Comprehensive over view of identification of risk factors and its assessment. understanding basics and specialized investigations, its interpretation and methodical use of algorithm.targeted to enhance identification of risks and prevention of complications
5. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
RISK
Pulmonary Complications
• Atelectasis
• Broncho-spasm
• Chronic Lung Disease - Exacerbation
• Thromboembolic disease
• Respiratory failure and prolonged mechanical
ventilation
• Infection (Pneumonia or bronchitis)
• ↑ Morbidity , Hospital Stay and Mortality
Assessment is to PREDICT
ABC TRIMM
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
7. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
Postoperative Pathophysiological Features
Leading to Pulmonary Complications
1. Atelectasis and Shunting with Hypoxia
– Striking and persistent decline in VC and FEV1
– Decreased >> Compliance and
Efficiency of Ventilation
– Increased >> Shunting
Pulmonary Dead Space
P(A-a)O2 AND P(A-a)CO2
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
8. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
Postoperative Pathophysiological Features
Leading to Pulmonary Complications
1. Atelectasis and Shunting with Hypoxia
– Striking and persistent decline in VC and FEV1
– Decreased >> Compliance and
Efficiency of Ventilation
– Increased >> Shunting
Pulmonary Dead Space
P(A-a)O2 AND P(A-a)CO2
Applicable Mainly to
ABDOMINAL
THORAICIC SURGERIES
ABDOMINAL SURGERIES IN OBESE
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
9. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
Average Change - Spirometry Values & PO2 ((%)
After Thoracic (T) Or Abdominal (A) Surgeries
-70
-60
-50
-40
-30
-20
-10
0
-1 0 1 2 3 4 5 6 7
A PO2
T PO2
A VC
A FEV1
T VC
T FEV1
Perioperative Day
%
Change
in
Values
Postoperative Pathophysiological Features
Leading to Pulmonary Complications
10. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
2. Respiratory Failure
Common in Severe COPD
– Decreased Volumes & Flow Rates Added
By Pain, Weakness, Sedation
– Pre Operative Co2 Retention, Sepsis,
Obesity And Shock >> Higher Risk
– Post Operative Infection > Fever > More
Co2 Production
Postoperative Pathophysiological Features
Leading to Pulmonary Complications
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
11. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
3. Infection - Pneumonia
– Impaired Transport Of Mucus
– Aspiration
– Pre Existing Lung Infection
– Impaired Coughing
Postoperative Pathophysiological Features
Leading to Pulmonary Complications
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
12. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
3. Infection - Pneumonia
– Impaired Transport Of Mucus
– Aspiration
– Pre Existing Lung Infection
– Impaired Coughing
Atelectasis V/Q Mismatch Infection
Postoperative Pathophysiological Features
Leading to Pulmonary Complications
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
13. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
Pneumonia
– Impaired Transport Of Mucus
– Aspiration
– Pre Existing Lung Infection
– Impaired Coughing
Right Lung Collapse -Consolidation
RMB -Bronchial plug & Collapse
Postoperative Pathophysiological Features
Leading to Pulmonary Complications
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
14. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
Pneumonia
– Impaired Transport Of Mucus
– Aspiration
– Pre Existing Lung Infection
– Impaired Coughing
Right Lung Collapse -Consolidation
RMB -Bronchial plug & Collapse
Postoperative Pathophysiological Features
Leading to Pulmonary Complications
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
After treatment
15. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
4. Pulmonary Embolism
Risk factors : Advanced Age Obesity
Malignancy Recent Surgery
H/o DVT Smoker
Risk : 11% w/o any factor
50% with any 3 factors
100% with 4 or more
Despite knowing this, low usage of Thrombo-
embolic prophylaxis (9-56%) in high risk group !!
Postoperative Pathophysiological Features
Leading to Pulmonary Complications
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
16. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
What to Assess for?
To Identify - Risk Factors
A. Patient related
B. Procedure related
To assess - immediate Pre-Operative Risk
To plan Risk Reduction Strategies
PREVENT, PROTECT and MITIGATE
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
17. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
What to Assess for?
