Preoperative Assessment: A Case-Based Approach

✍ Scribed by Derek Dillane (editor), Barry A. Finegan (editor)

• Publisher: Springer
• Year: 2021
• Tongue: English
• Leaves: 309
• Category: Library

✦ Synopsis

This book uses a case-based approach to provide current information on a range of medical issues with the goal of enhancing preoperative evaluation and optimization. It meets the market need for a resource that concisely encapsulates current knowledge on the medical management of specific topics in a setting relevant to the preoperative clinic. In so doing the book aims to improve patient care and safety, enhance resource use, facilitate appropriate and timely management of preexisting conditions and diminish patient concerns.

Organized into sections according to body system, each section consists of chapters delineating a specific disorder. Each chapter starts with a clinical vignette followed by a question-and-answer style investigation of the relevant issues. These questions attempt to address commonly encountered clinical dilemmas where opinion often differs between, and occasionally within, medical sub-specialties. Expertly written chapters are also supplemented bya number of chapters which address special considerations such as the frail patient and chronic opioid use.

Preoperative Assessment: A Case-Based Approach is an invaluable reference for all physicians involved in preoperative assessment including anesthesiologists, surgeons, internists, family doctors and residents in these fields. Nurse practitioners and other allied heath professionals involved in preoperative evaluation may also find this a book a valuable and timely resource.

✦ Table of Contents

Foreword
Preface
Laboratory Test Reference Values
Contents
Editors (and Authors)
Contributors
1: Preoperative Assessment and Optimization
References
Part I: Cardiac
2: The Cardiac Patient Undergoing Noncardiac Surgery
How Long Should Noncardiac Surgery Be Delayed Following Acute Myocardial Infarction?
What Is the Difference Between Type 1 and Type 2 Myocardial Infarction?
What Is Acute Coronary Syndrome?
What Complications Is the Patient with Ischemic Heart Disease Subject to in the Perioperative Period?
What Are the Characteristic Features of Perioperative Myocardial Infarction?
What Is Myocardial Injury After Noncardiac Surgery (MINS)?
Describe a General Approach to Evaluation of a Patient with a History of Acute Coronary Syndrome Who Is Scheduled to Undergo Noncardiac Surgery?
Having Decided That Our Patient Has Established Coronary Artery Disease, How Do We Negotiate Step 2 of the ACC/AHA?
How Is the Risk of a Major Cardiovascular Complication Estimated Prior to Surgery?
Revised Cardiac Risk Index or NSQIP Surgical Risk Calculator—Which Is Better for Assessing Perioperative Risk?
What Do the RCRI and the NSQIP Surgical Risk Calculator Tell Us About Our Patient?
Having Established That the Patient Is at Risk for a Major Cardiac Complication, What Are the Next Steps in Assessment?
Is Echocardiographic Assessment of Left Ventricular Function of Benefit?
Which Noninvasive Imaging Technique—Stress Radionuclide Myocardial Perfusion Imaging or Stress Echocardiography—Is Preferable?
When Is Preoperative Angiography Indicated?
What Are the Indications for Revascularization in the High-Risk Cardiac Patient Awaiting Noncardiac Surgery?
For How Long Should Surgery Be Postponed in a Patient Who Has Undergone Coronary Artery Stenting?
ACS in Our Patient Was Treated with Intravenous Heparinization and DAPT. If He Had Not Experienced Frank Hematuria, For How Long Should DAPT Have Been Continued?
How Can Perioperative Cardiac Risk Be Medically Modified?
Should This Patient Have BNP Measured Preoperatively as a Screening Measure for Postoperative Myocardial Injury?
References
3: The Adult Congenital Cardiac Patient for Noncardiac Surgery
What Are the Physiologic Effects of a Fontan Procedure?
What Are Some of the Systemic Complications in the Patient with Failing Fontan Physiology?
How Should This Patient Be Evaluated Preoperatively?
What Factors May Influence Planning for Sites of Invasive Monitoring?
What Perioperative Hemodynamic Goals Should Be Taken into Consideration when Preparing for Noncardiac Surgery in the Patient with Failing Fontan Physiology?
Are There Any Other Preoperative Considerations Specific to Fontan Patients for Noncardiac Surgery?
What Monitoring Modalities Do You Envisage Using for This Procedure?
Is a Neuraxial Technique Appropriate for This Case?
The Patient Is Curious About What to Expect in the Early Recovery Period. What Factors Should Be Taken into Consideration When Counseling Him?
Can This Procedure Be Performed on an Ambulatory Basis?
References
4: Hypertension
What Is Considered Abnormally High Blood Pressure (Hypertension)?
What Are the Current Pharmacological Treatment Strategies for Control of Hypertension?
What Is the Goal for Long-Term Pharmacological Treatment of Hypertension?
Is There Any Evidence That Aggressive Therapeutic Lowering of BP Is Harmful?
What Are the Perioperative Risks for the Hypertensive Patient?
Which Long-Term Consequences of Hypertension Are Associated with an Adverse Perioperative Outcome?
How Successful Is Treatment of Hypertension in Prevention of These Long-Term Consequences?
How Should the Hypertensive Patient Be Optimized Preoperatively?
Should Perindopril Be Continued Throughout the Operative Period?
Is There a Cutoff for Systolic or Diastolic BP Above Which Elective Surgery Should Be Cancelled?
What Do We Know About Perioperative Complications and Degree of Hypertension?
How Do You Manage a Patient Who Has Not Previously Been Diagnosed with Hypertension Whose BP Is Significantly Elevated at the Anesthesia Preassessment Clinic?
Should This Patient Continue on Aspirin Therapy?
Why Did This Patient Have Echocardiography and Nuclear Stress Myocardial Perfusion Imaging at the Time of Diagnosis of Hypertension? Are Any Other Investigations Indicated?
