Risk reduction: perioperative smoking intervention

Smoking is a well-known risk factor for perioperative complications. Smokers experience an increased incidence of respiratory complications during anaesthesia and an increased risk of postoperative cardiopulmonary complications, infections and impaired wound healing. Smokers have a greater risk of postoperative intensive care admission. Even passive smoking is associated with increased risk at operation. Preoperative smoking intervention 6-8 weeks before surgery can reduce the complications risk significantly. Four weeks of abstinence from smoking seems to improve wound healing. An intensive, individual approach to smoking intervention results in a significantly better postoperative outcome. Future research should focus upon the effect of a shorter period of preoperative smoking cessation. All smokers admitted for surgery should be informed of the increased risk, recommended preoperative smoking cessation, and offered a smoking intervention programme whenever possible.     

Optimizing preoperative lung function

The exacerbation of chronic lung disease, bronchospasm, atelectasis, pneumonia, and respiratory failure with prolonged mechanical ventilation are considered to be clinically relevant postoperative pulmonary complications associated with increased morbidity and mortality. Careful history taking and a thorough physical examination are the most sensitive ways to identify patients at risk. Lung function tests serve as management tools for optimizing preoperative therapy and to assess postoperative lung function and individual risk in lung resection candidates. Additional cardiopulmonary exercise testing provides valuable information in borderline cases. The cessation of smoking, optimizing nutritional status and physiotherapy serve to prevent postoperative pulmonary complications. Moreover, medical therapy is recommended, especially for patients with obstructive airway diseases. In the absence of controlled clinical trials, medical therapy along the respective guidelines, with the primary goals of minimizing symptoms and improving lung function to the optimum seems to be a reasonable approach.     

Experience of four cases of postoperative pulmonary embolism requiring surgical treatment

Four patients underwent a pulmonary embolectomy using cardiopulmonary bypass for acute pulmonary embolism which had occurred after various operations. In two cases, dehydration due to either diabetes insipidus or ileus had existed. In two cases, pulmonary embolism suddenly occurred in our hospital. In the remainder, the disease occurred in the previous hospitals and its diagnosis was established on the 6th and 7th postoperative days, respectively. In massive pulmonary embolism, echocardiography and/or enhanced chest CT are useful for prompt and noninvasive diagnosis. Thrombolytic therapy was performed in only one case before surgical embolectomy, which was not effective. Three patients were discharged without any postoperative complications, but one requiring preoperative external cardiac massage died of multiple organ failure 9 days after operation. Acute pulmonary embolism is one of the fatal postoperative complications. Recognition of this entity, and prompt diagnosis and treatment are essential for managing the fatal disease. Even in the early postoperative period, embolectomy using cardiopulmonary bypass is a safe and effective treatment.     

Preoperative alcoholism and postoperative morbidity.

BACKGROUND: Preoperative risk assessment has become part of daily clinical practice, but preoperative alcohol abuse has not received much attention. METHODS: A Medline search was carried out to identify original papers published from 1967 to 1998. Relevant articles on postoperative morbidity in alcohol abusers were used to evaluate the evidence. RESULTS: Prospective and retrospective studies demonstrate a twofold to threefold increase in postoperative morbidity in alcohol abusers, the most frequent complications being infections, bleeding and cardiopulmonary insufficiency. Wound complications account for about half of the morbidity. The pathogenic mechanisms include preoperative immune incompetence, subclinical cardiac insufficiency and haemostatic imbalance. In addition, surgical trauma and/or postoperative abstinence result in an exaggerated stress response, which may further contribute to postoperative morbidity. CONCLUSION: Alcohol consumption should be included in the preoperative assessment of likely postoperative outcome. Reduction of postoperative morbidity in alcohol abusers may include preoperative alcohol abstinence to improve organ function, or perioperative alcohol administration to avoid the abstinence response.     

吸烟对围术期患者病理生理和麻醉效果的影响

背景 每年都有成千上万的吸烟患者需要手术和麻醉,而大多数麻醉医师未充分认识到吸烟对围术期的危害.目的 为提高麻醉管理水平,改善围术期吸烟手术患者的预后,现将吸烟对围术期患者病理生理和麻醉效果的影响作一综述.内容 吸烟不仅能增加术后并发症(包括肺部并发症、心血管并发症和伤口相关并发症),还能增加麻醉相关并发症(譬如低氧血...     

