Preoperative Pulmonary Evaluation

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Preoperative Pulmonary Evaluation Powered By Docstoc
					Preoperative
 Pulmonary
 Evaluation
   Michael E. Lazarus M.D.
   Division of General Internal
   Medicine
   David Geffen School of Medicine at
   UCLA
    Postoperative Pulmonary
         Complications

   Pneumonia
   Bronchitis
   Lobar atelectasis
   Respiratory failure
   Prolonged intubation
                    Risk factors
   Patient related:               Procedure related
       Chronic lung disease           Surgical site
       Smoking                        Duration of surgery
       Obesity                        Anesthesia type
        (BMI>27.5kg/m2)                Type of
       Age > 70 years                  neuromuscular
       General Health status           blockade
        Predicting Postoperative
        Pulmonary Complications
   Pulmonary Function Tests
   Unexplained dyspnea
       Smokers
       All cardiothoracic surgery
   Symptom limited stair climbing
   Exercise capacity (6 minute walk)
      Prevention and Treatment
   Aggressive treatment of underlying
    pulmonary disease preoperatively
   Smoking cessation
   DVT prophylaxis
   Incentive spirometry
   Analgesia
   Nasal CPAP
Smoking Cessation
   Smoking increases post operative
    pulmonary complications by 4 fold.
   Paradoxical increase in pulmonary
    complications in patients who quit smoking
    1-2 months before surgery (VA study)
Pulmonary Artery Catheters
   1994 patients undergoing elective and emergent
    noncardiac surgical procedures randomly
    assigned to standard care or hemodynamic
    manipulation directed by PAC
   Those who underwent PAC insertion had more
    transfusions, IV colloids, inotropes and anti-
    hypertensives.
   In hospital mortality was 7.8% in the PAC group
    and 7.7% in the control group.
Multifactorial Risk Index for
Postoperative Pneumonia
   Large database of veterans undergoing
    non cardiac surgery
   316 071 predominantly male patients
   Mean age 61.3 years
   The type of surgery dominates the analysis
    Postoperative
    Pneumonia Risk Index
   Type of Surgery                 Weight loss > 10% in 6 mo 7
      AAA                15        Hx COPD                  5
      Thoracic           14        Gen Anesth               4
      Upper Abdominal    10        Impaired Sensorium       4
      Neck               8         Hx CVA                   4
      Neurosurgery       8         BUN
      Vascular           3            < 8mg/dL              4
   Age                                22-30 mg/dL           2
      > 80 yrs           17           > 30 mg/dL            3
      70-79 yrs          13        Transfusion > 4 units 3
      60-69 yrs          9         Emergency Surgery        3
      50-59 yrs          4         Chronic Steroid use      3
   Functional Status               Current smoker within 1 yr 3
      Totally dependent   10       Alcohol > 2 drinks in 2 wks 2
      Partially dependent 6

                                    Arozullah et al, Ann Intern Med 2001
Postoperative Pneumonia Risk Index
Scores in Two Cohorts
 Risk Class       Cohort         Postop Pneum    Postop Pneum
                                 Developmental   Validated
                                 Cohort Rate     Cohort Rate
 0 – 15 Points    69,333 (43%)   0.24%           0.24%

 16 – 25 Points   55,757 (35%)   1.19%           1.18%

 26 – 40 Points   32,103 (20%)   4%              4.6%

 41 – 55 Points   3517 (2%)      9.4%            10.8%

 > 55 Points      95 (0.1%)      15.8%           15.9%



                                 Arozullah et al, Ann Intern Med 2001
Case
 Abdominal Surgery     10
 Age 68                9
 COPD                  5
 Gen Anesthesia        4
 Smoker           3
 Chronic Steroids      3
Total              34 = 4% risk index
Symptom Limited Stair Climbing
 Self reported or directly observed exercise
  capacity stratifies risk for major
  postoperative cardiopulmonary
  complications
 Girlish et al 83 patients about to undergo
  major thoracic surgery Chest 2001;120:1147-51
 Number of stairs climbed inversely
  proportional to postoperative event rates

				
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