12 Feb 09
Posted in Pre-operatie evaluation at 0:11 by Laci
By B J Sweitzer
Current Opinion in Anaesthesiology 2008;21:711-718
Preoperative evaluation and optimization of a patient’s medical conditon are important components of anesthesia practice. With ever increasing numbers of patients with serious comorbidities having complex procedures as outpatients, the task of gathering information and properly preparing for their care is challenging. Improvements in assessment and management can potentially reduce adverse events, improve patient and caregiver satisfaction, and reduce costs.
Recent findings
A growing body of literature and evidence-based practices and guidelines can assist clinicians who work in the expanding field of preoperative medicine. Care providers from various specialties in medicine are developing innovative methods, tools, and knowledge to advance science and processes. Data-driven practices are beginning to close the information gap that has plagued this field of medical practice.
Summary
Preparation of patients before surgery is a necessary and vital component of perioperative medicine. Practices are developing to guide effective interventions that benefit patients and healthcare systems. Outpatients present special challenges to preoperative assessment.
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11 Feb 09
Posted in Pre-operatie evaluation at 0:46 by Laci
By R Struthers, P Erasmus, K Holmes, P Warman, A Collingwood and J R Sneyd
BJA 2008;101:774-780
Accompanying editorial in BJA
Morbidity and mortality are higher in patients with poor preoperative cardiorespiratory reserve. This study aimed to ascertain fitness and therefore risk in elective patients, comparing three measures: Duke Activity Status Index (DASI) questionnaire, incremental shuttle walk test (ISWT), and cycle cardiopulmonary exercise testing (CPET). We looked for correlation between the measures and for thresholds on the questionnaire or shuttle test which could identify fit patients and render CPET unnecessary.
Methods
A prospective cohort trial of 50 patients having intra-abdominal surgery. Each performed DASI, ISWT, and CPET during a single visit to the hospital.
Results
There was a significant correlation between measured oxygen consumption and both ISWT and DASI. Receiver operator curve showed both the shuttle walk test and the DASI are sensitive and specific predictors of VO2peak >15 ml O2 kg–1 min–1 and anaerobic threshold (AT) >11 ml O2 kg–1 min–1. Thirty-two patients would be considered lower risk, having achieved both VO2peak and AT cut-offs. Setting an ISWT threshold of 360 m identified 13 of the lower risk patients [positive predictive value (PPV) 1.0, negative predictive value (NPV) 0.49]. Setting a DASI threshold score of 46 identified nine lower risk patients (PPV 1.0, NPV 0.44).
Conclusions
We found a significant correlation between the tests. However, many patients with poor questionnaire scores or shuttle walks had satisfactory CPET results. Hence, the ability of either simple test to determine risk in a heterogeneous surgical population is poor. CPET provides an objective measurement of cardiopulmonary fitness; however, evidence for this information improving patient outcome is limited and requires further research.
Editorial
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10 Feb 09
Posted in Pre-operatie evaluation at 0:10 by Laci
By S R Bapoje, J Feliz Whitaker, T Schulz, E S Chu and R K Albert
Chest 2007;132:1637-1645
Preoperative pulmonary evaluation is important in the management of patients with lung disease who are undergoing elective cardiothoracic or noncardiothoracic surgery. In some instances, preoperative pulmonary evaluations may also contribute to the management of patients being considered for urgent surgery. The incidence of postoperative pulmonary complications (PPCs) is high and is associated with substantial morbidity and mortality, and prolonged hospital stays. Perioperative pulmonary complications in patients undergoing elective noncardiothoracic surgery can be more accurately predicted than in patients undergoing elective cardiothoracic surgery. Effective strategies to prevent complications in the postoperative period are few. Incentive spirometry and continuous positive airway pressure are the only modalities of proven benefit. Identifying patients who are at risk for the development of PPCs and managing their underlying modifiable risk factors aggressively prior to surgery is essential.
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09 Feb 09
Posted in Pre-operatie evaluation at 0:09 by Laci
By A Qaseem, V Snow, N Fitterman, R Hornbake, V A Lawrence, G W Smetana, K Weiss et al for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians
Ann Intern Med. 2006;144:575-580
Postoperative pulmonary complications play an important role in the risk for patients undergoing noncardiothoracic surgery. Postoperative pulmonary complications are as prevalent as cardiac complications and contribute similarly to morbidity, mortality, and length of stay. Pulmonary complications may even be more likely than cardiac complications to predict long-term mortality after surgery. The purpose of this guideline is to provide guidance to clinicians on clinical and laboratory predictors of perioperative pulmonary risk before noncardiothoracic surgery. It also evaluates strategies to reduce the perioperative pulmonary risk and focuses on atelectasis, pneumonia, and respiratory failure. The target audience for this guideline is general internists or other clinicians involved in perioperative management of surgical patients. The target patient population is all adult persons undergoing noncardiothoracic surgery.
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