Perioperative Medicine: Managing for Outcome, 2nd Edition

Front Cover
Front Matter
Copyright
Dedication
Contributors
Acknowledgment
Contents
PART I INTRODUCTION AND BACKGROUND
Implications of Perioperative Morbidity for Long-Term Outcomes
Cardiac Injury
Pulmonary Injury
Neurologic Injury
Renal Injury
Association Versus Causality
Conclusion
References
The Inflammatory Response to Surgery
Introduction
Defining Acute Systemic Inflammation After Surgery
Where It All Starts: Cellular Origins of Surgical Inflammation
PAMPs may also Contribute to Systemic Inflammation After Surgery
Systemic Processes Triggered by DAMPs/PAMPs
Autonomic Changes
Neuroendocrine Response
Host Influences on Perioperative Inflammatory Response
Age
Chronic Kidney Disease
Diabetes Mellitus
Perioperative Modulation of the Inflammatory Response
Anesthesia and Analgesia
Blood Transfusion
Steroids
Conclusions
References
The Coagulation Cascade in Perioperative Organ Injury
Significance of Perioperative Organ Injury
Current Understanding of Coagulation and the Fibrinolytic Process
How Does Inflammation Interfere With/Change the Coagulation Process?
Perioperative Monitoring of Coagulation
Alteration of Coagulation Status During Perioperative Period
Intraoperative Activation of Coagulation
Stress Response or Pain
Site of Surgery
Mode of Anesthesia
Intravenous Fluid Management
Body Temperature
Trauma Coagulopathy
Postoperative Activation of Coagulation
Pain Control
Consequences of Dysregulated Coagulation
Proinflammatory Actions of Coagulation Proteases
Summary and Recommendations
References
PART II PREOPERATIVE ASSESSMENT
The Value of Preoperative Assessment
Value
Preoperative Assessment Elements
Goals of Preoperative Assessment
Ensuring High-Quality Shared Decision-Making and Appropriateness of Care
Preoperative Assessment Should Ensure Appropriate Risk Assessment and Optimization
Preoperative Assessment and Population Management
Preoperative Assessment and Regulatory Issues
Preoperative Assessment Should Ensure Appropriate Use of Testing
Documentation and Transmission of All Important Information to Downstream Providers
Patient/Family Education and Discharge Planning
Conclusions
References
Perioperative Cardiac Risk Assessment in Noncardiac Surgery
Introduction
Preoperative History and Physical Examination
ECG
Metabolic Equivalents
Risk Assessment
Risk Models
Cardiac Testing
Interventions: Preoperative Coronary Revascularization
Percutaneous Coronary Intervention
Coronary Artery Bypass Grafting
Summary
References
Cardiovascular Risk Assessment in Cardiac Surgery
Purpose of Risk Assessment Before Cardiac Surgery
Outcome Measurement in Cardiac Surgery
Development of Perioperative Risk Assessment for Cardiac Surgery
Established Risk Assessment Models in Cardiac Surgery
Parsonnet
EuroSCORE
ACEF
Society of Thoracic Surgery
Frailty Versus Age
Congenital Heart Surgery
Extracorporeal Mechanical Support
Ventricular Assist Devices
Beyond Mortality
References
Central Nervous System Risk Assessment: Preventing Postoperative Brain Injury
Postoperative Delirium
Definition
Risk Factors
Intraoperative Management
Emergence Delirium
Treatment of Postoperative Delirium After the Immediate Recovery Period
Postoperative Cognitive Dysfunction
Definition
Incidence
Risk Factors
Screening Tools
Pathophysiology and Association with Anesthesia
Interventions
Seizure Disorders and Epilepsy
Recent Concussion
Stroke Risk
Prior Stroke
Risk for Hypoxic-Ischemic Injury
Implanted Neurostimulator and Other Devices
References
Risk Assessment and Perioperative Renal Dysfunction
Influence of Surgery and Anesthesia on Renal Perfusion
Patient Characteristics and the Risk of Postoperative Acute Kidney Injury
Patient Characteristics Associated with Reduced Renal Reserve
