TEMA: Valoración preoperatoria en Neumología. TIENES SOLAMENTE 10 MINUTOS. ES IMPOSIBLE PRESENTAR ESTA CANTIDAD DE INFORMACION EN ESTE TIEMPO. TIENES QUE QUITAR 10 DIAPOSITIVAS. ESCOGE CON PRECISIÓN LO QUE REALMENTE QUIERES QUE EL PUBLICO APRENDA Y QUITA EL RESTO. RECUERDA: SOLO 10 TRANSPARENCIAS EFECTIVAS. USA SOLO IDIOMA ESPAÑOL. Dr. Erik Alan Martínez Landeros Residente de 3er año Medicina Interna dr_erikmtz@hotmail.com 8119104911 TEMA: Valoración preoperatoria en Neumología.

Agenda Incidencia Factores de riesgo Evaluación (pasos para la valoración preoperatoria) Estrategias para disminución del riesgo Conclusiones

Incidencia Complicaciones posoperatorias pulmonares (CPP) se presentan en 2 al 19% en cirugías no cardiacas. CPP aumentan hasta un 39% en pacientes con cirugías cardiacas. En ambas situaciones prolonga la estancia intrahospitalaria. cPP atelectasis, infecciones como bronquitis, neumonia, broncoespasmo, embolismo pulmonar, exacerbacion de alguna enferemdad pulmonar cronica, falla respiratoria, prolongacion de VM o VMNI, SIRA; cuando son cirugias cardiotoracicas: lesiones de nervio frenico, derrame pleural, fistula broncopleural, infeccion esternal y empiema, arritmias posoperatorias.

Factores de riesgo Preoperatorio: Transoperatorio: EPOC, edad, tabaquismo, NYHA II, Hipertensión pulmonar, SAOS, estado nutricional. Transoperatorio: Sitio, duración y gravedad de la cirugía, anestesia general, Pancuronio.

Factores de riesgo EPOC Tabaquismo Factor de riesgo independiente de CPP para o no cirugía torácica. Tomar en cuenta la limitación al flujo de aire. Aumenta el riesgo de arritmias en Cxs cardiotorácica. Tabaquismo Activo, actual. Although there is no incremental risk with an increasing severity of airflow limitation in patients undergoing noncardiothoracic surgery, such an association has been found in patients undergoing thoracic surgery.10 COPD also increases the risk of postoperative arrhythmias in patients undergoing cardiothoracic surgery. A history of smoking increases the risk of PPCs for patients undergoing surgery, and the risk is increased for current smokers

Factores de riesgo Edad: Hipertensión pulmonar: Mayores de 65 años. Falla cardiaca congestiva. CPI. arritmias. Stroke. Falla respiratoria (mas frecuente). Disfuncion hepática o renal. Uso de vasopresores. A review of patients with pulmonary hypertension (defined as a right ventricular systolic pressure of 35 mm Hg) undergoing noncardiac surgery found that having a New York Heart Association functional class 2, a history of pulmonary embolus, or obstructive sleep apnea (OSA) increased the risk of postoperative congestive heart failure, cardiac ischemic events, arrhythmias, strokes, respiratory failure (the most frequent morbidity), hepatic dysfunction, renal dysfunction, or the need for postoperative inotropic or vasopressor support. Easily identifiable factors associated with mortality in this study were right-axis deviation on the ECG, right ventricular hypertrophy by two-dimensional echocardiography, or having a history of pulmonary embolus. Lack of nitric oxide availability, use of intraoperative dopamine or epinephrine, or having a right ventricular systolic pressure/systolic BP ratio of 0.66 also portended increased perioperative morbidity and Mortality. Easily identifiable mortality. Patients with pulmonary hypertension who cannot walk 332 m during a 6-min walk test have a higher mortality rate than those who can

Factores de riesgo Enfermedad intersticial: SAOS: 1.- Grado 3 o 4 de disnea, mas alta mortalidad por biopsia quirúrgica pulmonar; radio de PACO2/PO2 > .72 mayor valor predictivo. 2.- DLCO o FEV1 menor al 60% del esperado. SAOS: No se sabe con certeza si el tratamiento preoperatorio tenga beneficio. Incrementa la morbimortalidad. Three studies have assessed the preoperative evaluation of patients with interstitial lung disease (ILD). The first study16 found that having grade 3 or 4 dyspnea at rest (using the American Thoracic Society shortnessof- breath scale) resulted in a higher mortality rate from surgical lung biopsy, and those with a Paco2/Pao2 ratio of 0.72 had the greatest predictive value. Other studies17,18 have found that having either a low Dlco or an FEV1 or FVC 60% predicted identified patients who were poor surgical candidates. Although all patients undergoing surgery should be screened for OSA by clinical evaluation, it has not been determined whether more sensitive testing is Needed. Numerous studies have shown, however, that the presence of OSA correlates with increased postoperative morbidity and mortality. The preoperative treatment of OSA may reduce these risks perhaps by earlier institution of treatment with continuous positive airway pressure (CPAP).

SAOS Mayor alta prevalencia de CPP, 44 vs 28%. Benzodiacepinas, opiodes, propofol, agentes halogenados. No se recomienda utilizar PSM previa. Varias escalas: Berlin ASA STOP-BANG, > = 3 puntos, alto riesgo.

Consideraciones preoperatorias: Anestesia local o bloqueo nervioso periférico. Uso de medicamentos de acción corta. Extubar hasta que el paciente se encuentre completamente despierto. Monitoreo de oxígeno. 30 grados de fowler. Analgésicos no opioides. Usar CIPAP posoperatorias:

Estudios de Función pulmonar Espirometría, DLCO. Radiografías. Albúmina y BUN. Suspender tabaquismo 6 a 8 semanas antes. Usar otros relajantes que pancuronio. Espirometría incentiva. CPAP. Medidas preventivas While screening pulmonary function tests (PFTs) [ie, spirometry with or without measurement of the diffusion capacity of the lung for carbon monoxide (Dlco)] accurately identify patients who are not likely to survive resectional thoracic surgical procedures, and those who will not have a prolonged survival following lung volume reduction surgery,6,7 the role of preoperative pulmonary function assessment for patients undergoing other types of operations is less clear. as there is no lower limit of FEV1 below which a PPC will definitely occur and PPCs can occur even when the preoperative FEV1 is normal. One review11 found a lower rate of PPCs in patients who received preoperative chest roentgenograms (12.8% vs 16%), but, interestingly, the results only altered management in 1 to 4% of the patients. The National Veterans Affairs Surgical Risk Study found that serum albumin level was a strong predictor of 30-day mortality and was independently associated with a 22 to 44% incidence of PPCs when it was 3.5 g/dL. The association between an increase in all-cause mortality and a decrease in serum albumin level was linear. A BUN level of 8 or 21 mg/dL was also associated with an increased risk of PPCs.

Conclusiones Es importante realizar una valoración pulmonar preoperatoria sobre todo en pacientes en los que se les vaya a realizar alguna cirugía cardiotorácica. Tomar en cuenta que si existen medidas para disminuir la probabilidades de CPP y llevarlas a cabo en la práctica diaria.