[HSF] Pre op room air blood gases.

[erdinç naseri]

Dear Dr. Harris,
Regarding our patient ,only L uper lobectomy and several lower lobe segmentectomies would suffice for the prevention of postop air leak.Having done this we wouldn't be able to prevent the second round of massive air leak from the R lung.
In our practice if there are sevral excisable bullae we excise them otherwise: low tidat volume hyperventilation  and smooth extubation as soon as possible. 
erdinc> Date: Sun, 24 Jun 2007 23:05:13 +0100> From: drdharris at yahoo.co.uk> Subject: RE: [HSF] Pre op room air blood gases.> To: OpenHeart-L at lists.hsforum.com> CC: > > I do not understand why some are debating whether a> pre-op blood gas should be done.....it shows what the> baseline is, and as trends are more important than> pure values during the postop period, a baseline> should always be done. Similarly for renal and liver > function, we want to know what was normal for the> patient before he walked in. Our anaesthesiologists> always, routinely do a room air blood gas as soon as> the arterial line has been inserted. It is on occasion> useful to refer back to it if a patient ends up long> term on a ventilator, and gives us an idea of what pO2> to accept when weaning (we never allow sats below 90%)> > Patients with large bullae are not uncommon in our> practice, and our routine practice is to remove them> before giving the heparin. It has been my experience> that you will pay an even higher price afterwards if> you do not remove them. They will more often get air> leaks anyway, and this can be disastrous if the bullus> (or bullae) are not excised. > Dave Harris> > > --- erdinç naseri <enaseri at hotmail.com.tr> wrote:> > > > > Ben,> > WRT your question let me share my experience with a> > patient of mine who underwent CABG 3 weeks ago:52> > y/O male smoker( 20 pack-year) diabetic and athletic> > build up,CAD( 3 vessel disease),Nothing special on> > physical exam,CXR: aortic arch calcification,> > increased in bronchovascular marking.Forgot to take> > ABG preop.> > OP:CABG X 4 ( Lima,RA,RGEA),whole upper lobe and> > upper segments of the llower eft lung full of> > bullaes.decided not to touch the lung,Reoperation> > for bleeding in the 5.th hour and extubated the same> > day with PO2 60.s and transfered to the normal ward> > on postop 2.nd day.Air leak in the 3.rd day with> > falling PO2 and S%O2.Transfered to ICU and> > reintubated.(Tidal vol.ins 450 cc ,Tidal vol.exp 250> > cc) taken to the operation room and repair one major> > leak in the upper lobe.uneventful day and night and> > extubated with no air leak, transfererd to normal> > ward.Postop 5.day massive facial emphysema ( left> > thoracic tube working properly),CXR:complete> > collapse of R lung,Tube thoracostomy with massive> > air leak and deteriorating hemodynamic and> > neurologic status,transfered to ICU reintubated ,TV> > ins 410 TV exp 280,PO2 50 mmHg, hemodynamic> > deterioration worsens ,BGL at 500.s despite daily> > 100 units of insulin).Taken to OR,Resternotomy and> > open R mediastinal pleura to see severe adhesion of> > the lung and bubbles coming deep from> > hemithorax.Release of the adhesions and complete> > inflation of the lungs but no air leak detected> > .Taken to ICU andverything normailzed. finally> > discharged at postop 10.th day.> > Retrospectively there was a minimal hyperaeration of> > the left lung on CXR corresponding to a big air sac> > in the upper lobe( missed by me)> > Had some trouble to explain to family about 4 times> > OR visit and lung problem.> > Lesson:ABG +/- thoracic CT preop if required> > .Explain accordingly about mortality and morbidity> > to the family.> > erdinc> > > Date: Sun, 24 Jun 2007 13:48:09 +1000> To:> > OpenHeart-L at lists.hsforum.com> From:> > benjamin.bidstrup at bigpond.com> Subject: Re: [HSF]> > Pre op room air blood gases.> CC: > > We should list> > the tests that get done preop and then rank them in> > > order of value for management.> e.g. My Sunday pm> > start of the list.