Patient Characteristics Suggesting Reduced Renal Blood Flow
Other Preoperative Patient Variables Associated with Kidney Injury
Other Preoperative Patient Factors Associated with Postoperative Renal Dysfunction
Surgical Interventions Associated With Substantial Intraoperative Renal Ischemia
Cardiopulmonary Bypass
Pharmacologic Management of Post-Cardiopulmonary Bypass AKI
Major Aortic Surgery
Perioperative Testing of Renal Function
Perioperative Renal Risk Scoring Algorithms
Conclusion
References
Pulmonary Risk Assessment
Introduction
Epidemiology
Definition
Etiology and Pathophysiology
Preoperative Pulmonary Evaluation for Nonthoracic Surgery
Patient Factors
Pulmonary Factors
STOP-Bang Questionnaire
Physical Examination
Extrapulmonary Factors
Surgical Factors
Preoperative Tests
Risk Prediction Scores
Evaluation Paradigm for Nonthoracic Surgery
Evaluation of the Lung Resection Candidate
Conclusion
References
Hematologic Risk Assessment
Red Blood Cell Transfusion
Hemostasis
Preoperative Risk Assessment
Medical History and Physical Examination
Laboratory Testing
Tests of Primary Hemostasis: Platelet Count and Function
Tests of Secondary Hemostasis: PT and aPTT
Point-of-Care Testing
Management of Patients Under Antiplatelet Therapy
Aspirin
Dual Antiplatelet Therapy
Management of Patients on Anticoagulation Therapy
Neuraxial Blockade
Summary
References
PART III PRESERVATION OF ORGAN FUNCTION AND PREVENTION AND MANAGEMENT OF PERIOPERATIVE ORGAN DYSFUNCTION
Prevention of Ischemic Injury in Cardiac Surgery
Perioperative Ischemia Prevention Strategies
Optimal Timing of Cardiac Surgery after Acute Myocardial Infarction
Intraoperative Ischemia-Prevention Strategies
Nonoperative Strategies
Anesthesia Considerations
Monitoring for ischemia
Anesthetic agents
Metabolic Considerations
Systemic temperature
Myocardial acid-base management
Blood glucose
Transfusion strategy
Operative Strategies to Prevent Ischemia and Ischemia-Reperfusion Injury
Myocardial Protection Strategies
Cardioplegia
Cardioplegia composition: blood versus crystalloid
Cardioplegia solutions: single dose
Cardioplegia temperature: warm versus cold
Cardioplegia route of delivery: antegrade versus retrograde
Noncardioplegia myocardial protection strategies
Hypothermia
Arrest variations
Hypothermic fibrillatory arrest
Cannulation techniques
CPB circuit modifications
Heparin-bonded circuits
Cardiotomy suctioning
Open versus closed circuit
Pump type
Blood filtration: leukocyte depletion
Pharmacologic protection strategies
Corticosteroids
Hemostatic agents
Antioxidants
Alternative Approaches to Myocardial Protection
Bypassing CPB: off-pump CABG
Myocardial conditioning
Preconditioning
Postconditioning
References
Prevention of Ischemic Injury in Noncardiac Surgery
Introduction
Pathophysiology and Natural History of Perioperative Ischemia
Preoperative Optimization
Screening and Risk Stratification
Myocardial Revascularization
Medication Optimization
Beta-Blockade
Current Recommendations
Statins
Current Recommendations
Angiotensin-Converting Enzyme Inhibitors/Angiotensin Receptor Blockers
Current Recommendations
Alpha-2 Agonists
Current Recommendations
Aspirin and Antiplatelet Agents
Current Recommendations
Intraoperative Management
Anesthetic Selection
Monitoring for Ischemia
Management of Intraoperative Ischemia
Ischemic Preconditioning
Future Directions in Ischemia Prevention/Management
References
Treatment of Perioperative Ischemia, Infarction, and Ventricular Failure in Cardiac Surgery
Perioperative Myocardial Ischemia and Infarction
Definition
Etiology
Management
Intraoperative Preprocedural Phase
Intraoperative Postprocedural Phase
Postoperative Phase
Perioperative Ventricular Dysfunction and Failure
Failure to Wean from Cardiopulmonary Bypass
