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The Mystery of Surgical Clearance Shane Hull, D.O. Edmond Pulmonology.

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Presentation on theme: "The Mystery of Surgical Clearance Shane Hull, D.O. Edmond Pulmonology."— Presentation transcript:

1 The Mystery of Surgical Clearance Shane Hull, D.O. Edmond Pulmonology

2 "It is what we think we know already that often prevents us from learning." Claude Bernard


4 Objectives Define the purpose of the pre- operative assessement List the major risk factors for post- operative complications Review some strategies for postoperative risk reduction


6 To identify, stratify, and minimize post-operative and peri-operative complications Purpose:

7 Risk Factors Pre-operative – COPD – Age – Inhaled tobacco use – OSA – Nutritional Status – Health Status – Obesity – ETOH use

8 Risk Factors Intra-operative – Surgical site – Anesthesia – Duration of surgery – Use of paralytic – Emergency surgery Post-operative – Pain – Immobility – Aspiration

9 Evaluation History and Physical Chest X-ray PFTs/Spirometry Polysomnogram Exercise testing Chemistry EKG ABG




13 ClassDefinition Rates of PPCs by Class, % IA normally healthy patient1.2 IIA patient with mild systemic disease5.4 III A patient with severe systemic disease that is not incapacitating11.4 IV A patient with an incapacitating systemic disease that is a constant threat to life10.9 V A moribund patient who is not expected to survive for 24 h with or without operationNA VI A declared brain-dead patient whose organs are being removed for donor purposesNA ASA Physical Status Classification

14 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/m 2

15 What do you do?

16 Chest X-ray- Reduced PPC by 3%




20 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 value at age 25) 25 50 75 100 0 Age (years) 255075 COPD Risk and Smoking Cessation



23 Post operative prevention Volume expansion therapy – Incentive spirometry – EZ-Pap/ IPPB – CPAP Pain control- PCA DVT prophylaxis Aspiration prophylaxis

24 Bapoje, S. R. et al. Chest 2007;132:1637-1645 Stepwise approach to preoperative pulmonary assessment

25 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

26 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

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