Selection of Pulmonary Resection Procedures to Avoid Postoperative Complications

Purpose We previously found a potential predictive value in a retrospective analysis of spirometry and an expired gas analysis during the exercise. We sought to reduce postoperative cardiopulmonary complications by selecting lung tumor resection procedures based on a combination of specific preoperative cardiopulmonary function test results. Methods Out of the 53 patients requiring a lung tumor resection, five preoperative parameters (forced expiratory volume in 1 s for intact-side, maximal oxygen uptake, ejection fraction, occluded pulmonary artery pressure, and occluded total pulmonary vascular resistant index) were used to assign patients to one of five risk categories in order to select the optimal pulmonary resection procedure. The patients were later grouped according to their postoperative course to test the value of this procedure selection method. Results No patient died or developed severe complications after surgery. Five patients had mild complications, while 46 had a good postoperative course; the 13 deaths, in the cancer cases, included 11 from primary or metastatic cancer and 2 from other causes. The overall five-year survival was 61.4%. Conclusion This method for determining a pulmonary resection procedure avoided postoperative deaths and severe cardiopulmonary complications, while achieving a good outcome.     

心脏移植患者术前肺动脉压力与术后并发症的关系及防治

目的分析心脏移植患者术前肺动脉压力和肺血管阻力（PVR）与术后右心功能不全、并发症发生和死亡的关系,总结围术期肺动脉高压的管理经验,以利于心脏移植术后患者早期心功能的恢复。方法125例接受同种原位心脏移植手术的患者,根据术前肺动脉收缩压（PASP）和PVR不同分为两组,肺动脉高压组（n=56）：术前PASP〉50 mm Hg或PVR〉5 Wood.U;对照组（n=69）：术前PASP≤50 mm Hg,PVR≤5 Wood.U。通过Swan-Ganz导管监测两组手术前心脏排血指数（CI）,手术前、后肺动脉     

The superiority of pulmonary function after minimally invasive direct coronary artery bypass

OBJECTIVE: We determined whether minimally invasive direct coronary artery bypass (MIDCAB) leads to excellent postoperative pulmonary function, and which contributes more to this--minithoracotomy or avoidance of cardiopulmonary bypass. METHODS: Pulmonary function 1 week before and 2 weeks after surgery was evaluated in 8 patients undergoing MIDCAB (Group M), 10 undergoing off-pump coronary artery bypass (Group O), and 12 undergoing conventional coronary artery bypass grafting (Group C). Parameters were adjusted by their predicted values and postoperative values were expressed as a ratio to preoperative ones. RESULTS: Only Group M maintained postoperative vital capacity and forced expiratory volume in 1 second close to the preoperative level and thus, showed significantly better recovery than Groups O and C. No significant difference was seen between Groups O and C. CONCLUSIONS: MIDCAB provides better recovery of pulmonary function early postoperatively than other procedures thanks to minithoracotomy rather than avoidance of cardiopulmonary bypass.     

术前放化疗对食管癌患者肺功能和术后肺部并发症的影响

目的 探讨术前放化疗对食管癌患者肺功能及术后肺部并发症的影响.方法 回顾性收集2002-2013年间中山大学肿瘤防治中心连续收治的术前同期放化疗并手术治疗的63例食管鳞癌患者放化疗前后肺功能指标及其术后肺部并发症的发生情况,分析放化疗前后肺功能的各项指标的变化及其对术后肺部并发症的影响.结果 放化疗后,63例患者一氧化碳弥散量（DLco％）较治疗前明显降低（83.7±17.7比96.4±17.8,P＜0.01）,而其他肺功能指标均未见明显变化（P＞0.05）.术后肺部并发症发生率为34.9％（22/63）,其中肺炎19例,急性肺损伤/急性呼吸窘迫综合征3例.术前肺弥散功能正常者（DLco％大于或等于80）和异常者（DLco％小于80）,术后肺部并发症发生率的差异无统计学意义[29.7％（11/37）比41.7％（10 /24）,P=0.338].放疗后DLco％明显下降者（DLco％下降大于或等于15％）和无明显下降者（DLco％下降小于15％）,术后肺部并发症发生率的差异亦无统计学意义[31.6％（6/19）比37.8％（14/37）,P=0.664].结论 术前放化疗会降低食管癌患者肺弥散功能,但并不损伤肺通气功能,亦不会增加术后肺部并发症发生率.     