Postoperative Low Cardiac Output State
Assessment
General Assessment
Hemodynamic and Echocardiographic Assessment
Management Strategies for Postoperative Low Cardiac Output
Optimization of Cardiac Rate and Rhythm
Preload and Afterload
Inotropic State
Intra-aortic Balloon Pump
Venoarterial Extracorporeal Membrane Oxygenation
Ventricular Assist Devices
CentriMag
Impella System
Perioperative Right Ventricular Dysfunction
Etiology
Diagnosis
Management
References
Perioperative Management of Valvular Heart Disease
Preoperative Assessment
Preoperative Preparation
Antimicrobial Prophylaxis
Anticoagulation
Chronic Medications
Intraoperative Management
Pathophysiology of Disease and Physiologic Principles of Management
Nonpharmacologic Management
Premedication
Type of Anesthesia: General, Regional, or Local with Monitored Sedation
Monitoring Options
Postoperative Management
Specific Valvular Lesions
Aortic Stenosis
Mitral Stenosis
Aortic Regurgitation
Mitral Regurgitation
Tricuspid Valve Disease
Pulmonic Valve Disease
Mixed Valvular Lesions
Summary and Recommendations
References
Prevention and Management of Perioperative Dysrhythmias
Introduction
Mechanisms of Arrhythmia Generation
Contributing Factors
Anesthetic Medications
Electrolyte Disturbances
Hemodynamic and Physiologic Causes
Other Causes
Types of Tachyarrhythmias
Narrow QRS Complex Tachycardia
Sinus Tachycardia
AV Nodal Reentrant Tachycardia
Atrial Flutter and Atrial Fibrillation
Multifocal Atrial Tachycardia
Wide QRS Complex Tachycardia
Premature Ventricular Contractions
Nonsustained Ventricular Tachycardia
Ventricular Tachycardia
Supraventricular Tachycardia with Aberrant Conduction
Ventricular Paced Rhythms
Wolff-Parkinson-White Syndrome
Bradyarrhythmias
Sinus Bradycardia and Asystole
Bundle Branch Blocks
Conduction Defects
Diagnosis and Medical Therapy for Arrhythmias
Standard Electrocardiography
Recognition of Artifacts
Atrial Fibrillation and Flutter
Ventricular Tachycardia
Interventions for Cardiac Arrhythmias
Catheter Ablation for Atrial Fibrillation
Surgical Ablation for Atrial Fibrillation
Left Atrial Appendage Occlusion
Catheter Ablation for Ventricular Tachycardia
Implantable Cardioverter-Defibrillators for Ventricular Tachycardia
Neuromodulation Therapies for Ventricular Tachycardia
Pacemakers for Bradyarrhythmias
Conclusion
References
Perioperative Fluid Management
Overview
Physiological Stressors of Venous and Arterial Volume
Liberal Versus Restrictive Fluid Therapy
Dangers of Fluid Overload
Preoperative Fluid Management
Maintaining Normal Intravascular Volume During Perioperative Period
Goal-Directed Fluid Therapy
Higher Levels of Cardiovascular Monitoring
Maintaining Adequate Mean Arterial Pressure
Background
Fixing Flow, Then Maintaining Mean Arterial Pressure
Choice of Intravenous Perioperative Fluid and Postoperative IV Fluid Maintenance Rate
Maintaining Optimal Hemoglobin Levels and Nadir Hematocrit
Laparoscopic Surgery
Emergency General Surgery
Summary: Perioperative Fluid and Hemodynamic Plan
References
Preservation of Renal Function
Introduction
Renal Physiology
Medullary Hypoxia
Unique Physiology/Vulnerable Populations
The Immature Kidney
The Kidney During Pregnancy
Geriatrics and Renal Function
Cardiac Surgery-Associated AKI as a Generalizable Model for Perioperative AKI
Diagnosis of Acute Kidney Stress/Injury
Current Consensus Diagnostic Criteria for AKI and Related Adverse Outcomes
Future (Early) AKI Biomarkers
Measures of Kidney Stress
Measures of Kidney Function
Measures of Kidney Tubular Damage
Mechanisms of Surgery-Related Acute Renal Injury
Ischemia/Reperfusion
Inflammatory
Embolic
Pigment (Hemoglobin and Myoglobin)
Nephrotoxins
Renal Preservation: Best Practices
Preoperative Management and Planning