To Identify - Risk Factors
A. Patient related
B. Procedure related
To assess - immediate Pre-Operative Risk
To plan Risk Reduction Strategies
PREVENT, PROTECT and MITIGATE
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
24. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
Smoking
• Important risk factor – Relative Risk = 1.73X
• Smoking history of
20 pack years or more ↑risk
of pulmonary complications
• Stopped smoking < 2 months v/s
Stopped for > 2 months = 4:1
• Quit smoking > 6 months v/s
Never smoked = 1:1
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
26. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
Asthma
• Inadequate control of asthma ↑ risk of
postoperative complications
• Well controlled, peak flow measurement
of > 80% of predicted or personal best
average risk
• Asthmatic patients treated with
corticosteroids before surgery have a low
incidence of complications
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
29. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
Health Status - General
American Society of Anesthesiologists
(ASA) classification
Physical Status Classification – Aimed to
assess FITNESS of a person to undergo
surgery
Comprehensively includes History and
past treatments
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
35. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
Surgical site
• The most important predictor of
pulmonary complications
• The incidence of complications is
inversely related to the distance of the
surgical incision from the diaphragm
• The complication rates for upper
abdominal and thoracic surgery are
the highest (range 10% to 30%)
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
37. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
Rodgers A, Walker N, Schug S, et al. BMJ 2000; 321: 1493
Duration and type of Anesthesia
Anesthesia time of > 3.5 hours → ↑↑
incidence of pulmonary complications
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
In a very high risk patient
Be Less Ambitious, Keep Procedure Briefer
39. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
What to Assess?
To Identify - Risk Factors
• Patient related
• Procedure related
To assess - immediate Peri-Operative Risk
To plan Risk Reduction Strategies
PREVENT, PROTECT and MITIGATE
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
43. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
AT 1 - Clinical evaluation
Complete history
– Smoking,
– Poor exercise tolerance,
– Unexplained dyspnoea or cough
– Unrecognized chronic lung disease should be
determined
Good physical examination
– Directed toward evidence for Obstructive Lung
Disease - decreased breath sounds, wheeze,
rhonchi or prolonged expiratory phase
44. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
AT 2 - Chest Radiography
Patients With out RISK FACTORS
Patients With RISK FACTORS
(Cardiac, Pulmonary)
Rucker L, Frye EB, Staten MA. JAMA 1983; 40: 1022.
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
46. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
AT 3 – Pulmonary Function Tests
To be done when the patient is clinically stable and receiving
maximal bronchodilator therapy
NOT to be used as the primary factor to deny surgery
NOT to be routinely ordered
Qaseem A, Snow V, Fitterman N. et al. Ann Intern Med 2006; 144: 575.
47. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
AT 3 – Pulmonary Function Tests
To be done when the patient is clinically stable and receiving
maximal bronchodilator therapy
NOT to be used as the primary factor to deny surgery
NOT to be routinely ordered
Qaseem A, Snow V, Fitterman N. et al. Ann Intern Med 2006; 144: 575.
PFT helps confirm and define severity of
disease identified with clinical impression
48. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
AT 3 – Pulmonary Function Tests
• All candidates for lung resection should have
preoperative PFT
• PFTs should not be ordered routinely prior to
abdominal surgery or other high risk surgeries
• PFT is Must for
–Patients undergoing coronary bypass or upper
abdominal surgery with a history of smoking or
dyspnoea.
–Patients undergoing Head & Neck, Orthopedic, or
Lower Abdominal Surgery with unexplained
dyspnoea or pulmonary symptoms
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
49. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
Simple Peak Flowmetry
Computerised Spirometry
Diffusion Study
Pulse Oxymetry & ABG
2D Echo
6MWT
Ergometry
V/Q Scan
Sleep Study
Testing Pulmonary Functions
PFT
Cardio-Pulm
Relation
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
51. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
SIMPLE PEAK FLOW METERY
BELL SPIROMETERY
COMPUTERISED SPIROMETERY
DIFFUSION STUDY
PULSE OXYMETRY & ABG
2D ECHO
ERGOMETRY
V/Q SCAN
SLEEP STUDY
Spirometry and DLCO
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
54. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
Spirometry
VC / FVC
VC - if less than 80% of predicted: Lung volume testing can
reveal if caused by restriction
FVC (should be within 150 ml of VC) - Criteria for Acceptability
• Maximal effort; no cough or glottic closure during the first
second; no leaks or obstruction of the mouthpiece.