References
5: Cardiac Failure
What Complications Is the Patient with Cardiac Failure Subject to in the Perioperative Period?
How Is Cardiac Failure Classified?
In Which Patient Populations Should We Maintain a High Index of Suspicion for the Presence of Cardiac Failure?
What Are Prognostic Indicators in the Heart Failure Patient Presenting for Elective Surgery?
What Is the Prognostic Significance of Whether the Patient Is Symptomatic or Not?
How Is Acute Decompensated Heart Failure Recognized?
What Is Heart Failure with Preserved Ejection Fraction?
How Should the Patient with Cardiac Failure Be Evaluated Preoperatively?
What Are the Goals of Optimization?
What Medical Therapy Is Used to Optimize the Heart Failure Patient?
What Is the Role of Implantable Cardioverter-Defibrillators and Permanent Pacemakers in the Heart Failure Patient?
How Should the Decision-Making Process Be Approached Regarding the Appropriateness of the Proposed Surgery for This Patient?
References
6: Atrial Arrhythmias
What Complications Is the Patient with Atrial Fibrillation Subject to in the Perioperative Period?
What Potentially Modifiable Conditions Associated with AF Should Be Optimized in This Patient Prior to Surgery?
Are There Any Other Factors Which May Contribute to the Development of AF?
How Should the Patient with AF Atrial Be Evaluated Preoperatively?
History
Physical Exam
Investigations
How Is the Stroke Risk in Patients with AF Calculated?
How Would the Presence of Valvular Heart Disease with AF Impact Preoperative Optimization?
What Specific Medications for Rate and Rhythm Control Should We Expect to See in the Preoperative Patient with AF?
Does This Patient Need to Be Bridged?
Surgery and DOACs: An Approach
References
7: Aortic Stenosis
What Complications Is the Patient with AS Subject to in the Perioperative Period?
How Should the Patient with AS Be Evaluated Preoperatively?
History
Physical Exam
Investigations
What Is the Etiology of AS?
How Is the Severity of AS Categorized?
Which Patients with AS Are Considered Candidates for Surgical Repair/Replacement?
What Are the Reasons for Not Replacing a Severely Stenotic Valve Prior to Noncardiac Surgery?
What Potentially Modifiable Conditions Associated with AS Should Be Considered/Optimized in This Patient Prior to Surgery?
Is Spinal Anesthesia an Option for This Patient?
What Is the Significance of Prediabetes in This Patient?
References
8: Pulmonary Hypertension
What Are the Symptoms/Signs That Might Suggest the Presence of Severe PAH?
What Is the Definition of PAH?
How Should “Elevated” PAP Reported in a Routine Echocardiogram Be Interpreted?
What Are the Causes of PH?
What Are the Treatment Options for Patients with PH?
Is This Patient at “Normal” Risk for Elective Surgery?
Should Regional Anesthesia Be Discussed as an Option for Patients with PH?
How Should This Patient’s Medications Be Managed Preoperatively?
What Is the Preferred Location to Perform Elective Invasive Surgery in Patients with Severe PH?
References
9: Cardiac Implantable Electronic Devices
What Is a Cardiac Implantable Electronic Device (CIED)?
What Are the Indications for Permanent Cardiac Pacing?
What Do the Letters of the Pacemaker Code Signify?
Our Patient Has a VDD Pacemaker. What Does This Mean?
What Complications Is a Patient with a CIED Subject to in the Perioperative Period?
What Are Potential Sources of Electromagnetic Interference in the Perioperative Setting?
Is Electroconvulsive Therapy (ECT) a Source of Electromagnetic Interference?
Are There Any Guidelines to Aid in Decision-Making with Regard to the Safety of Patients with CIEDs in the Perioperative Period?
Who Is Responsible for Ensuring that the Patient’s CIED Functions Appropriately Throughout the Perioperative Period?
What Information Should Be Communicated to the CIED Team in Advance of Surgery?
What Factors Must Be Established Preoperatively in the Patient with a CIED?
What Is the Significance of Unipolar Versus Bipolar Pacemaker Leads?
Do CIEDs Have Any Other Inbuilt Protective Mechanisms to Prevent Electromagnetic Interference?
Does This Patient’s Device Need to Be Interrogated Prior to Surgery?
The CIED Programmer Was Previously Concerned About a “Failure to Capture.” What Is “Failure to Capture”?
Is There a Requirement for the Pacemaker Device to Be Reprogrammed Prior to Surgery?
The CIED Team Tells You to Apply a Magnet to the Pacemaker Intraoperatively. How Do You Respond?
Should an Echocardiogram Be Performed Preoperatively in This Patient?
What Valvular Abnormality Is Not Uncommonly Associated with Transvalvular ICD/Pacemaker Lead Presence?
Is Spinal Anesthesia Contraindicated for This Patient?
References
Part II: Vascular
10: Carotid Endarterectomy
What Is the Primary Objective of CEA Surgery?
What Are the Indications for Carotid Endarterectomy?
Should the Patient with Acute Ischemic Stroke Have Invasive or Noninvasive Neurovascular Imaging?
When Is the Optimum Time for Surgery Relative to the Onset of Neurological Symptoms?
When Is Carotid Angioplasty and Stenting Favored Over CEA?
What Complications Is the CEA Patient Subject to in the Perioperative Period?
How Should This Patient Be Evaluated Preoperatively?
How Should Hypertension Be Managed Perioperatively in This Patient Population?
How Are Arrhythmias Managed?
Describe an Approach to Anticoagulant Medications in the Perioperative Period
Should This Patient Continue Statin Therapy in the Perioperative Period?
Is Glucose Control in the Perioperative Period in This Cohort of Patients Important?
