java barcode reader api open source Risk Factors for the Development of Postoperative Pulmonary Complications in Objective-C

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Risk Factors for the Development of Postoperative Pulmonary Complications
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The risk of developing a pulmonary complication is highest in patients undergoing cardiac, thoracic, and upper abdominal surgery, with reported complication rates ranging from 9% to 19% The risk in patients undergoing lower abdominal or pelvic procedures ranges from 2% to 5%, and for extremity procedures the range is less than 1 3% The pulmonary complication rate for laparoscopic procedures appears to be much lower than that for open procedures In one series of over 1500 patients who underwent laparoscopic cholecystectomy, the pulmonary complication rate was less than 1% Three patient-specific factors have been repeatedly found to increase the risk of postoperative pulmonary complications: chronic lung disease, morbid obesity, and tobacco use Patients with chronic obstructive pulmonary disease (COPD) have a twofold to fourfold increased risk compared with patients without COPD In a single large prospective cohort of US military veterans, additional risk factors for the development of postoperative pneumonia included age over 60 years, dependent functional status, impaired sensorium, and prior stroke Several studies have found that a low serum albumin level is associated with a higher risk of pulmonary complications and overall mortality Patients with asthma are at increased risk for bronchospasm during tracheal intubation and extubation and during the postoperative period However, if patients are at their optimal pulmonary function (as determined by symptoms, physical examination, or spirometry) at the time of surgery, they do not appear to be at increased risk for other pulmonary complications Postoperative pneumonia is approximately twice as likely to develop in morbidly obese patients those weighing over 113 kg (250 lb) than in patients weighing less Mild to moderate obesity does not appear to increase the risk of clinically important pulmonary complications Several studies have shown that current cigarette smoking is associated with an increased risk of postoperative atelectasis In a single study, cigarette smoking was also found to double the risk of postoperative pneumonia, even when controlling for underlying lung disease A summary of the known risk factors for pulmonary complications is presented in Table 3 5
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Pulmonary Function Testing & Arterial Blood Gas Analysis
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The majority of studies have shown that preoperative pulmonary function testing (PFT) in unselected patients is not
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Table 3 5 Clinical risk factors for postoperative pulmonary complications
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Upper abdominal or cardiothoracic surgery Prolonged anesthesia time (> 4 hours) Age > 60 years Chronic obstructive pulmonary disease Congestive heart failure Tobacco use (> 20 pack-years) Impaired cognition or sensorium Functional dependency or prior stroke Morbid obesity Low serum albumin level
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helpful in predicting postoperative pulmonary complications The data are conflicting regarding the usefulness of preoperative PFT in certain selected groups of patients: the morbidly obese, those with COPD, and those undergoing upper abdominal or cardiothoracic surgery Assessment of the severity of COPD using PFT has not been shown to improve upon the clinical risk assessment with the exception that patients with a forced expiratory volume in 1 second (FEV1) under 500 mL or an FEV1 below 50% of the predicted value appear to be at particularly high risk However, there is no clear degree of PFT abnormality that can be used as an absolute contraindication to non lung resection surgery At present, definitive recommendations regarding the indications for preoperative PFT cannot be made In general terms, such testing may be helpful to confirm the diagnosis of COPD or asthma, to assess the severity of known pulmonary disease, and perhaps as part of the risk assessment for patients undergoing upper abdominal surgery, cardiac surgery, or thoracic surgery Arterial blood gas measurement is not routinely recommended except in patients with known lung disease and suspected hypoxemia or hypercapnia
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spirometry (IS), continuous positive airway pressure (CPAP), intermittent positive-pressure breathing (IPPB), and deep breathing exercises (DBE) Although trial results have been mixed, all these techniques have been shown to reduce the incidence of postoperative atelectasis and, in a few studies, to reduce the incidence of postoperative pulmonary complications In most comparative trials, these methods were equally effective Given the higher cost of CPAP and IPPB, IS and DBE are the preferred methods for most patients However, in a randomized trial of patients undergoing esophageal or gastric resection, CPAP was more effective at preventing respiratory failure than IS or DBE and thus may be preferable after these operations IS must be performed for 15 minutes every 2 hours DBE must be performed hourly and consist of 3-second breath-holding, pursed lip breathing, and coughing These measures should be started preoperatively and be continued for 1 2 days postoperatively A single-blind, randomized trial found that an intensive preoperative inspiratory muscle training program reduced the risk of postoperative pneumonia from 16% to 65% in patient undergoing coronary bypass surgery Most studies suggest that postoperative epidural opioid and local anesthetic agents provide excellent pain control but do not appreciably reduce pulmonary complication rates Finally, limiting the use of nasogastric decompression tubes after abdominal surgery to only those patients who have specific indications (such as postoperative ileus) has been shown to reduce pulmonary complications
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Hulzebos EH et al Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery JAMA 2006 Oct 18;296(15):1851 7 [PMID: 17047215] Lawrence VA et al; American College of Physicians Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the American College of Physicians Ann Intern Med 2006 Apr 18;144(8):596 608 [PMID: 16618957] Qaseem A et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians Ann Intern Med 2006 Apr 18;144(8):575 80 [PMID: 16618955] Salpeter S et al Cardioselective beta-blockers for chronic obstructive pulmonary disease Cochrane Database Syst Rev 2005 Oct 19;(4):CD003566 [PMID: 16235327] Smetana GW et al; American College of Physicians Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians Ann Intern Med 2006 Apr 18;144(8):596 608 [PMID: 16618957]
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