NMS. Casos Clínicos

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Part I ♦ Foundations

Case 1.5  Urgent Surgery in a Patient with Severe, Acute Pulmonary Function Problems You are asked to see a man in the emergency department who is quite ill, with right upper quadrant (RUQ) pain and a temperature of 103°F . He states that he is a heavy smoker and that he becomes short of breath on mild exertion. He has scant sputum production —a thin, white secretion. Examination indicates a barrel chest with decreased breath sounds bilaterally and scattered wheezes, as well as acute tenderness over the RUQ at Murphy point. CXR findings are typical of advanced COPD , and an abdominal ultrasound study shows gallstones and a thickened, inflamed gallbladder. You diagnose his abdominal problem as acute cholecystitis . Q: How would you manage the patient’s pulmonary problem? A: To assess pulmonary disease, ABGs , preferably on room air, are necessary. A Pao 2 of less than 60 mm Hg correlates with pulmonary hypertension, and a Pa co 2 of more than 45 mm Hg is associated with increased perioperative morbidity. Pulmonary toilet can improve the patient’s pulmonary condition including bronchodilators for bronchospasm, antiin- flammatory medications (inhaled or systemic steroids) for inflammation, antibiotics for infection, chest physiotherapy for atelectasis or mucus plugging. Knowledge of patients’ preoperative pulmonary status helps determine intra- and postoperative management. If this patient’s septic picture worsens, he will need to go to the operating room regardless of his pulmonary function. If his septic picture improves, pulmonary function tests can be used to quantify his pulmonary disease (Table 1-6). It is most likely that the sepsis is secondary to biliary infection from gallstones, and the patient may respond to antibiotics, hydration, and IV fluids. The surgery may be postponed until the patient is in better condition. However, the course of the disease is unknown at this time: prompt evaluation is essential. Preoperative bronchodilator therapy and other efforts to improve pulmonary status prior to surgery may be appropriate. The patient is normally very short of breath at rest but that his current breathing problems are much worse than usual. He cannot speak a complete sentence without gasping for air. On room air, Po 2 is 49 mm Hg, and Pco 2 is 65 mm Hg. Q: How would your management plans change if the patient has severe COPD in addition to acute cholecystitis? A: This patient is at high risk for pulmonary failure with surgery . Further workup should include a CXR to rule out underlying pneumonia. In addition, the patient must be asked whether he requires oxygen at home and to determine baseline respiratory status, includ- ing previous pulmonary studies. If the surgery is absolutely necessary, the patient should be taught incentive spirometry before the surgery, and perioperative bronchodilators may be used. Evidence supports the use of incentive spirometry as a risk reduction strategy for pulmonary complications postoperatively. It is also important to minimize the duration of anesthesia. To prevent atelectasis, the patient should be mobilized postoperatively as soon as possible. SAMPLE