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