Selection of pulmonary resection procedures to reduce postoperative complications in 200 patients

Purpose  

We previously demonstrated in a pilot study that postoperative cardiopulmonary complications could be reduced by selecting pulmonary resection procedures based on the results of a combination of specific preoperative cardiopulmonary function tests. The present study reports a re-examination of the criteria for preoperative screening and prospectively assessed whether the selected surgical procedures were appropriate in 200 patients who underwent the planned extent of pulmonary resection.     

Pre-operative respiratory optimisation: an expert review

Postoperative pulmonary complications are common and cause increased mortality and hospital stay. Smoking and respiratory diseases including asthma, chronic obstructive pulmonary disease and obstructive sleep apnoea are associated with developing postoperative pulmonary complications. Independent risk factors for such complications also include low pre-operative oxygen saturation, or a recent respiratory infection. Postponing surgery in patients who have respiratory infections or inadequately treated respiratory disease, until these can be fully treated, should, therefore, reduce postoperative pulmonary complications. There is evidence from several studies that pre-operative smoking cessation reduces such complications, with no agreed duration at which the benefits become significant; the longer the abstinence, the greater the benefit. Intensive smoking cessation programmes are more effective, and there are long-term benefits, as many patients become permanent non-smokers following their surgery. Supervised exercise programmes normally last 6–8 weeks, and although they reduce overall complications, the evidence of benefit for postoperative pulmonary complications is mixed. High-intensity interval training can improve fitness in just 2 weeks, and so may be more useful for surgical patients. Specific respiratory pre-operative interventions, such as deep breathing exercises and incentive spirometry, can help when used as components of a package of respiratory care. Pre-operative inspiratory muscle training programmes that involve inspiration against a predetermined respiratory load may also reduce some postoperative pulmonary complications. Pre-operative exercise programmes are recommended for patients having major surgery, or in those where pre-operative testing has shown low levels of cardiorespiratory fitness; interval training or respiratory interventions are more feasible as these reduce complications after a shorter pre-operative intervention.     

呼吸功能不全病人术前相关功能评价

对合并肺功能不全病人的术前评估,应对个人的具体情况作出判断,以降低手术的风险。包括：6min步行试验、胸部CT检查、肺通气功能、肺弥散功能、放射性核素肺通气、肺血流灌注显像及运动性心肺功能检查等有助于做出正确的判断。最稳妥的办法是术前心脏、呼吸及麻醉专业的医生共同评价手术风险及预后。     

Expired Gas Analysis During Exercise Testing Pre-pneumonectomy

Purpose Expired gas analysis has enabled the successful prediction of postoperative complications in patients undergoing thoracic esophagectomy. We conducted this study to determine whether preoperative expired gas analysis during exercise testing can help identify patients at high risk of postoperative complications after pneumonectomy. Methods We measured the vital capacity, percent vital capacity, forced expiratory volume in 1.0 s, percent forced expiratory volume in 1.0 s, maximum oxygen uptake per minute, anaerobic threshold, arterial partial pressure of oxygen, and arterial partial pressure of carbon dioxide in 27 patients scheduled to undergo pneumonectomy. Group A consisted of 18 patients without postoperative cardiopulmonary complications and group B consisted of 9 patients with postoperative cardiopulmonary complications. We compared preoperative cardiopulmonary data between these two groups. Results Postoperative cardiopulmonary complications developed in 9 of the 27 patients (33.3%), 3 (11%) of whom died. The maximum oxygen uptake and the anaerobic threshold were significantly higher in group A than in group B (P < 0.05), whereas spirometric pulmonary function testing and arterial blood gas analysis showed no intergroup differences. Conclusion Expired gas analysis during exercise testing can help identify patients at high risk of postoperative cardiopulmonary complications after pneumonectomy.     

