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You are asked to perform a preoperative risk assessment on a 78-year-old female with a traumatic femur fracture after slipping on ice. The patient takes no medications, has no known medical problems, has no cardiac symptoms, has no problems with easy bruising or prolonged bleeding, and is usually able to climb several flights of stairs. The patient does have a 50 pack-year smoking history, but quit smoking about 10 years ago.

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Physical examination is unremarkable except for evidence of the femur fracture.

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Preoperative tests show a normal sinus rhythm on ECG, hyperinflation of the lungs on chest x-ray, and unremarkable electrolytes and CBC. The surgical resident indicates that the surgery will take about 3 hours and require general anesthesia.

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1. What additional tests are needed to assess this patient's risk of surgical complications?

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2. What are this patient's risk factors for postoperative pulmonary complications?

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3. What actions should be taken postoperatively to reduce the patient's risk of complications?

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Answers

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  1. No additional tests will influence the decision as to whether the patient is appropriate for this urgent surgery. The patient does not appear to have any active cardiac issues and has good exercise tolerance. The ACC/AHA Guidelines on Perioperative Evaluation and Care for Noncardiac Surgery indicate that it is reasonable to proceed to surgery under these circumstances. Pulmonary function tests are not strong predictors of perioperative pulmonary complications, and checking a PT and PTT is not needed because the patient has no history of bleeding disorders.

  2. Age (over 60 years) and the prospect of a prolonged surgery under general anesthesia are known risk factors for postoperative pulmonary complications. Cigarette smoking is not a risk factor because the patient quit smoking about 10 years ago. The patient may have COPD based on her smoking history and hyperinflation of the lungs. If the patient does have COPD, it is an additional risk factor for postoperative pulmonary complications.

  3. This patient would benefit from DVT prophylaxis in the postoperative time frame. Due to the nature of the injury and surgery, the patient is at increased risk of DVT. In addition, monitoring for evidence of bleeding should be routine after a surgical procedure.

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This patient has no known medical problems, good functional status (>4 METS), and no active cardiac issues. Using the ACC/AHA Guidelines on Perioperative Evaluation and Care for Noncardiac Surgery criteria, this patient can go to surgery without further cardiac testing or the initiation of a beta-blocker or other drug therapy. Additional testing, though commonly performed, is unlikely to alter the decision regarding the patient's stability for surgery.

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Part of a preoperative examination is to also identify potential postoperative risks. This patient is at increased risk of pulmonary and thrombotic complications. Recommending DVT prophylaxis and incentive spirometry is appropriate.

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