The Patient Has Read on the Internet That He Can Be Awake for His Carotid Endarterectomy. How Do You Advise Him?
What Approaches Are Available for a Regional Anesthetic Technique?
Is Assessment of Neurocognitive Function During Cross-Clamping Important During Awake Carotid Endarterectomy?
References
11: Abdominal Aortic Aneurysm
When Is an Enlargement of the Aorta Considered Aneurysmal?
What Are the Risk Factors, Screening Recommendations, Time Course of Enlargement, and Point of Consideration of Surgical Intervention for AAA?
Are There Validated AAA Perioperative Risk Assessment Tools?
Is There a Mortality Difference in Outcome Between OAR and EVAR?
What Specific Preoperative Assessment/Investigations/Interventions Are Recommended Prior to AAA?
What Forms of Anesthetic Management Should Be Discussed with the Patient Scheduled for Elective EVAR?
What Anesthetic Management Strategy Should Be Discussed with the Patient Scheduled for an Elective OAR?
References
12: Marfan Syndrome
What Is Marfan Syndrome?
What Are the Clinical Manifestations of MFS?
What Is the Aortic Root?
What Are Nuss Bars?
What Pulmonary Manifestations May Be Relevant Perioperatively?
What Cardiac Findings Are Associated with MFS?
What Is the Medical Management for MFS?
What Is the Life Expectancy for Individuals with MFS?
How Should the Patient with MFS Be Evaluated Preoperatively?
How Should This Patient’s ICD Be Managed Perioperatively?
Why Was This Patient on Warfarin?
References
Part III: Pulmonary
13: Obstructive Sleep Apnea
How Is Obstructive Sleep Apnea (OSA) Defined?
Is There Any Difference Between OSA and OSA Syndrome?
How Is Severity of OSA Classified?
What Is the Prevalence of OSA in the General Population? How Does the Prevalence Change in the Presence of Obesity?
What Are the Risk Factors for the Development of OSA?
How Is OSA Diagnosed?
What Is Central Sleep Apnea (CSA)?
How Is OSA Screened for Preoperatively?
What Percentage of Patients Who Screen Positive for OSA with STOP-Bang Test Positive with Sleep Studies?
What Comorbidities Are Associated with OSA?
How Can the OSA Patient Be Optimized Preoperatively?
What Are the Perioperative Complications of OSA?
What Circumstances May Exacerbate the Risk of Perioperative Complications Occurring in the OSA Patient?
Is There Any Reason Why This Patient Should Not Have an Interscalene Brachial Plexus (ISBP) Block to Reduce Perioperative Opioid Use?
What Factors Determine Whether Surgery Should Be Performed on an Inpatient or Outpatient Basis?
References
14: Chronic Obstructive Pulmonary Disease (COPD)
What Is COPD?
What Are the Pathophysiological Consequences of COPD?
How Is the Severity of COPD Assessed?
What Is the Utility of GOLD Grading and Grouping in the Perioperative Period?
What Coexisting Conditions Should One Consider in a Patient with COPD?
What Are the Two Classes of Bronchodilators Commonly Used in the Treatment of COPD?
What Are the Current Recommendations for Maintenance Bronchodilator and Steroid Therapy in COPD?
If My Patient Is not on Current Recommended Therapy, Should I Initiate Treatment in the Preoperative Period?
How Useful Is a Chest Radiograph in the Diagnosis and Assessment of COPD?
Does the Type of Anesthetic Influence Postoperative Outcome in Patients with COPD?
References
15: Asthma
What Is Asthma?
How Is Asthma Diagnosed?
How Is Asthma Managed?
What Are Leukotriene Receptor Antagonists?
What Other Pathogenesis-Modifying Agents Are Available to Treat Asthma Phenotypes?
How Is Asthma Control Assessed?
What Are the Risk Factors for a Future Exacerbation of Asthma?
Is Medication Compliance a Problem in Asthma Management?
What Is Samter’s Triad?
What Is a Suggested Approach to the Asthmatic Patient Presenting for Surgery?
References
16: Restrictive Lung Disease
How Is Restrictive Lung Disease Classified?
What Are the Causes of Interstitial Lung Disease?
What Are the Characteristics of IPF?
What Complications Is the Patient with ILD Subject to in the Perioperative Period?
What Are the Independent Risk Factors for the Development of Postoperative Pulmonary Complications in Patients with ILD?
What Are the Characteristic Pulmonary Function Test (PFT) Features of Restrictive Lung Disease?
How Should the Patient with Restrictive Lung Disease Be Evaluated Preoperatively?
History and Physical Examination
Investigations
How Is Disease Severity in IPF Classified?
What Risk Scores Provide an Estimate of Postoperative Respiratory Failure?
What Specific Medications Should We Expect to See in the Preoperative Patient with IPF?
What Complications of IPF Should the Patient Be Evaluated For?
References
Part IV: Endocrine
17: Diabetes Mellitus
How Is DM Classified?
What Complications Is the Patient with Diabetes Mellitus (DM) Subject to in the Perioperative Period?
What Target Blood Glucose Level Should We Aim for Preoperatively?
What End-Organ Abnormalities Associated with Diabetes Are of Particular Concern Perioperatively?
How Should the Patient with DM Be Evaluated Preoperatively?
History
Physical Exam
Investigations
Should Elective Surgery Be Cancelled Because of a High Preoperative HbA1c Value?
What Medications Should We Expect to See in the Preoperative Patient with DM?
What Terminology Is Used to Describe Commonly Used Insulin Regimens Outside of the Operating Room Environment?
What Is the Significance of Rosuvastatin Use in a Diabetic Patient?
What Factors Contribute to the Development of DKA or HHS Perioperatively?