Prévention des complications respiratoires après chirurgie abdominale

Abdominal surgery, especially upper abdominal surgical procedures are known to adversely affect pulmonary function. Pulmonary complications are the most frequent cause of postoperative morbidity and mortality. This review article aimed to analyse the incidence and risk factors for postoperative pulmonary morbidity and their prevention. The most important means for preoperative assessment is the clinical examination; pulmonary function tests (spirometry) are not reliably predictive for postoperative pulmonary complications. Age, type of surgical procedure, smoking and nutritional state have all been identified as potential predictors for postoperative complications. However, usually there is not enough preoperative time available to obtain beneficial effects of stopping smoking and improvement of nutritional state. In patients with COPD, a preoperative multidisciplinary evaluation including the primary care physician, pulmonologist/intensivist, anesthesiologist and surgeon is required. Consensus as to preoperative physiologic state, therapeutic preparation, and postoperative management is essential. Simple spirometry and arterial blood gas analysis are indicated in patients exhibiting symptoms of obstructive airway disease. There are no values that contra-indicate an essential surgical procedure. Smoking should stop at least 8 weeks preoperatively. Preoperative therapy for elective surgery with antibiotics, beta2-agonist, or anticholinergic bronchodilator aerosols, as well as training in cough and lung expansion techniques should begin at least 24 to 48 hours preoperatively. Postoperative therapy should be continued for 3 to 5 days. Usually, anaesthesia is responsible for early complications, whereas surgical procedures are often associated with delayed morbidity. Laparoscopic procedures are recommended, as postoperative morbidity and hospital stay seem reduced in patients without COPD. Regional anaesthesia is given as having less adverse effects on pulmonary function than general anaesthesia. However, for unknown reasons these benefits are not associated with a decrease in postoperative respiratory complications. Moreover, the quality or the type of postoperative analgesia does not influence postoperative respiratory morbidity. Postoperatively, oxygen administration increases SaO₂, but cannot abolish desaturation due to obstructive apnea. The various techniques of physiotherapy (chest physiotherapy, incentive spirometry, continuous positive airway pressure breathing) seem to be equivalent in efficacy; but intermittent positive pressure breathing has no advantages, compared with the other treatments and could even be deleterious. Chest physiotherapy and incentive spirometry are the most practical methods available for decreasing secretion contents of airways, whereas continuous positive airway pressure breathing is efficient on atelectasis. In stage II or III COPD patients, admission in a intensive therapy unit and prolonged mechanical ventilation may be required.     

Anesthesia in bronchial asthma

Between 2% and 5% of the population suffer from bronchial asthma. The disease is characterized by bronchial hyperreactivity to physical, chemical, pharmacological, and/or immunological irritants. The incidence of perioperative complications is higher in asthmatics than in non-asthmatics. Careful pre- and postoperative care can reduce complications in these patients. Successful management of an asthmatic patient undergoing anesthesia starts with the identification of patients with asthma, the preoperative assessment, and evaluation of the pulmonary function. No elective surgery should be performed in patients suffering from unstable asthma or an acute attack. Thorough knowledge of the effects and interactions of broncholytic therapy with anesthesia is mandatory. Preanesthetic management must take into consideration the etiology of the disease; intraoperatively, attention must be paid to the pathophysiology. Appropriate perioperative monitoring can help to prevent complications. No one type of anesthesia is associated with lower postoperative complications. The skill of the anesthesiologist, early recovery from general anesthesia, and good postoperative care greatly reduce the incidence of complications. Besides the changes in pulmonary function that occur following anesthesia and surgery, asthmatics may suffer from abnormalities in control of ventilation and mucociliary function postoperatively. The patient with a history of asthma needs close supervision during the postoperative period: many sudden deaths from asthma and many episodes of ventilatory arrest occur during the night and in the early morning.     