> > EKG> CXR> ABG> RFTs (basic> > spirometry)> RFTs (lung volumes, DLCO)> CT Chest>> > Full blood count> Electrolytes> Liver Function>> > Cardiac Enzymes> Renal function (BUN, Cr)> > How> > many of these are defensive tests and how many> > really influence management?> What is the cost of> > these tests?> > > > >If it showed one or more lung> > tumors it would certainly change my > >plan for> > management. John Flege> >> >> >-----Original> > Message-----> >From: Michael Firstenberg> > <msfirst at gmail.com>> >To:> > OpenHeart-L at lists.hsforum.com> >Sent: Sat, 23 Jun> > 2007 11:05 am> >Subject: Re: [HSF] Pre op room air> > blood gases.> >> >> >> >> >> >> >I dont think anyone> > is arguing against a pre-op CXR. Although, > > > >> >interestingly - how does that EVER change> > management. But, again - one of > >> >those> > "expensive tests" that is probably useless until the> > first post-op CXR > >> >is abnormal and you are> > quickly looking for the pre-op baseline. > >> >> >>> > >-michael > >> >> >> >On 6/23/07, Michael> > Firstenberg <msfirst at gmail.com> wrote: > >> >>> >>> > >>Actually, the real problem that we see is the> > opposite.> >> >>Patients get labeled as having COPD,> > bad lungs, etc as a function of> >their > >>> > >>smoking histories and so they get extubated> > (usually at the> >insistence of > >> >>the Fellows)> > with mariginal blood gases (i.e. some degree of> > hypoxia> >or > >> >>hypercarbia) and everyone then> > says: "oh, Sats in the mid 80's is> >fine, > >>> > >>they are smokers" - fine until they get obtunded,>> > >hypoxic/hypercarbic, and > >> >>need reintubation> > under sometimes less than idea clinical situations.>> > >> >>> >> >>-michael> >> >>> >> >>> >> >> On> > 6/23/07, Ani Anyanwu <anianyanwu at hotmail.com>> > wrote:> >> >> > > >> >> >> > Michael> >> >> >> >> >> > Surely you> > do not need an ABG to confirm, refute, or even> > elucidate> >> >> > severity of COPD? Also, in what> > way does a preop ABG help in> >getting you off > >>> > >> > the ventilator? What exactly are your criteria> > for extubating> >patients and > >> >> > where does> > the ABG come in the decision making? That a test is> > easy> >to get > >> >> > and easily accessible does> > not indicate its usage.> >> >> >> >> >> > Sounds> > like a real interesting population you have down> > there - are> >they > >> >> > just dumping the crap> > on the new guy or is it typical of your> >entire >> > >> >> > center's practice?> >> >> >> >> >> > Ani> >>> > >> >> >> >> >> >> >> >> >> >> > ----- Original> > Message -----> >> >> > From: Michael Firstenberg> >>> > >> > Sent: Saturday, June 23, 2007 10:38 AM> >> >> >> > To: OpenHeart-L at lists.hsforum.com> >> >> > Subject:> > Re: [HSF] Pre op room air blood gases.> >> >> >> >>> > >> > As this discussion hopefully continues.> >> >>> > > We have point of ca> > re ABGs - which means the RT on the floor can>> > >walk to > >> >> > the> >> >> > bedside, draw the> > gas, and walk to the lab 10 meters down the hall>> > >and > >> >> > get> >> >> > the results in 5> > minutes.> >> >> >> >> >> > I advocate that many of> > our patients do have multiple risk factors> >- > >>> > >> > long smoking histories> >> >> > history of> > "COPD" - often never proven just assumed over the> > years.> >> >> > shortness of breath is often a major> > complaint> >> >> >> >> >> > large operations are> > planned - we do a lot of VADs (bridge, DT,>> > >salvage) > >> >> > and> >> >> > low EF's with> > valves.> >> >> > Even our simple CABGs these days> > have multiple medical problems> >> >> >> >> >> > In> > fact the healthiest patient I have operated on in> > the past> >couple of > >> >> > weeks was no medical> > problems other than bad multiple sclerosis for> >>> > >> > which> >> >> > she needed frequent interferon> > treatments (and now CAD and CHF due> >to > >> >> >> > her> >> >> > acute left main thrombosis)> >> >> > > >> >> >> > Many of our patients do not have> > cardiologists nor have the seen a> >> >> > doctor> > in> >> >> > years (if ever)> >> >> > Histories are> > unreliable -> >> >> > One patient I did, also for> > bad left main disease, already had a> >lung > >> >>> > > biopsy for IPF and still smoked, according to her> > 8 cigs/day -> >although > >> >> > the> >> >> > rest> > of her family (including her husband) all insisted> > it was more> >like > >> >> > 3> >> >> > packs a day!