Surgery and Hypoglycemic Agents: An Approach
References
18: Hyperthyroidism
What Is the Difference Between Thyrotoxicosis and Hyperthyroidism?
What Is Graves’ Disease and What Distinguishes It from Other Causes of Hyperthyroidism?
How Can a Patient with Hyperthyroidism Gain Weight?
What Is the Significance of a Long QT Interval in a Patient with Hyperthyroidism?
Is There a Link Between Pulmonary Hypertension and Hyperthyroidism?
What Complications Is the Patient with Thyrotoxicosis Subject to in the Perioperative Period?
How Should the Patient with Thyrotoxicosis Be Evaluated Preoperatively?
History
Physical Exam
Investigations
What Specific Medications Should We Expect to See in the Preoperative Patient with Thyrotoxicosis?
What Is the Goal of Preoperative Optimization Prior to Surgery?
References
19: Adrenal Insufficiency
What Is Primary Adrenal Insufficiency?
What Is Secondary Adrenal Insufficiency?
Provide a Brief Overview of Adrenal Gland Physiology Including Hormone Production
What Glucocorticoid Hormones Are Produced by the Adrenal Cortex?
What Is the Physiological Role of Cortisol?
What Is the Physiological Role of Aldosterone?
What Complications Is the Patient with Adrenal Insufficiency Subject to in the Perioperative Period?
What Are the Features of an Acute Adrenal Crisis?
What Are the Options for Steroid Hormone Replacement Therapy in Primary Adrenal Insufficiency?
How Can We Ascertain That This Patient Is on the Optimal Dose of Glucocorticoid and Mineralocorticoid Replacement Therapy?
What General Measures Can Be Taken to Ensure That the Patient with Primary Adrenal Insufficiency Is Optimized Prior to Surgery?
How Much Cortisol Is Normally Produced Daily? How Does This Change in the Perioperative Period?
Describe an Appropriate Approach to Surgical Stress Dosing of Glucocorticoid Therapy for the Perioperative Period in the Patient with Primary Adrenal Insufficiency
Describe a General Approach to Surgical Stress Dosing of Glucocorticoid Therapy for the Perioperative Period for the Patient with Possible Secondary Adrenal Insufficiency Secondary to Chronic Steroid Use
References
20: Pituitary Adenoma
What Is Acromegaly?
How Are Pituitary Adenomas Classified?
What Are the Objectives of Preoperative Evaluation?
What Complications Is the Patient with Acromegaly Subject to in the Perioperative Period?
How Is Acromegaly Treated?
What Is the Surgical Cure Rate?
Are the Anatomical and Physiological Changes Associated with Acromegaly Reversible with Treatment?
What Investigations Should Be Available Preoperatively in the Patient with Acromegaly Scheduled for Transsphenoidal Excision of Pituitary Adenoma?
References
21: Pheochromocytoma
What Complications Is the Patient with Pheochromocytoma Subject to in the Perioperative Period?
What Is the Significance of the Presence of Neurofibromatosis in This Patient?
Should We Be Surprised That This Patient Previously Had an Adrenalectomy for a Contralateral Pheochromocytoma?
When Should Preoperative Evaluation Occur?
What Are the Objectives of Preoperative Evaluation?
How Should the Patient with Pheochromocytoma Be Evaluated Preoperatively?
History and Physical Examination
Investigations
What Are the Goals of Medical Optimization Prior to Surgery?
What Options Are Available for Medical Preparation for Surgery?
What Complications Are Associated with Medical Management of Pheochromocytoma-Induced Hypertension?
When Consenting Patients for Anesthesia, What Contingencies for Monitoring Should Be Taken into Consideration?
References
Part V: Hepatobiliary
22: Liver Dysfunction
What Laboratory Tests Are Helpful in Screening for Undiagnosed Liver Disease Preoperatively?
What Commonly Used Drugs Can Be Associated with Elevated Liver Transaminases?
What Is Cirrhosis?
What Are the Common Causes of Cirrhosis?
How Important Is It to Identify the Cirrhotic Patient Prior to Elective Surgery?
Are There Any Simple Non-invasive Scoring Systems to Assist in Reaching a Probable Diagnosis of Cirrhosis?
How Is the Severity of Cirrhosis Estimated?
Can Perioperative Mortality Risk in Cirrhotic Patients Be Predicted?
What Was the Etiology of Liver Dysfunction in This Case?
References
23: The Patient Presenting for Liver Transplantation
What Are the Common Reasons for Transplantation?
What Is a MELD Score?
Is This Patient’s Hyponatremia a Concern?
What Can Be Done to Correct the Hyponatremia?
This Patient’s RVSP Is Higher Than Normal—Is This a Concern?
Does This Patient Need a Cardiac Stress Test?
References
Part VI: Gastrointestinal
24: Crohn’s Disease
What Is Crohn’s Disease?
What Are the Common Classifications of Crohn’s Disease?
What Are the Risk Factors for Aggressive Disease Activity?
What Extraintestinal Manifestations of Crohn’s Disease Are of Perioperative Concern?
What Medications Can We Expect to See Prescribed for the Crohn’s Disease Patient?
Glucocorticoids
5-Aminosalicylates (5-ASA): Sulfasalazine, Mesalamine
Immunomodulators
Methotrexate
Antibiotics
Anti-TNF Agents
Ustekinumab (Stelara)
What Instructions Should Be Given to Patients with Regard to Discontinuation of Medications Prescribed for Management of Crohn’s Disease?
What Are the Indications for Surgery in Crohn’s Disease?
Are There Any Specific Concerns That Need to Be Addressed Preoperatively in This Patient Population?
How Is Nutritional Status Assessed Preoperatively?
What Perioperative Precautions Should Be Taken for Venous Thromboembolism Prophylaxis in the Patient with Crohn’s Disease?
