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The Operation Summary* FREE TO VIEW

Judah Skolnick, MD, FCCP
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*Judah Skolnick, MD, FCCP, was the moderator for this section of the conference, and the participants were Jay B. Brodsky, MD; Myer H. Rosenthal, MD; and Janice G. McFarland, MD.

Correspondence to: Judah L. Skolnick, MD, FCCP, 224 E Broadway, Louisville, KY 40202

Chest. 1999;115(suppl_2):47S. doi:10.1378/chest.115.suppl_2.47S
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A multidisciplinary group reviewed intraoperative monitoring, fluid management, and blood and blood component transfusions. The conclusions took into account existing recommendations of the appropriate specialty societies. Existing definitions of high, low, and intermediate risk of the American Society of Anesthesiology (ASA) were used. A low operative risk is a surgical procedure involving peripheral or superficial surgery with no entrance into a body cavity. An intermediate-risk procedure is a peripheral or superficial procedure with high risk of blood loss, or an intra-abdominal or intrathoracic procedure with no risk of physiologic impairment. A high-risk procedure is a major intra-abdominal, intrathoracic, or intracranial procedure with high risk of physiologic impairment.

For the low-risk patient, the recommendation for intraoperative monitoring is to endorse existing ASA standards. The same recommendation is made for intermediate- and high-risk patients with the addition of appropriate invasive monitoring and laboratory studies as indicated in each specific case.

Recommendations for Future Directions in Research

  1. Quantify risk based on patient physical status and type of operation.

  2. Continued evaluation of old and new invasive monitoring techniques to define indications.

Intraoperative fluid management was considered. For low-risk patients, the recommendation is to administer IV maintenance fluids in amounts to maintain the patient euvolemic with fluids that would be expected to maintain normal electrolyte status, at the discretion of the provider. For intermediate- and high-risk patients, the same recommendation as for low-risk patients is recommended with further additions as follows:

Additional fluids should be administered to deal with blood loss and fluid shifts. This should be based on an assessment of intravascular volume and tissue perfusion and in response to laboratory values. If the choice of fluids involves Hetastarch, established guidelines should be followed that govern the amount to be used per 24-h period to avoid coagulopathy. Dextrose-containing fluids should not be used routinely unless there is likelihood or evidence of hypoglycemia, and appropriate laboratory studies are done.

Recommendation for Future Directions in Research

  1. The choice of fluid to be used: crystalloid vs colloid.

Intraoperative blood component therapy was considered next. The recommendations are the same for low-, intermediate-, and high-risk patients. There appears to be no standard minimum level of hemoglobin or hematocrit required for surgery. Consideration should be given to the patient’s cardiac and respiratory status and to oxygen demand. The determinants may be cardiac output, oxygen saturation, and oxygen demand.

Recommendation for Future Directions in Research

  1. Further research and assessment of substitutes for RBCs to provide oxygen-carrying capacity.

Intraoperative use of coagulation factors was considered. The recommendations are the same for low-, intermediate-, and high-risk patients. There are guidelines by the American College of Pathology and by the ASA. These should be endorsed. The only indication for fresh frozen plasma, platelets, or cryoprecipitate is known or suspected coagulopathy. Appropriate laboratory studies to assess coagulation status should be initiated prior to administration.

Recommendations for Future Directions in Research

  1. Continued evaluation of what are safe levels of coagulation factors.

  2. Continued assessment of risks and benefits of blood component therapy.




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