围术期戒烟病理生理与国内外麻醉医师对戒烟干预研究进展

背景 吸烟患者在围术期均处于不同的戒烟期,麻醉医师在围术期承担重要角色,但戒烟对围术期病理生理的影响有多大,哪些因素影响患者的围术期戒烟及戒烟实施情况并不十分清楚. 目的 提高麻醉管理水平,改善围术期吸烟患者的预后. 内容 回顾当前关于短期(时间范围从数小时到数周)和长期戒烟病理生理方面的变化,尤其是与术后转归密切相关的几个方面.此外,还探讨围术期戒烟的影响因素、国内外麻醉医师在围术期戒烟中的作用与实践. 趋向 围术期戒烟还有很长的路要走,需要今后的临床研究和实验进一步探讨,以便更好地帮助患者围术期甚至长期戒烟,减少麻醉手术相关并发症.     

Risk factor assessment in 101 total hip arthroplasties: a medical perspective.

Our experience with 101 consecutive T.H.A.'s in 91 patients was examined in an attempt to identify preoperative risk factors for postoperative medical complications, especially pulmonary embolism and thrombophlebitis. Six per cent of patients developed postoperative clinical thrombophlebitis, and 8% a pulmonary embolism. Advancing age and previous venous thrombosis served as predictors for pulmonary embolism and thrombophlebitis, respectively (p less than 0.01), but obesity, venous varicosities, diabetes mellitus, cigarette smoking, previous pulmonary embolism, and length of surgery did not, for either. Fifty per cent of the patients with preoperative abnormal kidney function developed some form of medical complication postoperatively, a significant increase in risk (p less than 0.05) over patients with normal kidney function. We were unable to identify an increase in postoperative atelectasis or pneumonia associated with smoking or obesity in these patients. No consistent decrease in post-operative medical morbidity could be assigned to preoperative medical consultations, suggesting that we have not yet identified all significant risk factors. A thorough preoperative preparation and improvement in intra- and postoperative techniques and management may account for differences found in this study from traditionally held risk factors.     

Tests of pulmonary function before thoracic surgery

Respiratory complications contribute significantly to perioperative morbidity and mortality after surgery. There are evidence-based guidelines that support the use of pulmonary function tests (PFTs) and cardiopulmonary exercise testing (CPET) in the preoperative assessment of patients undergoing lung resection surgery to determine whether patients can tolerate the resection. Spirometry, lung volumes and flow–volume analysis provide information on the respiratory mechanics of the patient while transfer factor and arterial blood gas analysis help to evaluate the ability of lung parenchyma in gas exchange. CPET evaluates the dynamic response of the cardiac and pulmonary function to exercise. The forced expiratory volume at 1 second (FEV₁) and predicted postoperative FEV₁ (ppoFEV₁) are useful indicators of postoperative respiratory complications following thoracic surgery. CPET measures VO_2Max and can help in the selection patients for lung resection.     

肺功能与肺癌全肺切除术后近期预后的关系

分析２６５例非小细胞肺癌术前肺功能等因素与全肺切除术后近期预后的关系，证实肺功能越差，术后近期预后越差，尤其当ＶＣ、ＭＶＶ占预计值〈６０％，ＦＥＶ１〈１．５Ｌ或ＦＥＶ１％〈５０％时，全肺切除术后危险性明显增高，有长期吸烟史和慢性支气管炎史，有心血管疾病或术前作过化疗或放疗者，术后并发症也随之增多。     

Long-term results of operation for non-small cell lung cancer in the elderly

We surgically treated 185 patients with non-small cell lung cancer who were 70 years old or older. The operative mortality rate was 3%, and the 5-year survival rate was 48%. The mortality and prognosis were similar to those in younger patients. The number of elderly patients who smoked heavily or who had ventilatory defects was high, but the incidence of pneumonectomy was low. There were no differences based on age in regard to histological type, TNM classification, and curability. Pulmonary complications occurred in 21% of the elderly patients and were correlated with preoperative pulmonary function and smoking habits. When the elderly are to undergo elective pulmonary resection for lung cancer, the preoperative evaluation of pulmonary function should be thorough, and both preoperative and postoperative physical therapy should be given. If postoperative pulmonary function is predicted to be less than 0.8 L/m2 of vital capacity and 0.6 L/m2 of forced expiratory volume in 1 second, a limited resection or nonsurgical therapy should be considered.