How Should This Patient Be Educated Regarding Postoperative Pain Control?
Is There Evidence That NSAID Use Is a Risk Factor for Disease Exacerbation?
What Are the Preoperative Considerations in a Patient Who Smokes Marijuana on a Daily Basis?
Should Surgery Be Performed Laparoscopically When Feasible? Is There Any Difference in Outcomes for Laparoscopic Versus Robot-Assisted Approaches?
References
25: Carcinoid Tumor
What Are Carcinoid Tumors?
Do All Patients with a Carcinoid Tumor Have Carcinoid Syndrome?
How Do Carcinoid Tumors Present?
How Is a Diagnosis of Carcinoid Syndrome Confirmed?
What Is Carcinoid Heart Disease?
What Are the Clinical Manifestations of Carcinoid Heart Disease?
What Is a Carcinoid Crisis?
How Are Carcinoid Tumors Treated?
How Are Patients with Carcinoid Tumors Optimized for Surgery?
How Is Carcinoid Crisis Managed? Can Any Measures Be Taken Preoperatively to Prevent the Intraoperative Occurrence of a Carcinoid Crisis?
References
Part VII: Renal
26: Chronic Kidney Disease and the Dialysis Patient
What Is the Definition of Chronic Kidney Disease (CKD) and What Are the Common Causes?
When Is Dialysis Indicated in CKD Patients?
What Complications Is the Patient with CKD Subject to in the Perioperative Period?
What Specific Considerations Should Be Evaluated During the Preoperative Assessment of CKD Patients?
Chronic Kidney Disease
Dialysis
Electrolyte and Metabolic Abnormalities
Fluid Status
Cardiovascular System
Bleeding and Blood Loss
Surgical Factors
What Medications Should We Expect to See in the Preoperative CKD Patient?
How Should CKD Patients Be Optimized Prior to Elective Surgery?
A CKD Patient on Dialysis Presents for Surgery with a K+ of 6.2 mmol/L. How Would You Proceed?
References
27: Non-transplant Surgery for the Transplant Patient
Does This Patient Need to Be Referred to a Center That Does Transplant Surgery to Have His Hip Surgery?
Which Surgical Post-transplant Patients Should Be Referred to a Transplant Surgery Center to Have Non-transplant Surgery?
Is This Patient at Increased Risk for Traumatic Hip Fracture?
What Are the Physiological Features of the Transplanted Heart?
Are There Any Unique ECG Features That May Be Seen Following Orthotopic Heart Transplant?
Describe a General Approach to Preoperative Evaluation of this Patient
What Blood Tests Should He Have Before Surgery?
Should This Patient Have an Echocardiogram or Chest Radiograph?
Do Other Transplanted Solid Organs Differ from Native Organs?
Do the Systemic Effects of the Condition Leading to the Organ Failure and Transplant Persist?
What Complications Are Common Among Organ Transplant Patients?
Are There Any Special Considerations for Liver Transplant Recipients?
Does This Patient Need a Cardiology Consult Before Surgery?
What Immunosuppression Protocols Are Typically Seen in Transplant Patients?
How Do the Immune System-Modifying Drugs Affect Anesthetic Management?
How Should the Immune System-Modifying Drugs Be Managed?
Can This Patient Have a Regional Anesthetic, or Should He Have a General Anesthetic?
Does the Patient Need a Pacemaker Available Perioperatively?
Are There Any Concerns Perioperatively with Regard to Other Solid Organ Recipients, for Example, Liver, Kidney, Lung?
References
Part VIII: Musculoskeletal
28: Systemic Sclerosis
What Is Systemic Sclerosis?
What Is the Difference Between Scleroderma and Systemic Sclerosis?
What Specific Surgeries Is the Scleroderma Patient Likely to Present For?
What Systemic Complications Is the Patient with Systemic Sclerosis Subject To?
How Should the Patient with Scleroderma Be Evaluated Preoperatively?
What Is the Significance of the Improvement in 6-Minute Walk Test After Cardiac Rehabilitation?
Are There Any Other Tests of Functional Ability That Could Be Used for This Patient?
What Medical Therapies Can We Expect to See in Patients with a Diagnosis of Systemic Sclerosis?
Is Steroid Stress Dosing Required?
References
29: Rheumatoid Arthritis
What Is Rheumatoid Arthritis?
What Is the Current Approach to Management of a Patient Presenting with RA?
How Should These Medications Be Managed Perioperatively?
What Are the Extra-articular Manifestations of RA of Concern Perioperatively?
Should This Patient Receive “Stress Dose” Steroid Treatment?
What Is the Current Approach to Opioid Use in RA?
Are There Any Specific Laboratory Tests That Should Be Ordered Preoperatively in a Patient with RA Being Treated with Any Form of DMARD?
How Common Is Cervical Spine Disease in the Patient with RA?
Is Regional Anesthesia the “Best” Choice in This Patient?
References
30: Systemic Lupus Erythematosus
What Is SLE?
How Is SLE Diagnosed?
What Common Clinical Features of SLE Are of Concern During the Perioperative Period?
What Cardiovascular Features of SLE Are of Perioperative Concern?
What Is the Association Between SLE and Hypertension?
What Are the Renal Features of SLE?
What Pulmonary Features of SLE Are of Perioperative Concern?
Are There Any Airway Concerns in SLE Patients?
What Hematologic Features Should We Be Aware Of?
What Are the Neuropsychiatric Manifestations of SLE?
What Gastrointestinal and Hepatobiliary Features Are Concerning?
Are Patients with SLE at Increased Risk for Perioperative Thromboembolic Complications?
What Musculoskeletal Complications Occur with SLE?
Are Patients with SLE More Susceptible to Infection?
How Is SLE Treated?