Procedural Selection
Cardiac Surgery Modifications
Reduction of Tissue Trauma
Smaller incisions: mini-thoracotomy/mini-sternotomy
Endovascular approaches
Neuraxial Analgesia
Nonpharmacologic Interventions
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Procedure Delay Versus Avoidance of Contrast Agents
Ischemic Preconditioning Reflex
Pharmacologic Agents
Intraoperative Management
Intraoperative Fluid Choice
Intraoperative Volume Management
Blood Pressure Management
Cardiopulmonary Bypass Management
Modifiers of Renal Oxygen Delivery
Modifiers of Renal Oxygen Demand
Avoidance of Ascending Aortic Atheroembolism
Selection of Antifibrinolytic Agent
Selection of Vasoactive Agents
Pharmacologic Agents
Fenoldopam
Dopexamine
Mannitol
N-Acetylcysteine
Postoperative Management
Intravenous Fluid Choice
Fluid Removal/Diuretics
Loop Diuretics
Natriuretic Peptides
Glucose Management
Pharmacologic Agents
Steroids
Non-steroidal Anti-Inflammatory Drugs: Aspirin and Cyclo-Oxygenase-2 Inhibitors
Alpha 2 Adrenergic Agonist Agents
Calcium Channel Blockers
Renin-angiotensin System (RAS) Blockers
Endothelin Receptor Antagonists
Erythropoietin
Growth factors (IGF-I, EGF, HGF)
Pulmonary Vasodilators (PGE1, PGI2, NO)
Kidney Protective Bundle
Kidney Failure Requiring RRT
Summary and Future Directions in Renal Preservation
References
Evaluation and Treatment of Acute Oliguria
Pathophysiology
Prerenal Oliguria
Oliguria as a Consequence of Renal Tubular Injury
Obstructive Oliguria
Evaluation of Patients With Oliguria
Obstructive Oliguria
Functional Oliguria versus AKI
History
Clinical Parameters
Laboratory Parameters
Treatment
Hypovolemia and Shock
Cardiac Dysfunction and ACS
Oliguria Secondary to AKI
Oliguria Secondary to Obstruction
Conclusion
References
Perioperative Management of Renal Failure and Renal Transplant
Introduction
Acute Renal Failure
Chronic Renal Failure
Chronic Kidney Disease Is Common
Chronic Kidney Disease Increases Cardiovascular Risk
Chronic Kidney Disease Is a Risk Factor for Acute Kidney Injury
Acute Kidney Injury Accelerates the Progression of Chronic Kidney Disease
Pathophysiology of Chronic Renal Failure
Uremia
Fluid and Electrolyte Balance
Sodium and Water Homeostasis
Potassium Balance
Magnesium Balance
Calcium Phosphate Balance
Metabolic Acidosis
Vascular Access
Hematologic Abnormalities
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Anemia
Uremic Bleeding Diathesis
Gastrointestinal Abnormalities
Nutritional and Metabolic Disturbances
Neurologic Disturbances
Immunologic Dysfunction
Pharmacology in Chronic Renal Failure
Choice of Anesthetic Technique
General Considerations
General Anesthesia
Induction Agents
Muscle Relaxants
Opioids
Inhaled Anesthetics
Total Intravenous Anesthesia
Regional Anesthesia
Intraoperative Considerations
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Monitoring
Fluid Management
What type of fluid is best?
Balanced Crystalloid Solution
Colloids vs crystalloids
Liberal vs restrictive
Positioning
Kidney Transplantation
Kidney Donor Criteria
Living-Donor Kidney Transplantation
Recipient Selection
Cardiac Disease Evaluation and Management
Postoperative Management
Transplantation Immunology
Anesthesia Management
Kidney Viability in Transplant Surgery
Living Kidney Donor
Deceased Donor Kidney (DDK)
Kidney Preservation
Experimental Techniques to Increase Viability
Intraoperative Management of Kidney Recipients
Hemodynamics and Intravascular Volume
Choice of Resuscitation Fluid
Albumin
Diuretics
Calcium Channel Antagonists
Dopamine
Summary
References
Prevention and Treatment of Postoperative Pulmonary Complications
Introduction
What Are Postoperative Pulmonary Complications (PPC)?
How Common Are Postoperative Pulmonary Complications?
How Important?
