
Edmond Pulmonology
"It is what we think we know already
that often prevents us from learning."
Claude Bernard
Objectives
• Define the purpose of the preoperative assessement
• List the major risk factors for postoperative complications
• Review some strategies for
postoperative risk reduction
Purpose:
To identify, stratify, and minimize
post-operative and peri-operative
complications
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
ASA Physical Status Classification
Class
Definition
Rates of PPCs
by Class, %
I
A normally healthy patient
1.2
II
A patient with mild systemic disease
5.4
III
A patient with severe systemic disease that is not
incapacitating
11.4
IV
A patient with an incapacitating systemic disease that is
a constant threat to life
10.9
V
A moribund patient who is not expected to survive for 24
h with or without operation
NA
VI
A declared brain-dead patient whose organs are being
removed for donor purposes
NA
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%
COPD Risk and Smoking
Cessation
FEV1 (% of value at age 25)
100
Never smoked
or not
susceptible to
smoke
75
Smoked
regularly and
susceptible to
effects of smoke
50
Stopped
smoking at
45 (mild
COPD)
Disability
25
Death
0
25
Fletcher CM, Peto R. BMJ. 1977;1:1645-1648.
50
Age (years)
75
Stopped
smoking at
65 (severe
COPD)
Post operative prevention
• Volume expansion therapy
– Incentive spirometry
– EZ-Pap/ IPPB
– CPAP
• Pain control- PCA
• DVT prophylaxis
• Aspiration prophylaxis
Stepwise approach to preoperative pulmonary assessment
Bapoje, S. R. et al. Chest 2007;132:1637-1645
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