How Can the SLE Patient Be Optimized Prior to Surgery?
What Advice Should the Patient Be Given Regarding Continuation of Medications Perioperatively?
References
31: Duchenne Muscular Dystrophy
What Is Duchenne Muscular Dystrophy?
What Complications Can Be Expected Perioperatively in the Patient with Duchenne Muscular Dystrophy?
How Should the Patient with Duchenne Muscular Dystrophy Be Evaluated Preoperatively?
Cardiac Evaluation
Pulmonary Evaluation
Airway Evaluation
Evaluation of Myopathy
Gastrointestinal and Nutritional Evaluation
Endocrine Evaluation
What Can Be Ascertained from This Patient’s PFTs?
What Is the Significance of This Patient Being on BiPAP?
Are DMD Patients at Increased Risk of Stroke?
What Options Are Available for Optimization of the Patient with DMD?
References
Part IX: Neurological
32: Myasthenia Gravis
What Is Myasthenia Gravis?
What Is Seronegative Myasthenia Gravis?
What Are MuSK Antibodies?
How Does MG Present?
How Is MG Diagnosed?
What Conditions Are Associated with MG?
What Is the Role of the Thymus in the Pathogenesis of Myasthenia Gravis?
How Is Disease Severity in MG Graded?
Can Aspiration Risk Be Predicted?
How is MG Treated?
What Is a Myasthenic Crisis?
What Measures Can Be Taken Preoperatively to Ensure That the Patient with MG Is Optimized for Anesthesia and Surgery?
What Recommendations Regarding Preoperative Management of MG Medications Should Be Provided to the Patient?
What Is the Optimal Time for Elective Surgery?
The Patient Wants to Know If She Can Have an Epidural for Postoperative Analgesia. What Do You Tell Her?
References
33: Ischemic Stroke
What Complications Is the Patient with Prior Ischemic Stroke Subject to in the Perioperative Period?
What Evidence Is There That the Patient with a History of Ischemic Stroke Is at Increased Perioperative Risk for a Repeat Ischemic Stroke?
What Other Factors Are Known to Increase the Risk of Perioperative Stroke?
Does Beta-Blockade Increase the Risk of Perioperative Stroke?
What Is the Precise Definition of Perioperative Stroke?
What Is the Risk of Perioperative Stroke in the General Population?
Is Perioperative Stroke Always Clinically Obvious?
What Are the Consequences of a Perioperative Stroke?
What Is the Optimal Time Interval Between Ischemic Stroke and Surgery?
How Should Patients with a History of Stroke or Transient Ischemic Attack Be Evaluated Preoperatively?
What Is the Optimal Blood Pressure Target in the Ischemic Stroke Patient?
Should Aspirin Be Held Perioperatively in the Patient with a History of Stroke or Transient Ischemic Attack?
How Is Perioperative Anticoagulation Managed in Patients with Atrial Fibrillation Being Treated with a Direct Oral Anticoagulant After Ischemic Stroke?
How Is Anticoagulation with Warfarin Managed Perioperatively?
Should the Patient’s Ramipril Be Continued Perioperatively?
Should Statin Therapy Be Continued Perioperatively?
References
34: Parkinson Disease
What Is PD?
Are Patients with PD More at Risk Than the General Population of Perioperative Morbidity and Mortality?
What Drugs Are Used to Treat the Motor Symptoms of PD?
Dopamine Replacement Therapy
Dopamine Agonists
Monoamine Oxidase-B Inhibitors
Amantadine
What About the Non-motor Effects of PD?
What Are the Issues with Levodopa for the Patient Scheduled to Undergo Surgery?
Describe a General Approach to the Perioperative Management of Medications Used to Control the Symptoms of PD
Are There Any Issues in Preoperative Assessment Specifically Related to the Presence of a DBS System in This Patient?
If This Patient Was Scheduled to Undergo a Bowel Resection, What Other Management Steps Should Be Considered?
References
35: Multiple Sclerosis
What Is Multiple Sclerosis?
What Are the Epidemiological Features of MS?
How Is MS Diagnosed?
What Drugs Are Used for Management of MS?
For How Long Are Disease-Modifying Agents Continued in Patients with Relapsing-Remitting MS?
What Are the Perioperative Implications of Drugs Used for Treatment of MS?
Should Disease-Modifying Medications Be Continued Perioperatively?
What Complications is the Patient with MS Subject to in the Perioperative Period?
What Are the Objectives of Preoperative Evaluation?
Is There Evidence for Preferred Anesthetic Agents When Administering General Anesthesia to an MS Patient?
Should Premedication Be Prescribed for This Patient?
Is Neuraxial Anesthesia Contraindicated in This Patient?
Is Insertion of a Popliteal Sciatic Nerve Block Catheter Contraindicated?
References
36: Intracranial Mass
What Is a Seizure?
What Is Status Epilepticus?
What Causes Seizures?
What Medications Are Commonly Used to Control Seizures in Patients with Brain Tumors?
Which Antiseizure Medications Induce Hepatic Metabolism?
Is There a Role for Glucocorticoids in the Management of Patients with an Intracranial Mass?
Is Premedication Contraindicated?
What Is Intracranial Hypertension?
Does the Patient Require a Preoperative Electroencephalogram (EEG)?
Does the Patient Require Preoperative Consultation with a Neurologist?
How Can the Risk of Venous Air Embolism Be Modified Preoperatively?
Are Seizures Commonly Associated with a Brain Mass?
What Are the Anesthetic Options for Craniotomy?
What Additional Preoperative Preparation Is Necessary for the Patient Scheduled for Awake Craniotomy?
Are Intraoperative Mannitol and Hypertonic Saline Required?
Is Intraoperative Hyperventilation Required?
