1. Preoperative Management of Hypoxic Patients

2. Classification of Hypoxia
Pathophysiologic Category
Clinical Example
Hypoxic hypoxia
Decreased Pbarom or FiO2
Altitude, O2 equipment error
Alveolar hypoventilation
Drug overdose, COPD exacerbation
Pulmonary diffusion defect
Emphysema, pulmonary fibrosis
V/Q mismatch
Asthma, pulmonary emboli
R-->L shunt
Atelectasis, cyanotic congenital heart disease
Circulatory hypoxia
Reduced cardiac output
CHF, MI, dehydration

3. Classification of Hypoxia
Pathophysiologic Category
Clinical Example
Hemic hypoxia
Reduced Hb content
Anemia
Reduced Hb function
Carboxyhemoglobinemia, methemoglobinemia
Demand hypoxia
Increased oxygen consumption
Fever, seizures
Histotoxic hypoxia
Inability of cells to utilize oxygen
Cyanide toxicity

4. Atelectasis and pulmonary embolism are most likely causes of the desaturation.

5. Atelectasis

6. Preoperative Evaluation for Postoperative Pulmonary Complications
Postoperative Pulmonary Complications (PPC)
Atelectasis
Pneumonia
Respiratory failure
ARDS
Pleural effusion
Med Clin N Am 87(2003)

7. Med Clin N Am 87(2003)

8. Med Clin N Am 87(2003)

9. Preoperative Evaluation for Postoperative Pulmonary Complications
Risk Reduction Strategies
Preoperative smoking cessation
Abstinence for at least 8 weeks probably decreases PPC risk
Med Clin N Am 87(2003)

10. Preoperative Evaluation for Postoperative Pulmonary Complications
Risk Reduction Strategies
Perioperative lung expansion maneuvers
Incentive spirometry
Chest physical therapy
deep breathing exercise
postural drainage
percussion and vibration
cough
suctioning
mobilization
Med Clin N Am 87(2003)

11. Preoperative Evaluation for Postoperative Pulmonary Complications
Risk Reduction Strategies
Perioperative lung expansion maneuvers
Intermittent positive pressure breathing
CPAP
Patient education in lung maneuvers initiated preoperatively is more effective in reducing PPC versus education initiated postoperatively
Med Clin N Am 87(2003)

12. Preoperative Evaluation for Postoperative Pulmonary Complications
Risk Reduction Strategies
Postoperative analgesia
Optimizing pulmonary function in patients with COPD and asthma
Delaying surgery for patients with acute exacerbations of chronic lung disease or URI.
No clear role for prophylactic antibiotic use.
Med Clin N Am 87(2003)

13. Pulmonary Embolism

14. Venous Thromboembolism (VTE)
The cornerstone of VTE diagnosis is clinical suspicion.
Because the first manifestation of VTE may be fatal pulmonary embolism (PE), patients with suspected VTE should be anticoagulated until the diagnosis is excluded.
Med Clin N Am 86(2002)

15. Diagnosis of VTE Duplex ultrasonography
Contrast venography or MR venography
Patient with suspected PE:
Lung ventilation and perfusion scan
Helical CT
Med Clin N Am 86(2002)

16. Prevention of Venous Thromboembolism
The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy
Chest 2004; 126:338S-400S

19. Recommendations: Trauma
Factors with increased risk of VTE:
Spinal cord injury
Lower extremity or pelvic fracture
Need for a surgical procedure
Increasing age
femoral venous line insertion or major venous repais
Prolonged immobility
longer duration of hospital stay

20. Recommendations: Trauma
We recommend that all trauma patients with at least one risk fector for VTE receive thromboprophylaxis, if possible
In the absence of major contraindication (intracranial bleeding, ongoing and uncontrolled bleeding, uncorrected major coagulopathy, incomplete SCI with suspected or proven perispinal hematoma...), we recommend that clinicians use LMWH prophylaxis starting as soon as it is considered safe to do so.

21. Recommendations: Trauma
We recommend that mechanical prophylaxis with intermittent pneumatic compression (IPC), or possibly with graduated compression stocking (GCS) alone, be used if LMWH prophylaxis is delayed or if it is currently contraindicated due to active bleeding or a high risk for hemorrhage

22. Recommendations: Trauma
We recommend DUS screening in patients at high risk for VTE and who have received suboptimal prophylaxis or no prophylaxis
We recommed against the use of inferior vena cava filters (IVCFs) as primary prophylaxis in trauma patients.

23. Recommendations: Trauma
We recommend the continuation of thromboprophylaxis until hospital discharge, including the period of inpatient rehabilitation.
We suggest continuing prophylaxis after hospital discharge with LMWH or a VKA (target INR, 2.5; INR range, 2.0 to 3.0) in patients with impaired mobility.

24. As for this patient... Atelectasis
Perioperative lung expansion maneuvers
Pulmonary embolism
undergo further examination to exclude or confirm this diagnosis
Thromboprophylaxis with anticoaulant or mechanical prophylaxis