Prediction of Postoperative Pulmonary Complications
ACS NSQIP
ARISCAT
Pathophysiology
Pulmonary Aspiration
Atelectasis, Sputum Retention, and Loss of Airway Patency
Pneumonia
Pulmonary Inflammation
Other Perioperative PPC
Prevention
Preoperative
Smoking Cessation Therapy
Oral Decontamination
Specific Therapies to Reduce Pulmonary Inflammation
Intraoperative
Ventilation
Residual Effects of Neuromuscular Blocking Agents (NMBA)
Postoperative
Ventilatory Support
CPAP and NIV
High-Flow Nasal Oxygen (HFNO2)
Care Bundles and Enhanced Recovery After Surgery
Treatment of PPC
Specific to the Diagnosis
Ventilatory Support in Respiratory Failure
Conclusions
References
Carotid and Intracranial Surgery
Anesthesia for Carotid Surgery
Carotid Endarterectomy
Preoperative Assessment
Cardiovascular System
Preoperative Risk Factors for Perioperative Stroke
Anesthetic Management
Physiologic Management
General Anesthesia
Regional Anesthesia
Cerebral Monitoring to Detect Ischemia During CEA
Postoperative Management
Endovascular Carotid Artery Angioplasty and Stenting for Carotid Stenosis
Anesthesia for Intracranial Surgery
Preoperative Evaluation
Anesthesia Induction
Anesthesia Maintenance
Management of Arterial Blood Pressure
Management of Ventilation
Intraoperative Fluid Management
Muscle Relaxants
Management of Emergence
Procedure-Specific Issues
Awake Craniotomy
The Wada Test: Determining Whether Speech Mapping Is Required
Intraoperative Electrophysiologic and Anatomic Components of Speech Mapping
Comparing Neurolept and General Anesthesia for Awake Cortical Mapping
Cerebral Aneurysm Clipping and Coiling Procedures
Preoperative Management
Neurologic
Cardiopulmonary
Electrocardiographic abnormalities and cardiac injury
Hypertension
Anesthetic Management for Aneurysm Clipping
Premedication
Monitoring
Induction
Maintenance
Emergence
Special Situations
Temporary Vessel Occlusion
Adenosine-Induced Circulatory Flow Arrest
Intraoperative Cerebral Protection
Intraoperative Rupture
Anesthetic Management for Aneurysm Embolization
Induction and Maintenance of Anesthesia
General Anesthesia Versus Sedation
Management of Procedural Complications
Aneurysm Rupture
Thrombotic Complications
Management of Intracranial Hypertension
Reducing Intracranial Contents
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Removal of mass lesions
Head positioning
Ventricular CSF drainage
Hyperventilation
Cerebral perfusion pressure
Hyperosmotic therapy
Reducing Cerebral Metabolism
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Anesthetic depth
Hypothermia
Summary
References
Protecting the Central Nervous System During Cardiac Surgery
Introduction
Neurological Injury After Cardiac Surgery with Cardiopulmonary Bypass
Incidence and Significance
Risk Factors
Etiologic Factors
Embolic Events
Hypotension, Hypoperfusion, and Cerebral Autoregulation
The Inflammatory Response
Genomic Factors
Temperature
Neuroprotective Strategies
Modifications to the Cardiopulmonary Circuit
Aortic Cannulation Strategy
Reducing Gaseous Emboli with Carbon Dioxide
Assessment of Aortic Atheroma
Blood Gas Management During Cardiopulmonary Bypass
Temperature Management: Hypothermia and Hyperthermia
Blood Pressure Management During Cardiopulmonary Bypass
Pulsatile Perfusion During Cardiopulmonary Bypass
Pharmacologic Therapies
Neurologic Injury After Off-pump Coronary Artery Bypass Grafting
Incidence and Significance
Etiologic Factors
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Inflammation
Manipulation of the Heart and Aorta
Cerebral Emboli
Strategies for Neuroprotection
Neurological Injury After Transcatheter Aortic Valve Replacement
Incidence and Significance
Etiologies of Neurological Injury after TAVR
Embolic Injury
Nonembolic Etiologies
Neuroprotective Strategies
Preoperative Neuroprotection
Intraoperative Neuroprotection
Heart team experience
Embolic protection
Postoperative Neuroprotection
Neurologic Injury During Thoracic Aortic Surgery
Introduction
Etiologic Mechanisms for Neurological Injury
Aortic Arch Repair
Thoracoabdominal Aortic Repair
