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Each year, more than 30 million surgical procedures are performed. During these, nearly 1 million patients suffer a postoperative complication (Mangano, 2004). As surgeons, gynecologists assume responsibility for assessing a patient’s clinical status to identify modifiable risk factors and prevent perioperative morbidity. However, clinicians should also be prepared to diagnose and manage such complications if they arise.
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PREOPERATIVE PATIENT EVALUATION
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A properly performed preoperative evaluation serves three important functions. It uncovers comorbidities that require further evaluation and improvement to avert perioperative complications. Second, evaluation allows effective use of operating room resources (Roizen, 2000). Finally, the surgeon is able to anticipate potential problems and devise an appropriate perioperative plan (Johnson, 2008).
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In many cases, a thorough history and physical examination averts the need for medical consultation. However, if a poorly controlled or previously undiagnosed disease is discovered, consultation with an internist can be beneficial. Preoperative internal medicine consultation does not provide “medical clearance” but rather offers a risk assessment of a woman’s current medical state. For consultation, a summary of the surgical illness is provided, and clear questions are posed to the consultant (Fleisher, 2009; Goldman, 1983). In addition, a complete history and physical examination and prior medical records that report already completed diagnostic testing should be available to the consulting physician. This can prevent unnecessary surgical delays and cost from redundant testing.
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Risk Factors for Pulmonary Complications
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Common postoperative pulmonary morbidities include atelectasis, pneumonia, and exacerbation of chronic lung diseases. Incidences of such complications following surgery are estimated to be between 20 and 70 percent (Bernstein, 2008; Brooks-Brunn, 1997; Qaseem, 2006).
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Risks for pulmonary complications fall into one of two major categories: procedure-related and patient-related. Of procedure-related risks, upper abdominal incisions as they approach the diaphragm can worsen pulmonary function through three mechanisms, shown in Figure 39-1. Resulting poor diaphragmatic movement can produce persistent declines in vital capacity and in functional residual capacity. These predispose to atelectasis (Warner, 2000). Surgery duration is another procedure-associated factor. Operations in which patients receive general anesthesia for longer than 3 hours are associated with nearly double the rate of postoperative pulmonary complications. Finally, emergency surgery remains a significant independent risk. Although these factors are largely unmodifiable, an appreciation of their sequelae should prompt increased postoperative vigilance.
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Of patient-associated factors, age plays a role. Individuals older than 60 years are at increased risk for developing postoperative pulmonary complications. After patients ...