• Tracing shows 6 seconds of exhalation or an obvious plateau
(<0.025L for ≥1s);
• No early termination or cut off
• Three acceptable spirograms obtained; two largest FVC values
within 150 ml; two largest FEV1 values within 150 ml
• The largest FVC and largest FEV1 (BTPS) should be reported, even
if they do not come from the same curve
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
55. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
Spirometry
FEV1 / FVC
FEV1 - The volume expired over the first second of an FVC
maneuver
FEV1 / FVC (should be > 75%)
• A decrease FEV1/FVC ratio is the “hallmark” of obstructive
disease FEV1/FVC <75%
• Restrictive diseases will have low FVC and FEV1 but normal
FEV1/FVC
– Neuromuscular disorders, e.g. Myasthenia Gravis, Guillain-Barre
– Chest deformities e.g. scoliosis / kyphoscoliosis
– Obesity or pregnancy
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
The ability to work or function in daily life is related to
the FEV1, FVC and FEV1 / FVC
57. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
Spirometry
MVV
Tests overall function of respiratory system
– Airway resistance
– Respiratory muscles
– Compliance of lungs/chest wall
– Ventilatory control mechanisms
At least 2 acceptable maneuvers should be performed
– Highest MVV (L/min, BTPS) and MVV rate (breaths / min)
should be reported
– Two largest should be within 10% of each other
– Volumes extrapolated out to 60 seconds and corrected to
BTPS
– MVV is approximately equal to 35 time the FEV1
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
MVV decreases in Moderate to Severe Obstruction,
Neuromuscular disease and with Low Endurance
60. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
DLCO
DLCO is recommended as standard PFT to use
routinely in the preoperative evaluation of
patients for Lung Resection.
DLCO has been shown to be an independent
predictor of postoperative outcome specifically
of mortality and postoperative complications
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
62. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
Blood Gas Analysis
MUST in Moderate -Severe Respiratory Disease
with Hypoxemia: SPO2 < 90% @ Room Air
Hypercapnoea: PaCO2 > 45mmHg
– Not necessarily an absolute contraindication for
surgery
– Suggests reassessment of the indication for the
proposed procedure and aggressive preoperative
preparation
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
ABG provides vital information on
METABOLIC Balance and Respiratory Compensation
63. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
AT 3 – PFT - Summary
Non-Resective Surgery - Risks
Test Parameter
Risk Level
Increased
Risk
High Risk
Spirometry
FEV1 < 50% or < 2 lit < 1 litre
MVV < 50%
Diffusion
Capacity
DLCO < 60% < 40%
Blood Gas
Analysis
SaO2 < 95% <90%
PaCO2 > 45 mm Hg
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
64. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
AT 3 – PFT - Summary
Lung Resection - Risks
Test Parameter
Lobectomy Pneumonectomy
Safe Limit High Risk
Spirometry
FEV1
> 60%
or
> 1.5 lit
> 80%
or
> 2.0 lit
> 60%
or
< 2.0 lit
MVV > 60% < 50%
Diffusion
Capacity DLCO > 60% < 60%
Blood Gas
Analysis
SaO2 > 95% <90%
PaCO2 <45 mm Hg > 45 mm Hg
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
70. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
AT 4 – RISK INDICES
Gupta Calculator - QXMD
http://www.qxmd.com/calculate-online/respirology/postoperativerespiratoryfailure-risk-calculator
Gupta H, Gupta PK, Fang X, et al. Chest 2011; 140(5): 1207-15
72. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
AT 4 – RISK INDICES
Obstructive Sleep Apnoea
Total Score = A + (Greater of B or C)
Gross JB, Bachenberg KL, Benumof JL, et al. Anesthesiology 2006; 104: 1081-93.
