NMS. Casos Clínicos

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Chapter 1 ♦ Preoperative Care

◆ ◆ This patient should be maintained on antihypertensive medications on the day of surgery. (Beta-blockers, in particular, have a high rate of rebound hypertension if withheld.) Studies have found that postponing surgery for mild hypertension (diastolic BP <110 mmHg) does not reduce perioperative risk.

Case 1.4 Surgery in a Patient with Pulmonary Symptoms

A 58-year-old has suffered several bouts of biliary colic in the past 10 days. An ultrasound study 4 days ago showed multiple small gallstones. The surgeon says a cholecystectomy is indicated. Q: How would you interpret the following findings, and how would they affect your proposed management? Case Variation 1.4.1. The patient has daily productive cough and has had this for many years. He smokes two packs per day. ◆ ◆ Ask questions about the number of cigarettes smoked daily, the duration of smoking, and any recent change in sputum quality. ◆ ◆ Because the planned cholecystectomy is elective surgery, this patient should be advised that abstaining from cigarettes 6–8 weeks prior to surgery will decrease the risk of postoperative complications. The patient should also be counseled to stop smoking permanently. ◆ ◆ The relative risk of postoperative complications in smokers is two to six times that of nonsmokers because cigarette smoking is toxic to respiratory epithelium and cilia, resulting in impaired mucous transport and therefore decreased resistance to infection. • Bronchial ciliary function returns to normal after 2 days of smoking cessation, and sputum volume decreases to normal after 2 weeks of smoking cessation. Studies indicate no improvement in postoperative respiratory morbidity until after 6–8 weeks of abstinence from smoking. Case Variation 1.4.2. The patient normally has daily sputum production, but his sputum has been green for 3 weeks. ◆ ◆ If this symptom represents bronchitis limited to the upper airways as assessed on chest auscultation in the absence of fever, oral antibiotics can be given, and the surgery can be rescheduled after treatment is complete . Acute or systemic symptoms from pneumonia or other serious diseases warrant further evaluation. Case Variation 1.4.3. The patient’s sputum has been blood-streaked for 3 weeks. ◆ ◆ Blood-tinged sputum in patients with a significant smoking history may suggest active infection or lung carcinoma . A full workup, including a CXR and most likely a computed tomography (CT) scan of the chest, should be performed prior to surgery to determine the cause of the problem. Bronchoscopy is also necessary to check for endobronchial lesions and obtain samples for cytology. SAMPLE