Neuroprotective Strategies: Aortic Arch Repair
Axillary Artery Cannulation
Hypothermia and Selective Cerebral Perfusion
Monitoring for Neurological Injury
Electroencephalography for aortic arch repair
Cerebral oximetry
Carotid Ultrasound
Blood Gas Management
Temperature Management During Cardiopulmonary Bypass
Pharmacologic Agents
Neuroprotective Strategies: Thoracoabdominal Aortic Repair
Early Recognition of Spinal Cord Ischemia
Intraoperative neuromonitoring
Postoperative neuromonitoring
Maximizing Spinal Cord Perfusion Pressure
Permissive systemic hypertension
Cerebrospinal fluid drainage
Segmental spinal artery preservation
Minimizing Spinal Cord Ischemic Time
Extending Spinal Tolerance of Ischemia
Thoracic Endovascular Aortic Repair
Conclusions
References
Preservation of Spinal Cord Function
Introduction
Traumatic Spinal Cord Injury
Paraplegia After Thoracic or Thoracoabdominal Aortic Aneurysm Repair
Spinal Cord Injury From Central Neuraxial Anesthesia and Analgesia
Spinal Cord Injury and Spine Surgery
Anesthetic and Medical Management of the Patient With Existing or Prior Spinal Cord Injury
References
Perioperative Management of Acute Central Nervous System Injury
Introduction
Monitoring Neurologic Examination
Mental Status, Cranial Nerves, Motor and Sensorial Function, and Reflexes
Mental Status
Intracranial Hypertension
Physiology
Factors That Exacerbate Intracranial Hypertension
Two Types of Intracranial Hypertension
Presentation
ICP Monitoring
Waveform Analysis
Treatment of Intracranial Hypertension
Intracranial Hypertension/Cerebral Herniation Treatment Algorithm
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Level Tier zero: L0
Airway, Breathing, and Circulation (ABCs)
Head of Bed Elevation
Antipyretics and Antishivering Drugs
Steroids
Imaging
Level Tier 1: L1 Cerebral Blood Volume Reduction
Hyperventilation
Cerebral and Systemic Effects of Hyperventilation
Hyperventilation in TBI
Target PaCO2 Recommendations in TBI
Hyperosmolar Therapy
Efficacy of HTS for Reduction of ICP
Intracranial Complications
Systemic Complications
CSF Drainage
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Level Tier 2: L2
CBV Decreasing Drugs
Propofol
Etomidate
Lidocaine
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Level Tier 3: L3
Barbiturates
Hypothermia
Surgical Decompression
Decompressive Craniectomy
Decompressive Craniectomy and TBI
Decompressive Craniectomy and Stroke
Physiologic Issues
Cerebrovascular Reserve
Airway Evaluation and Management
Concerns
Evaluation
Therapeutic Options
Awake Versus Asleep
Cricoid or No Cricoid Pressure?
Cervical Spine Distraction During Airway Instrumentation
Oxygenation
PaO2 Physiology
Outcome Data
PEEP and Intracranial Hypertension
Ventilation
PaCO2 Physiology
Hyperventilation
Optimal PaCO2
Temperature
Why Hypothermia for Neuroprotection?
Hypothermia and TBI
Hypothermia for Rescue ICP Therapy
Hypothermia and Hypoxic-Ischemic Encephalopathy After Cardiac Arrest
Timing and Duration of Targeted Temperature
Target Temperature
Temperature Monitoring and Rewarming
Complications Associated With TH
Fever
Glycemic Control
Cardiovascular
Blood Pressure Effects on ICP-Plateau Waves and Determination of the Blood Pressure Optimum
Blood Pressure Management
Hypertension
Hypotension Treatment and Induced Hypertension
Optimal Hemoglobin Level
Neurophysiologic Effects of Anemia
Perioperative Management of Adults With Acute Spinal Cord Injury
Spinal Shock
Cardiovascular Complications
Pulmonary Complications
Miscellaneous
Anesthetic Management and Considerations
Airway Evaluation
Monitors
Induction of Anesthesia
Airway Management
Hemodynamic Management
Anesthesia for Endovascular Therapy in Acute Ischemic Stroke
Planning the Anesthetic
Anesthesia Type
Blood Pressure Goals
Oxygenation and Ventilation
Fluid and Glucose Management
References
Prevention and Treatment of Gastrointestinal Morbidity
Aspiration of Gastric Contents
Incidence, Etiology, and Pathogenesis
Risk Factors
Risk Reduction
NPO Guidelines
Management Strategy
Postoperative Nausea and Vomiting