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
75. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
AT-Resection SX
Split lung function studies
Predicting post-resection pulmonary function
FEV1ppo =
X – -
Lung function can be calculated by counting the number of
segments removed – As Lungs contain total 19 segments,
Each segment approximates 5%
Pre-Operative
FEV1
1
% Functional Tissue Removed
------------------------------------------
100
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
Predicted Post-Operative FEV1 (FEV1ppo) is
the most valid single test available
76. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
AT-Resection SX
Split lung function studies
• FEV1ppo > 40%, DLCOppo > 40%
– Widely accepted as a predictor of average risk for
complications
• FEV1ppo < 40%, DLCOppo < 40%
– High risk of Perioperative complications including
death
• FEV1ppo < 1.0L → Sputum retention
• FEV1ppo < 0.8L → Preclude resection , dependent
on a ventilator
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
If Predicted Post-operative lung function show
borderline values → Cardio-Pulmonary Exercise Test
77. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
AT-Resection SX
Cardio-Pulmonary Exercise Test
Tests the entire cardiopulmonary and oxygen delivery
system under controlled stress → helps to predict expected
functional reserve after pulmonary resection
Maximal Oxygen Uptake (VO2max)
VO2max
RISK
Complication / Death
> 20 mL/kg/min Not increased
VO2max < 15 mL/kg/min Increased
VO2max < 10 mL/kg/min Very High
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
79. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
• Active Upper Respiratory Tract Infection – G/A?
• Active Bacterial Infection
– Prophylactic Empirical Antibiotic
• Koch’s – Always A Trouble??
• Malaria – Pre Operative
• Viral Infection
– HIV / Hepatitis
• Local site Infection
Special Conditions
Infection..
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
80. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
• Active Upper Respiratory Tract Infection – G/A?
• Active Bacterial Infection
– Prophylactic Empirical Antibiotic
• Koch’s – Always A Trouble??
• Malaria – Pre Operative
• Viral Infection
– HIV / Hepatitis
• Local site Infection
Special Conditions
Infection..
DEALING WITH EMERGENCY??
Infection Is Not A Contraindication
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
81. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
Special Conditions
Renal Dysfunction..
• BUN is necessity.. Not optional
• CREATININE CLEARANCE is a better marker
• RENAL SHUTDOWN? Simply Dialyse..
• AMINOGLYCOSIDES?
• FLUID replacement?
• Watch for ELECTROLYTES…
Keep an EYE on..
METABOLIC ACIDOSIS
Leading to
Tachypnoea and Fatigue
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
84. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
• Patient in ICU, “SERIOUSLY ILL” – needs “LIGHT
DIET / CLEAR LIQUIDS”..
• I.V. FLUIDS – Dextrose / Saline with Multi-
vitamins gives “ENOUGH ENERGY”..
• “Pre-formulated Feeds” are “total Solution”.
Special Conditions
Nutrition..
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
85. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
• Patient in ICU, “SERIOUSLY ILL” – needs “LIGHT
DIET / CLEAR LIQUIDS”..
• I.V. FLUIDS – Dextrose / Saline with Multi-
vitamins gives “ENOUGH ENERGY”..
• “Pre-formulated Feeds” are “total Solution”.
Special Conditions
Nutrition..
Nutrition is a science - critically ill PRE OPERATIVE
patients require PROPER assessment and
Supplementation of protein- caloric needs.
Negative Nitrogen balance – increases morbidity,
mortality.
Glutamine, Omega 3 fatty acids, Amino acids and
Lipids if supplemented, Reduces Post Op ICU stay &
mortality.
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849
89. P
R
E
-
O
P
E
R
A
T
I
V
E
A
S
S
E
S
S
M
E
N
T
PULMOCARE ASSOCIATES
Pulmonologists – Intensivists – Physicians
Dr. Parthiv Mehta MD FCCP
Senior Pulmonologist – Intensivist
Hon. Pulmonologist to H.E. Governor of Gujarat
U N Mehta Institute of Cardiology
Mehta Hospital & Cardiopulmonary Care Centre
Central United Hospital
Ahmedabad, Gujarat, INDIA
Dr. Jigar Parikh Dr. Komal Kothari Dr. Pankaj Vyas
Dr. Divyang Patel Dr. Kaushal Gandhi Dr. Saurabh Vanzara