The Surgeon Decides to Do the Craniotomy Under MRI Guidance. How Does This Affect Anesthetic Management?
References
Part X: Hematological
37: Easy Bruising
What Is a Practical Approach to the Patient Presenting in the Preoperative Clinic with a History of Apparently Clinically Significant Coagulation Disorder?
What Is the Basic Sequence of Events When the Hemostatic System Is Activated?
How May Bleeding Disorders Be Broadly Classified?
What Does the PT and APTT Assess?
How Should Prolonged PT and APTT Results Be Interpreted?
What Is a Mixing Study?
Who Should Have Surgery Deferred and/or Be Referred to a Hematologist for Further Evaluation and Management?
What Can Cause Isolated APTT Prolongation But Is Not Associated with Bleeding?
What Condition Causes Easy Dermal Bruising in the Elderly in the Face of Normal Coagulation Studies?
How Common and Concerning Is Easy Bruising Preoperatively?
References
38: Thrombocytopenia
What Is Thrombocytopenia?
How Should an Incidental Preoperative Finding of Recent Onset (<3 Months) Thrombocytopenia Be Approached?
What Are the Common Causes of Thrombocytopenia?
What Is the Usual Course of ITP?
Platelet Counts and Neuraxial Anesthesia—Is There a Consensus on What Are “Safe” Values?
When Is Prophylactic Platelet Transfusion Prior to Surgery Appropriate in the Thrombocytopenic Patient?
How Does the Platelet Count Relate to Bleeding Risk?
References
39: Long-Term Anticoagulation
What Potential Complications Is the Patient with a History of Venous Thromboembolism (VTE) Subject to in the Perioperative Period?
What Are the Main Risk Factors for Development of Perioperative Thromboembolism?
How Is the Thromboembolic Risk Associated with Atrial Fibrillation Estimated?
What Factors Determine Thromboembolic Risk in Patients with a Mechanical Heart Valve?
Do Patients with a Nonmechanical or Bioprosthetic Valve Require Chronic Anticoagulation?
How Is the Risk of Recurrent Venous Thromboembolism Estimated in Patients with a History of Prior VTE?
For What Period of Time Is Long-Term Anticoagulation Required in a Patient Who Has Had a VTE?
Which Patient Populations May Benefit from Indefinite Anticoagulation After VTE?
What Are the First-Line Agents for Long-Term Anticoagulation after VTE?
How Is the Risk of Procedural Bleeding Estimated?
Which Patients Are Considered Candidates for Perioperative Bridging?
Describe the Common Approaches to Perioperative Anticoagulation Management in the Presence of Varying Thromboembolic and Bleeding Risks?
What Are the Indications for Placement of a Temporary Vena Cava Filter?
References
40: Venous Thromboembolic Disease
What Is a Deep Venous Thrombosis (DVT)?
What Are the Symptoms/Signs of a DVT and How Is It Diagnosed?
What Is the Incidence of Venous Thrombosis?
What Are the Risk Factors for a DVT?
What Are the Clinical Characteristics Suggestive of Thrombophilia During a Thromboembolic Episode?
What Is the Most Common Inherited Thrombophilia Disorder?
How Does Factor V Leiden Alter Coagulation?
If One Suspects a Patient May Have Inherited Thrombophilia, What Is the Best Course of Action to Follow?
How Long Should a Direct Oral Anticoagulant (DOAC) Be Taken for Following an Isolated Provoked Transient Thromboembolic Event?
How Should This patient’s DOAC Be Managed During the Perioperative Period?
References
41: Anemia
What Is Anemia?
What Is the Prevalence of Anemia Prior to Elective Surgery and Is It Associated with Adverse Outcome?
What Is the Major Cause of Preoperative Anemia in Adults?
Why Are FID/IDA So Common in Surgical Patients?
What Other Types of Anemia Are Relatively Common in the Surgical Population?
What Can Be Deduced from Review of Values Shown on a CBC?
What Is “Patient Blood Management”?
Is There a Relationship Between Hepatic Adenomatosis and IDA?
References
42: Sickle Cell Disease
How Common Is SCD in the United States?
What Is the Pathophysiology of SCD?
What Acute Complications Can Occur in the SCD Patient That Require Evaluation and Treatment?
What Are the Current Disease-Modifying Therapies Used in SCD?
What Are Some of the Chronic Complications of SCD?
What Are the Key Issues to Elucidate During the Perioperative Evaluation of the Patient with SCD?
What Are the Laboratory Investigations That Should Be Ordered?
What Should Be Considered Preoperatively to Mitigate the Occurrence of Adverse Perioperative Events?
References
Part XI: Miscellaneous
43: The Pregnant Patient
What Are the Important Physiologic Changes Associated with Pregnancy?
How Should We Assess the Airway of a Pregnant Patient Prior to Non-obstetric Surgery?
Why Are Pregnant Patients Considered at Risk of Aspiration Under Anesthesia?
Are Fasting Guidelines Different in the Pregnant Patient?
What Are the Fetal Risks Associated with Non-obstetric Surgery During Pregnancy?
Can the Risk of Preterm Labor Be Mitigated?
What Role Do Glucocorticoids Play in Procedures Undertaken During Pregnancy?
Are Any Drugs Used in the Conduct of General Anesthesia Teratogenic?
Are Non-steroidal Anti-Inflammatory Drugs (NSAIDs) Safe During Pregnancy?
What Are the Risk Factors for Intrauterine Asphyxia?
What Is a Biophysical Profile (BPP) and What Is the Significance of a BPP of 6/8?
How Should We Assess Fetal Well-Being During Surgery?
For Which Non-obstetric Surgical Cases Should Fetal Monitoring Be Utilized?
How Are Fetal Heart Rate Tracings Categorized?
