General Surgery Rotation

Patient will present as → a 60-year-old male with a long-standing history of chronic obstructive pulmonary disease (COPD) presents for an elective cholecystectomy due to symptomatic gallstones. He reports a 40-pack-year smoking history, although he quit smoking 5 years ago. His COPD is managed with tiotropium and as-needed albuterol inhalers. He expresses concern about his breathing during and after the surgery. On preoperative evaluation, his pulmonary function tests show moderate obstructive lung disease with reduced FEV1/FVC ratio. His chest X-ray is clear without any acute pathology. The anesthesiologist and surgical team discuss the increased risk of postoperative pulmonary complications due to his COPD. Preoperative optimization includes a review of his COPD management, ensuring optimal medical therapy, and counseling on pulmonary hygiene exercises. He undergoes a successful laparoscopic cholecystectomy under general anesthesia. Postoperatively, he is closely monitored for respiratory function. He develops mild shortness of breath on postoperative day one, which is managed with bronchodilators and incentive spirometry. His recovery is otherwise uneventful, and he is discharged on postoperative day three with instructions to continue his COPD medications, perform breathing exercises, and follow up with his pulmonologist.

The most common perioperative complications involve the pulmonary system.

• Two determinants of risk: operative site and the presence of lung disease 
• Postoperative pulmonary complications (PPC) in patients with pulmonary diseases remain to be resolved clinical issue

Chronic obstructive lung disease

• Patients with chronic obstructive pulmonary disease (COPD) should be aggressively treated in order to achieve their best possible baseline level of function
• While any patient with lung disease should be treated regardless of plans for surgery, the focus is prevention of health and illness from pulmonary complications
• A minimum of one week of therapy, including cessation of smoking, administration of antibiotics for purulent sputum and bronchodilators when indicated

Asthma

Poorly controlled asthma is a risk factor for the development of postoperative pulmonary complications, but well-controlled asthma appears to confer little additional risk

• Patients whose asthma is not well-controlled should receive a step-up in asthma therapy; this may include a brief course of systemic glucocorticoids in patients whose forced expiratory volume in one second (FEV₁) or peak expiratory flow rate (PEFR) are below their predicted values or personal best
• For elective surgery, patients should be free of wheezing and have a peak expiratory flow rate greater than 80 percent of predicted or of their personal best prior to surgery
• For patients who require endotracheal intubation, administer an inhaled rapid-acting beta agonist two to four puffs or a nebulizer treatment within 30 minutes before intubation
• One to two days of systemic glucocorticoid therapy has sometimes been advised as a method to prevent acute bronchoconstriction at the time of intubation

Pulmonary fibrosis and restrictive lung disease

• Preoperative preparation is similar to that for any other lung disease and consists of treatment of infection, removal of sputum, and discontinuance of smoking

Acute lower respiratory tract infections (tracheitis, bronchitis, and pneumonia)

• These infections are absolute contraindications to elective surgery
• For emergency surgery, therapy includes humidification of inhaled gas is, removal of lung secretions, and continued administration of bronchodilators and antibiotics

Preoperative evaluation of pulmonary function

• The purpose of preoperative pulmonary evaluation is to assess the risk of perioperative lung complications.

Such evaluations should be made before hospital admission to allow time for treatment if indicated.

• The site of surgery is a major consideration in the decision to perform pulmonary function test (risk from high to low: thoracotomy, upper abdomen, lower abdomen, and periphery)
• Other indications include exceptional dyspnea, exercise tolerance, cough, production of sputum, history of smoking, previous pulmonary complications, asthma, age, and body weight.
• Patients with mild pulmonary compromise who are to undergo non-abdominal or thoracic surgery probably do not require pulmonary function testing.
• When testing is necessary, simple spirometry with measurement of forced expiratory airflow is usually all that is required.
• If airflow on forced expiration is reduced the response to bronchodilators should be measured and ABGs determined.
• At increased risk if FEv1 is less than 50% of normal or PaCO2 > 45 mm.

Preoperative strategies — Treatment to reduce the risk of postoperative pulmonary complications begins prior to surgery.

• Potential preoperative strategies include cigarette cessation, optimization of underlying chronic lung disease, and patient education.
• Antibiotics may be indicated for patients with lower respiratory tract infection as evidenced by purulent sputum or a change in the character of the sputum.

Intraoperative strategies: 

• Duration of surgery — Surgical procedures performed using a general anesthetic technique lasting more than three to four hours are associated with a higher risk of pulmonary complications
• Type of surgery— Upper abdominal, open aortic aneurysm repair, open thoracotomy, and head and neck operations carry the greatest risk of postoperative pulmonary complications
• Lung protective ventilation— For patients undergoing abdominal surgery, a lung protective strategy of low tidal volume ventilation (6 to 8 mL per kg of predicted body weight; PEEP at 6 to 8 cm of water; recruitment maneuvers every 30 min) is associated with a reduction in adverse pulmonary events.

Postoperative strategies: 

• Lung expansion — A variety of lung expansion maneuvers reduce postoperative pulmonary complications in selected patients, including chest physical therapy, deep breathing exercises, incentive spirometry, intermittent positive pressure breathing, and continuous positive airway pressure (CPAP).
• Deep breathing exercises or incentive spirometry should be used in patients undergoing thoracic, aortic, and upper abdominal surgery who are at higher than average risk for pulmonary complications. CPAP may be beneficial in selected patients.
• Early mobilization— Early mobilization after surgery facilitates deep breathing

Adapted from surgical recall, by Lorne Blackbourne