Background and Incidence
Risk Factors
Management of PONV
Pharmacologic Prophylaxis and Treatment
5-HT3 Receptor Antagonists
Dopamine Receptor Antagonists
Anticholinergics and Antihistaminergics
Other Antiemetics
Nonpharmacologic Therapies
Strategy for the Prevention of PONV
Treatment of Established PONV
Postoperative Ileus
Etiology
Role of Postoperative Opioids
Role of General Anesthesia
Prevention and Treatment of Postoperative Ileus
Nonpharmacologic Methods
Nasogastric Drainage
Early Enteral Nutrition
Postoperative Fluid Administration
Mobilization
Coffee
Chewing gum
Pharmacologic Therapies for the Treatment of POI
Agents Acting on the Autonomic Nervous System
Prokinetic Agents
Laxatives
Opioid Antagonists
Nonsteroidal Anti-Inflammatory Agents
Multimodal Analgesics
Epidural Analgesia
Goal-Directed Therapy and Gastrointestinal Outcome
Role of Fluid Composition
Conclusions
References
Prevention and Management of Deep Vein Thrombosis and Pulmonary Embolism
Pathophysiology
Prevention
Diagnosis
Diagnosis of Deep Vein Thrombosis
Diagnosis of Pulmonary Embolism
Treatment of Venous Thromboembolism
Complications of Treatment
Reversal of Anticoagulation
Special Considerations
Cancer
Pregnancy
Obesity
Renal Impairment
Liver Impairment/Coagulopathy
Trauma
Orthopedics
Critically Ill
References
Perioperative Management of Bleeding and Transfusion
Introduction
Patient Blood Management and Preoperative Evaluation
Preoperative Assessment of Bleeding Risk
Common Disease States Associated with Excessive Bleeding
Hepatic Insufficiency
Renal Failure
Clotting Factor Deficiency
Platelet Deficiency
Heparin-Induced Thrombocytopenia
Intraoperative Management
Anticoagulation Reversal
Antifibrinolytic Therapy
Intraoperative Blood Management
Cell Salvage
Acute Normovolemic Hemodilution (ANH)
References
Prevention of Perioperative Surgical Site Infection
Introduction
Surgical Site Infection
Classification of SSI
Microbiology
Sources of Pathogens
Risk Factors
Prevention of Surgical Site Infection
Preoperative Setting
Patient-Related Factors
Diabetes Status and Control
Smoking Cessation
Malnutrition
Procedure-Related Factors
Preoperative Bathing and Showering
MRSA Screening and Decolonization
Bowel Preparations
Intraoperative Setting
Procedure-Related Factors
Asepsis and Surgical Technique
Hair Removal
Skin Preparation
Surgical Hand Scrub
Surgical Attire
Gowns and Drapes
Antimicrobial Prophylaxis
Special Considerations: MRSA Prophylaxis
Wound Protectors
Antibiotic Sutures
Wound Closure
Perioperative Normothermia
Perioperative Supplemental Oxygen
Perioperative Glycemic Control
Facility-Related Factors
Ventilation
Traffic Control
Cleaning Environmental Surfaces
Microbiologic Sampling
Sterilization of Surgical Instruments
Flash Sterilization
Postoperative and PostDischarge Setting
Postoperative Antibiotics
Postoperative Showering
Surveillance
Prion Disease and the Operating Room
References
Perioperative Protection of the Pregnant Woman
Introduction
Causes of Maternal Morbidity and Mortality
Anesthetic Causes of Morbidity and Mortality
Thromboembolism and Thrombophilia
Hypertensive Disorders of Pregnancy
Management of Maternal Hypertension and Preeclampsia
Magnesium Sulfate
Labetalol, Hydralazine, and Nifedipine
Other Antihypertensives
Central Monitoring
Anesthetic Considerations in the Management of Hypertensive Disorders of Pregnancy
Thrombocytopenia and Coagulopathy
Fluid Management and Pulmonary Edema
Cardiac Disease in Pregnancy
Cardiomyopathy
Myocardial Infarction
Aortic Dissection
Chronic Cardiac Disease
Congenital Heart Disease
Pulmonary Hypertension
Reduction of Perioperative Anesthesia Risk
Maternal Hypotension during Regional Block
Vasopressor Selection: Ephedrine Versus Phenylephrine Versus Norepinephrine
Fluid Management: Preload Versus Coload
Obesity
Airway Management
Advanced Planning for the Difficult Airway
Peripartum and Postpartum Hemorrhage
References
Preservation of Fetal Viability During Noncardiac Surgery
Should the Pregnant Patient Undergoing Surgery During Pregnancy Be Tilted?