> > She did fine and when I saw her in follow-up and>> > >asked her > >> >> > about her smoking - she said> > she was down to 8 a day - her husband> >in > >> >> >> > the> >> >> > corner just rolled her eyes......> >>> > >> >> >> >> > I find that having a pre-op ABG is> > very helpful in it gives us some> >> >> > sense of>> > >> >> > what to shoot for in trying to get these> > patients off of the vent -> >> >> > particularly if> > they dont fly off right after surgery.> >> >> >> >>> > >> > In addition, granted not everyone needs them,> > but it is probably> >ea> > sier > >> >> > to> >> >> > have a pre-op protocol> > to get them in everyone rather than> >selectively >> > >> >> > pick> >> >> > and choose.> >> >> >> >> >> >> > -michael> >> >> >> >> >> >> >> >> >> >> >> > On> > 6/23/07, prasannasimha <prasannasimha at gmail.com>> > wrote:> >> >> > >> >> >> > > Something I wanted to> > ask too.> >> >> > > Prasanna> >> >> > >> >> >> > >> > Ani Anyanwu wrote:> >> >> > > > It is interesting as> > you move around different hospitals and> >speak > >>> > >> > to> >> >> > > different surgeons you get to> > realize how much of what you do is> >a > >> >> >> > waste of> >> >> > > time or unnecessary. I would> > actually go to the extreme of saying> >> >> > there> > is> >> >> > > no patient that NEEDS an ABG before> > elective heart surgery. It> >may be > >> >> > a> >>> > >> > > helpful guide in some patients but not a> > necessity. I trained in> >some > >> >> > > hospitals> > where we got PFTs, and sometimes room air ABG on> > every> >> >> > patient who> >> >> > > had ever> > smoked, was elderly or was high > > risk. However in my> >present > >> >> > > hospital,> > and we do much sicker patients and we have> > practically> >never > >> >> > got a> >> >> > > room> > air ABG and very rarely PFTs. The truth is somewhere> > in> >between > >> >> > but> >> >> > > either test is> > certainly not a necessity.> >> >> > > >> >> >> > > >> > What I would ask those who do or rely on these tests> > is to> >think > >> >> > back as> >> >> > > to how> > many times the results of this test has changed> > management> >and > >> >> > how?> >> >> > > >> >> >>> > > > > Ani> >> >> > > >> >> >> > > > ----- Original> > Message -----> >> >> > > > From: prasannasimha> >>> > >> > > > Sent: Saturday, June 23, 2007 7:46 AM> >>> > >> > > > To: OpenHeart-L at lists.hsforum.com> >> >> >> > > > Subject: Re: [HSF] Pre op room air blood gases.>> > >> >> > > >> >> >> > > > Michael , if the patient> > has an OK pulse oximetry value on room> >air > >> >>> > > he> >> >> > > > doesn't need a preop ABG. If he> > has an abnormal one he needs a> >PFT > >> >> > etc>> > >> >> > > > etc e> > tcand not just an ABG.> >> >> > > > We do a preop> > ABG selectively.> >> >> > > > Incidentally PFT's> > ABG's etc etc will all have a confounding> >value >> > >> >> > if> >> >> > > > the patients lungs are full> > of water eg MS or MR. or even an> >ASD. > >> >> > >> > > Prasanna> >> >> > > > Michael Firstenberg wrote:>> > >> >> > > >> >> >> > > >> We are in the midst of a> > heated discussion. I agrue that like> >> >> > basic>> > >> >> > > labs and chest xray a room air abg is> > needed before heart> >surgery. My > >> >> > >> > partners advocae that it is a waste of money unless> > clearly> >> >> > indicated. But> >> >> > > no one> > gives indications.> >> >> > > >>> >> >> > > >>> > Thoughts?> >> >> > > >> Practice patterns?> >> >> >> > > >> Bob - i am sure you wrote a few papers on> > this.> >> >> > > >>> >> >> > > >>> >> >> > > >>> > Michael > === message truncated ===> > > Dr. David G. Harris, FCS, MMED,> Cardiothoracic Surgeon > Suite 207 > Kuils River Private Hospital, > PO Box 1200, Kuils River, 7579, Cape Town, South Africa. > Tel +27-21-9006411 > Fax +27-21-9006412 Mobile +27-83-3309587> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------