Preoperative and postoperative care of standard and high risk surgical patients

Much of the clinical teaching concerning preoperative evaluation is based upon clinical observations made several decades ago in patients undergoing thoracotomy for both benign and malignant diseases. More recent experience suggests that many "high risk" patients will tolerate pulmonary parenchymal resection. All patients being considered for surgery should have a complete history and physical examination, chest roentgenogram, and screening spirometry. If this initial evaluation reveals normal or mildly obstructed spirometry and absence of comorbid conditions, then the patient is at low risk and postoperative function may be accurately estimated by simple calculation. For patients with moderate or severe obstruction on spirometry (FEV1 less than 50% to 65% predicted), hilar disease, pleural disease, or prior surgery, quantitative radionuclide lung scanning is indicated to allow accurate calculation of postoperative function. For patients with a PPO FEV1 less than 0.8-1.0 L, additional risk stratification should be done after any preoperative interventions. Typically, this includes a formal or informal assessment of exercise capacity. Patients with severely impaired exercise capabilities are at very high risk for postoperative morbidity and mortality, and nonsurgical therapy should be considered. All active smokers at the time of evaluation should quit 3 to 4 weeks prior to planned surgery. Patients with purulent sputum should be treated with appropriate antibiotics. All patients with obstruction demonstrated on spirometry should be started on inhaled beta agonists, with or without inhaled corticosteroids. Postoperative management should focus on early mobilization. This requires adequate analgesia without excessive sedation. This is most easily achieved with local or regional analgesia techniques. The use of this approach, as well as patient-controlled analgesia, allows early mobilization and results in a short length of hospital stay. It should be recognized that if patients have an uncomplicated recovery and leave the hospital quickly (less than 6 days), postoperative pain will be a significant issue at home. Patients should be discharged with an adequate analgesia plan and an adequate supply of analgesic medications.