Preoperative Evaluation

From an anesthetic perspective, patients with end-stage pulmonary disease are unstable, even with optimal medical therapy for their disease. Unfortunately, our ability to correctly identify patients at high risk for deterioration during and after surgery remains limited. Preoperative evaluation of LVRS patients is optimally performed within 2 wk of the planned procedure, with reevaluation on the day of surgery. The preop-erative visit is a time for patient evaluation, as well as instruction.

A careful history and physical examination are routine parts of any preoperative anesthetic evaluation. A history of previous general anesthetics, and, in particular, any difficulty with intubation or emergence from general anesthesia is noted. Airway anatomy is evaluated by the usual Mallampati criteria. Preoperative respiratory evaluation allows assessment of baseline breathing, laboratory values, and respiratory capacity. Attention to the degree of bullous disease, hyperinflation, bronchospasm, and resting oxygen requirements will allow preoperative plans to focus on problems that may occur during the period of anesthesia. This information is especially critical to the management of ventilation during the procedure and at the time of emergence and extubation. Preoperative blood gas analysis, in particular the degree of hypercarbia, may provide some guidelines for expectations at the time of extubation. All preoperative medications are noted at this time and the patient should be instructed to continue these up to the morning of surgery. Bronchodilators, steroids, and cardiac medications may need to be administered during the procedure and should be consistent with the patients prior therapeutic regimen. Landmarks for monitoring lines and the epidural catheter are noted during the physical examination (1-4).

Evaluation of the cardiovascular system will often reveal primary disease or disease as a complication of respiratory failure. Coronary artery disease is common in this patient population because of advanced age and shared risk factors with emphysema. The nature and stability of ischemic disease must be evaluated with attention to left ventricular function. Pulmonary hypertension secondary to end-stage pulmonary disease, with or without associated right ventricular failure, is common and may require additional intra- and postoperative monitoring (5,6).

Patient instruction begins with a discussion of the preinduction period. The patient is reminded to maintain all preoperative medication in their usual doses until the morning of surgery. An explanation of all required monitoring, including arterial, central venous, and Swan-Ganz catheters, as well as transesophageal echocardiography is given. If thoracic epidural analgesia is to be used, an explanation of awake catheter insertion and patient-controlled analgesia is given. Detailed instruction about the need for early postextubation, concentration on deep breathing, coughing, and incentive spirometry are included with emphasis on the need for early ambulation and postoperative pulmonary rehabilitation.

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