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Preoperative assessment 

Preoperative assessment
Chapter:
Preoperative assessment
Author(s):

Stephen Chapman

, Grace Robinson

, John Stradling

, Sophie West

, and John Wrightson

DOI:
10.1093/med/9780198703860.003.0011
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date: 26 October 2021

Introduction

The respiratory physician may be asked to assess a patient prior to elective or emergency surgery. These patients are usually those with pre-existing respiratory disease such as COPD.

  • The usual functional status of the patient should be determined

  • Their respiratory function should be optimized, if possible, with medication changes where appropriate.

These patients may require ventilatory support post-operatively. Ultimately, the decisions regarding fitness for surgery rest with the surgeon and the anaesthetist.

Preoperative assessment

  • Usual functional state and exercise tolerance (those with an exercise tolerance of <5m will not come off a ventilator)

  • O2 saturations on air and after exertion such as walking or climbing up and down a step for 2min. Cardiopulmonary exercise test (CPET) may be necessary (see Preoperative assessment p. [link])

  • ABG on air, if saturations <94%. Risk of surgery increases as the CO2 increases

  • Spirometry, with bronchodilator reversibility testing. Risk of surgery increased if FEV1 <0.8L

  • CXR—if 65+ and no CXR in last year, or if acute respiratory symptoms

  • History of snoring or OSA

  • ECG

  • Echo, if cardiac function compromised.

Management options

  • Regular inhaled or nebulized bronchodilators, if airflow obstruction

  • Regular inhaled steroid, if evidence of steroid reversibility

  • Preoperative course of oral steroids, if evidence of steroid reversibility

  • Preoperative course of antibiotics, if evidence of infection

  • Consider pulmonary rehabilitation

  • Consider chest physiotherapy with deep breathing exercises

  • Referral for CPAP, if OSA present

  • Optimize nutrition

  • Lose weight

  • Advise to stop smoking—ideally 8 weeks prior to surgery; reduces post-operative complication rate.

Risk factors for perioperative complications

  • Thoracic or upper abdominal surgery

  • Anaesthetic length >3.5h

  • Smoker

  • Chronic lung disease

  • Raised PaCO2

  • Current respiratory symptoms

  • Poor performance status

  • Concurrent cardiac disease

  • Obesity

  • Older age.