Perioperative Adverse Events - Essay Example

Running Head: Perioperative Adverse Event: Pulmonary Complications Student’s Name: Instructor’s Name: Course Code and Name: University: Date Assignment is due: Perioperative Adverse Event: Pulmonary Complications It is very important for perioperative pulmonary complications to be prevented from occurring. Preventing perioperative pulmonary complications is an important safety and quality measure in today’s health care system. Nurses need to take proactive measures so as to identify and reduce all the risks related to pulmonary complications. Perioperative pulmonary complications constitute an important part of surgery risk that may prolong a stay in the hospital by up to two weeks. The literature that exists on the assessment of many perioperative risks has centered on the identification of various cardiac risk factors. However, there are a significant number of pulmonary complications that are as common as perioperative cardiac complications. According to a recent review, pulmonary complications were seen to be as common as, and in some cases more common than, cardiac complications in the 17 out of 25 studies that were carried out on postoperative complications. The differences in the outcome of reports that study the risk factors of pulmonary complications are attributed to the different definitions that are used with regard to the term ‘pulmonary complications’. There is also variation in the manner in which patients are selected. Many early definitions included complications that had no any clinical significance. According to the most recent studies, complications either prolong the patient’s stay in the hospital or greatly contribute to mortality and morbidity. The most common pulmonary complications are respiratory failure with prolonged mechanical ventilation, pneumonia, atelectasis, brochospasm and exacerbation of a chronic lung disease. Patient-Related Risk Factors The factors that contribute to the risk of these complications on the part of the patient include old age, poor general health status, smoking, obesity asthma and chronic obtrusive pulmonary disease. Smoking has repeatedly been proven to be a very important patient-related risk factor for the occurrence of these complications. With smoking, risks are increased even when the patient does not suffer from a chronic lung disease. Unfortunately, this risk can only decline after eight weeks since preoperative cessation. The general health status of the patient The general health status of the patient is an important factor that can contribute to the occurrence of pulmonary complications. This status can be determined through the collection of important patient information such as history, laboratory data and physical examination. The index outcome can be used to predict cardiac as well as pulmonary complications. The American Society of Anesthesiologists classification system is widely used for evaluation of all risks that may contribute to perioperative mortality. The classification is a very strong predictor of perioperative pulmonary complications. Age Age is another factor that predisposes to the risk of pulmonary complications. Recent studies indicate that increase in pulmonary complications with age has not controlled for other co-existing conditions. Stratification of data by the American Society of Anesthesiologists indicates that the perioperative mortality of patients who are of over 80 year is 6.2 percent for all the 500 patients used in the study. Previous researches had indicated that the majority of deaths were as a result of infection or myocardial infarction. However, it is important to note that pulmonary complications show a stronger causal relationship with co-existing conditions than with age per se. Therefore, advancement in age is not a reason enough for withholding surgery. Obesity Obesity is another risk factor, though not a very significant one, for perioperative pulmonary complications. A study done on 10 patients who were morbidly obese, all of whom were undergoing a gastric bypass surgery indicated an incidence of atelectasis and pneumonia in 3.9 percent of the cases, a rate that is similar to patients who are not obese. More recently, researchers found no difference between non-obese and obese patients as far as pulmonary complications after laparoscopic cholecystectomy has been done. Chronic Obstructive Pulmonary Disease Patients who suffer from chronic obstructive pulmonary disease face an increased risk of encountering perioperative pulmonary complications. The incidences tend to vary according to the nature of complication, its definition and how severe the lung disease is. Physicians are supposed to be aggressive on patients suffering from chronic obstructive pulmonary disease, who are not experiencing an optimal reduction in symptoms and whose rate of airflow obstruction, upon physical examination, does not seem to reduce. Smetana (1999) notes that for patients who lack an optimal exercise capacity as well as those with acute exacerbation, elective surgery should be deferred. The treatments should be the same as those that are meant for patients who are not readying themselves for an operation. For these patients, postoperative pulmonary complications risk can be reduced through