Is There Any Evidence That Obstetric or Neonatal Outcomes Are Worse When Non-obstetric Surgery Has Been Performed During Pregnancy?
When Should Surgery Be Undertaken?
References
44: The Psychiatric Patient
A Suggested Approach to the Patient with a Pre-existing Psychiatric Diagnosis
What Are the Components of a Mental Status Examination (MSE)?
What Is the Prevalence of Mental Illness in the Population?
Is It Important to Identify Those with Decompensating Mental Illness Prior to Elective Surgery?
What Are the Potential Consent Issues in Patients with Decompensating Mental Illness Prior to Elective Surgery?
What Are the Classes of Drugs Currently Used to Manage Psychiatric Disorders and What Are the Issues to Be Aware of When Evaluating Patients Using These Medications?
How Should Psychiatric Patients Be Managed Preoperatively?
References
45: The Obese Patient Undergoing Non-Bariatric Surgery
What Is Super Morbid Obesity? How Is Obesity Defined and Classified?
What Medical Comorbidities Can Be Seen in Patients with a High BMI?
What Complications Is the Obese Patient Subject to in the Perioperative Period?
What Physiological Changes Can Be Seen in the Respiratory System of the Obese Patient?
What Is the Incidence of OSA in Obese Patients?
How Is OSA Screened for in the Anesthesia Pre-admission Clinic?
What Is Obesity Hypoventilation Syndrome (OHS)?
Why Do Obese Patients Get Pulmonary Hypertension?
Right Ventricular Systolic Pressure (RVSP) and Pulmonary Artery Systolic Pressure (PASP) Were Reported Together for our Patient. Is RVSP the Same as PASP?
How Should Respiratory Function Be Assessed Preoperatively in the Obese Patient?
What Perioperative Complications Is the Patient with OSA Subject To?
How Can the Obese Patient with OSA Be Optimized Preoperatively?
Are Obese Patients More Difficult to Intubate? Are Any Airway Evaluation Techniques of Specific Value in This Patient Population?
What Physiological Changes Can Be Seen in the Cardiovascular System in the Presence of Obesity?
What ECG Abnormalities Are Associated with Obesity?
How Is the Obese Patient Assessed Preoperatively from a Cardiac Perspective?
Is the Management of Hypertension Any Different in Obese Versus Non-obese Patients?
What Is Metabolic Syndrome?
Is Awareness More Common in Obese Patients?
References
46: The Frail Patient
What Are the Physiological Changes Associated with Advanced Age?
How Does Aging Influence Medication Kinetics?
What Is Frailty?
How Can Frailty Be Identified in the Preoperative Clinic?
Is Frailty Associated with Adverse Outcome Following Surgery?
Can One Predict Which Individual Patient Is Most Likely to Die Using a Frailty Scale?
Are There Interventions That Can Ameliorate Adverse Outcomes of Surgery in the Elderly?
What Are the Specific Issues That Should Be Addressed in the Preoperative Assessment of the Frail Patient?
References
47: The Opioid-Tolerant Patient
What Is Opioid Tolerance?
What Is the Difference Between Opioid Tolerance and Opioid-Induced Hyperalgesia (OIH)?
What Is the Significance of the Similarities Between Opioid Tolerance and OIH? Can a Definitive Diagnosis Be Made During Preoperative Evaluation?
How Are the Terms Addiction and Physical Dependence Defined?
How Should the Opioid-Tolerant Patient Be Evaluated Preoperatively?
How Should the Patient Taking Oral Opioids Be Managed Preoperatively?
How Should the Patient Taking Transdermal Opioids Be Managed Preoperatively?
Describe an Approach to Preoperative Evaluation and Management of the Patient Taking Buprenorphine
How Should the Patient Taking Intrathecal Opioids Be Managed Preoperatively?
How Should the Patient on Maintenance Methadone Be Managed Preoperatively?
What Opioid-Sparing Multimodal Analgesia Techniques Should Be Discussed with This Patient?
What Is the Evidence in Favor of Opioid Rotation?
Is There Any Evidence That Regional Anesthesia Techniques Are less Effective in Opioid-Tolerant Patients?
What Modifiable Preoperative Risk Factors Contribute to the Development of Chronic Postsurgical Pain?
References
48: Substance Abuse Disorder
What Is Splenosis?
What Is Eltrombopag?
What Is the Prevalence of Drug Use in the Adolescent/Adult Population?
What Are the Key Issues to Address in the Preoperative Evaluation of a Substance-Using Patient?
What Is Heroin?
What Is the Potency of Heroin Relative to Morphine, and What Are the Signs and Issues of Concern with Recent Use?
What Is Cocaine and What Are the Signs and Issues of Concern with Recent Use?
What Is Methamphetamine (“Ecstasy/Meth/Chalk/Ice/Glass”) and What Are the Signs of Recent Use?
References
49: Amyloidosis
What Is Amyloidosis?
What Are the Common Manifestations of Amyloidosis?
What Are the Treatment Options for Amyloid Disease?
What Are the Key Issues to Identify During the Preoperative Evaluation?
References
True/False Answers
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 9
Chapter 10
Chapter 11
Chapter 12
Chapter 13
Chapter 14
Chapter 15
Chapter 16
Chapter 17
Chapter 18
Chapter 19
Chapter 20
Chapter 21
Chapter 22
Chapter 23
Chapter 24
Chapter 25
Chapter 26
Chapter 27
Chapter 28
Chapter 29
Chapter 30
Chapter 31
Chapter 32
Chapter 33
Chapter 34
Chapter 35
Chapter 36
Chapter 37
Chapter 38
Chapter 39
Chapter 40
Chapter 41
Chapter 42
Chapter 43
Chapter 44
Chapter 45
Chapter 46
Chapter 47
Chapter 48
Chapter 49
Index