Thoracic surgery – perioperative considerations

 

(needs work)

 

Assessment:

Goal

·     Should this operation go ahead

·     Should the patient go to ICU?

Predictions

·     Correct for age, sex, height

·     Correct for amount of lung being removed

o  Left lung: 10+10 = 20 segments

o  Right lung: 6 + 4 + 12 = 22 segments

Mechanics

ppoFEV1:

·     <40%: elevated risk

·     <30%: high risk

·     <20%: nope

Notes:

·     Other indicators: FVC, MVV, RV/TLC

·     N.B. FEV1 is even lower immediately post-op

·     N.B. ppoFEV1 may be better than expected if severe COPD

Gas exchange

ppoDLCO:

·     <40% elevated risk

·     <20% nope

Notes:

·     Other indicators: PaO2, PaCO2

Global function

VE/VCO2 slope:

·     >35: high risk of respiratory complications and death

·     Strongest predictor

VO2max:

·     <20: elevated risk

·     <15: high risk

·     <10: nope

(two flights of stairs = VO2 12)

Anaerobic threshold:

·     <11: high risk

·     <11 + ischaemia + failure: nope

6MWT:

·     Desat >4%: high risk

·     (6MWT / 30 VO2max)

 

Complications:

Cardiovascular:

RV dysfunction

·     Amount of lung (hence vasculature) removed

·     Worse with high output (exercise, SIRS)

Arrhythmias

·     High incidence: 30-50%

·     Mostly atrial fibrillation

·     Risk factors: elderly, major surgery

·     Causes: ↑PVR, ↑SNS

Ischaemia

·     Moderate incidence: 5%

·     Risk factors: the usual, and common

·     Especially day 2-3 post-op

 

Respiratory:

Respiratory failure

·     Lung removal

·     Atelectasis

·     Pain

Pneumonia

 

 

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