combinations of physical therapy, bronchodilators, smoking cessation, antibiotics and corticosteroids. Few data are available on the preoperative benefit that individuals can get. Chronic obstructive pulmonary disease sufferers should be treated using inhaled ipratropium. You may add inhaled beta agonists as needed. These two agents have a very addictive effect. The latter one should be added in response to symptoms and even in this case, it should not be used more than four times a day. Patients who are in stable condition but who continue to exhibit symptoms even after using inhaled beta agonists should take anticholinergic drugs. It is not all patients suffering from chronic obstructive pulmonary disease respond to corticosteroid therapy. However a preoperative systematic corticosteroid course lasting two weeks is ideal for patients who continually exhibit the symptoms even after bronchodilator therapy. The course is also ideal for patients whose personal base-line level is not at its best as indicated by chest examination, symptoms, and spirometry. Clinicians are supposed to use preoperative antibiotics on patients in whom the continued presence of an infection is overtly suggested by changes in amounts and character of sputum. Indiscriminate use of preoperative antibiotics cannot necessarily reduce risks associated with post-operative pneumonia especially in patients who are undergoing nonthoracic surgery. For patients suffering from viral upper respiratory infection, the risk of perioperative pulmonary complications remains unknown. Asthma In a study done on patients with asthma, it was found that patients with upper respiratory infection with the 30 days preceding the operation did not encounter an increase in perioperative pulmonary complications. The procedure that are currently being used on Chronic Obstructive Pulmonary Disease patients can be more efficient if more studies were done to shed light on the nature of risks that patients who undergo major thoracic and abdominal surgery undergo. Meanwhile, for patients, it is good to delay elective surgery in upper respiratory infection patients. The overall perioperative complications rates for patients with asthma is 24 percent while in controls, it is 14 per cent. Recent studies are yet to confirm this risk. For instance, in a study involving 706 patients who had asthma, 33 percent of them were treated with bronchodilators during the 30 days preceding the surgery. The outcomes were that only 1.7 percent of them were reported to have incidences of perioperative bronchospasm. During surgery, asthma patients should have a peak flow of over 80 percent of either the predicted value or personal best value. Additionally, they should not have wheezing problems. If necessary, oral corticosteroids should be used. The best corticosteroid for asthma patients is 60mg of prednisone or its equivalent. For patients with asthma, a short perioperative corticosteroids course cannot increase infection risks. Additionally, it cannot increase postoperative complications. Procedure-Related Risk Factors Pulmonary complications can also be brought about by procedure-related risk factors. The most valuable predictor of pulmonary risk is the surgical site. The greatest risk is in thoracic and upper abdominal surgery. The risk ranges between 10 and 40 percent. For laparoscopic cholecystectomy, the risk is much lower, ranging between 0.3 and 0.4 percent, compared to that open cholecystectomy, which ranges between 13 and 33 percent. Pulmonary complications are rare in operations that have been done outside the abdomen or the thoracic area. Procedures that last for more than three hours greatly increase the risk of pulmonary complications. Shorter procedures should be preferred whenever possible. This should be the case especially for patients with unmodifiable factors that continue to put them at a very high risk. In most studies, the risk of pulmonary complications is greatly reduced when spinal or epidural anesthesia is used. When the general anesthesia is used, the risk is greatly increased. However, more research needs to be done in this area in order for these results to be clarified. In an early study involving a retrospective inquiry into patients who suffered from chronic obtrusive pulmonary disease, it was observed that 8 percent of all the 464 general anesthesia-bound patients died of respiratory failure. No deaths were reported among the 121 spinal anesthesia-bound patients. Regional anesthesia, for example, axillary block, exposes patients to a lower risk than general or spinal anesthesia. The role of the qualified perioperative nurse in pulmonary complication risk prevention The nurse should carefully take the history of the patient. He should also carry out a physical examination. A history of intolerance to exercise, chronic cough, and unexplained dyspnea should also be sought. The physical examination may lead to identification of findings that are suggestive of unrecognized pulmonary disease. Symptoms such as dullness to percussion, decreased breath sounds, wheezes, prolonged expiratory phase and rhonchi are predictive of an increase in pulmonary complications. Reference Smetana, G. (1999). Preoperative Pulmonary Evaluation, The New England Journal of Medicine. 340(12) 937-944. Read More