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Signa Vitae

Journal of Intensive Care and Emergency Medicine

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Preoperative Evaluation of High Risk Pulmonary Patient

Background

The most recent guidelines provide detailed algorithms for preoperative evaluation and preoperative risk assessment of lung resection candidates. There is no single gold standard test to predict the adequacy of post–resection lung function. Pulmonary evaluation includes “the three legged stool”: respiratory mechanics, pulmonary parenchymal and cardio-pulmonary function.

Keywords: preoperative evaluation, predictive postoperative forced expiratory volume in one second (ppoFEV1), cardiopulmonary exercise test (CPET), high-risk pulmonary patient.

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Preoperative Rehabilitation Program of Pulmonary Risk Patient in Slovenia

Background

In the recent year’s preoperative rehabilitation is gaining in importance. It is intended for patients that are found too risky for operation because of poor baseline status and low exercise capacity with weak muscle strength. Patients are because of that often referred to pulmonary rehabilitation program with the intention to improve their exercise tolerance, increase peripheral and respiratory muscle strength, reduce peri and post-operative complications and enhance postoperative recovery. Pulmonary rehabilitation is a comprehensive multidisciplinary intervention/program, designed to improve physical and psychological condition of people with chronic respiratory disease. Exercise training is the fundamental of the program with added education, behavioural change, nutritional and psychological help. In University Clinic of Pulmonary and Allergic Diseases Golnik we have started with the pulmonary rehabilitation program in 2006. Majority of our patients enrolled in the program are patients with chronic obstructive pulmonary disease. We also enrol patients with interstitial lung disease and other chronic lung diseases like asthma, bronchiectasis etc. In the recent years also the number of patients who are referred to our program because of preoperative rehabilitation is increasing. These are patients who are candidates or are in preparation period for eventual lung transplantation, patients with COPD who are candidates for lung volume reduction surgery etc. The program and level of physical activities is individually adjusted to each patient according to their initial physical performance.

Keywords: rehabilitation, exercise tolerance, muscle strength.

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Ischemic Heart Disease and Ongoing Surgery

The prevalence of ischemic heart disease in surgery patients is increasing. Up to 34 % of patients require surgery within one year of percutaneous coronary intervention (PCI) with stenting. Dual antiplatelet therapy (DAPT) should be introduced for at least 12 months to prevent late stent thrombosis, especially in drug-eluting stents (DES), where endothelisation of stented segment is slower. Risk of stent thrombosis is greater with recent myocardial infarction, bifurcation lesions, suboptimal stent deployment, first generation DES, while second generation DES and bare metal stents have lower risk of stent thrombosis. Although some randomized studies showed that it might be safe do discontinue DAPT 3-6 months after second generation DES implantation, stent thrombosis is still feared and grave complication in first year after PCI. The preoperative management of patients after PCI requires consideration of bleeding risk on DAPT and risk of stent thrombosis. There are no randomized data about optimal timing of surgery. Guidelines recommend postponing surgery for at least 6 months after percutaneous coronary intervention with drug-eluting stent implantation (DES-PCI) and 12 months if PCI was done following myocardial infarction. The 2016 American College of Cardiology/American Heart Association guidelines update strongly advises against elective noncardiac surgery <3 months after DES implantation, but surgery may be considered 3 to 6 months after DES-PCI, with discontinuation of DAPT if the delayed surgery risk is greater than the stent thrombosis risk. A big recent Danish study showed that surgery in first 12 months after DES-PCI was associated with an increased risk of myocardial infarction and cardiac death but not all-cause mortality compared to patients without ischemic heart disease. However, the increased risk was only present within first month after DES-PCI. According to PARIS registry it may be safe to interrupt DAPT for <14 days under physician guidance. Knowing both, surgery might be undertaken earlier than currently recommended. There is a consensus that excluding emergency, surgery can be done between 1 and 3 months after DES-PCI if there is uncontrolled bleeding or the outcome is strongly influenced by surgical delay. On the other hand, surgery should be delayed at least 3 to 6 months in acute coronary syndrome, diabetes mellitus, low left ventricular ejection fraction, history of stent thrombosis, PCI of left main, small stents and long stented segments.

Keywords: percutaneous coronary intervention, surgery, antiplatelet therapy.

Problems of Thoracic Surgery Residency in Slovenia

The introduction of minimally invasive technique in the surgical practice has significantly changed the image of thoracic surgery in our country. In the recent decade most of thoracic surgeons adopted a technique of different minimally invasive approaches for the treatment of wide spectrum of intrathoracic diseases. In our institution the greatest advancement in recent years has been made in the field of major lung resections with around 80% of resections being performed using video-assisted thoracic surgery.

Keywords: minimally invasive surgery, training programme, surgical skills.

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Comparison of the Rate of Preoperative and Post-Operative Pain in VATS and Open Surgery of the Lungs

Backgrounds

Our presentation includes a brief definition of videothoracoscopy and thoracotomy and brief comparison of both with focus on rib spacing in thoracotomy. Mention is also made of study that compared a number of parameters (time of drainage, time of hospitalization, total number and number of pulmonary complications) between VATS and thoracotomy. Following a key question, how is with the pain in both cases.

Keywords: videothoracoscopy, thoracotomy, pain rate.

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