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