Does Anesthesia During Pregnancy Have an Effect on the Fetus?
Management of Hypotension During Surgery on Pregnant Patients
Monitoring Fetal Heart Rate During Nonobstetric Surgery
Do Pregnant Patients Undergoing Nonobstetric Surgery Have Full Stomachs?
Use of 100% Oxygen During Nonobstetric Surgery
Should Hyperventilation Be Avoided in Pregnant Patients Undergoing Nonobstetric Surgery?
Risk of Preterm Labor or Miscarriage in Nonobstetric Surgery
Conclusions
References
PART IV EARLY POSTOPERATIVE CARE
Cardiac Surgery
Transport and Initial Assessment
ICU Admission
Respiratory Management
Mechanical Ventilation
Long-Term Ventilation and Weaning
Stabilization Phase
Perfusion Pressure
Blood Pressure
Cardiac Output
Modes of Mechanical Support
Postoperative Complications
Bleeding
Cardiac Dysrhythmia
Cardiac Tamponade
Postoperative Myocardial Infarction
Acute Kidney Injury
Neurologic Complications
Postoperative Fever and Infections
Gastrointestinal Complications
Fast-Tracking
Summary
References
General Thoracic Surgery
Preoperative Pulmonary Function Assessment
Pulmonary Function Tests
Assessment of Pulmonary Function Tests (PFTs)
Exercise Capacity
Predicted Postoperative Values
Special Considerations
Prevention of Postoperative Pulmonary Complications
Optimal Timing of Smoking Cessation
Use of Incentive Spirometer
Prevention of Arrhythmia
Preventing Postoperative Atrial Fibrillation
Treatment of Postoperative Atrial Fibrillation
Choice of Agent for Treatment
Rate Control
Rhythm Control
Use of Anticoagulation Therapy
Enhanced Recovery After Thoracic Surgery
References
Major Abdominal Surgery
Introduction
Pulmonary Management
Reducing Postoperative Pulmonary Complications
Pulmonary Management After Bariatric Surgery and in the Morbidly Obese
Fluid Management
Postoperative Nausea and Vomiting and Ileus
Nutrition
Surgical Site Infections
Conclusion
References
Major Orthopedic Surgery
Care After Total Joint Arthroplasty
Venous Thromboembolic Disease
Total Hip Arthroplasty
Total Knee Arthroplasty
Recommendations for Prophylaxis Against VTED
Fat Embolism Syndrome
Complications Relating to the Use of Intramedullary Cement
Care After Spine Surgery
Unique Issues after Spine Surgery
Cardiopulmonary Dysfunction
Acute Vision Loss
Intraoperative Blood Loss
Infection
Syndrome of Inappropriate Antidiuretic Hormone
Ileus and Colonic Pseudo-Obstruction
Superior Mesenteric Artery Syndrome
Conclusions
References
Solid Organ Transplantation
Types of Donors
Immunosuppression
Liver Transplantation
Recipient
Donor
Postoperative Management
Kidney Transplantation
Recipient
Donor
Postoperative Management
Pancreas Transplantation
Recipient
Donor
Postoperative Management
Intestinal Transplantation
Recipient
Donor
Postoperative Management
Heart Transplantation
Recipient
Donor
Postoperative Management
Lung Transplantation
Recipient
Donor
Postoperative Management
Infections
Conclusion
References
Multisystem Trauma
Resuscitation
Balanced Resuscitation
Choice of ICU Resuscitation Fluid
Transfusion Triggers
Endpoints of Resuscitation
Special Considerations in Trauma
Damage Control
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)
Intraabdominal Hypertension and the Abdominal Compartment Syndrome
Other Compartment Syndromes
Management of Patients with Brain Injury
Venous Thromboembolism (VTE)
Other Postinjury Considerations
Stress Ulcer Prophylaxis
Nutrition Support
Glycemic Control
Infectious Complications
Analgesia
Summary
References
Neurosurgery
Neurologic Support
Focused Neurologic Examination
Postoperative Imaging
Postoperative Intracranial Pressure Monitoring
Management of Postoperative Complications
Respiratory Support
Hypoxia and Hypercarbia in Brain Injury
Airway Assessment and Management
Outline placeholder
Decreased Level of Consciousness
Raised Intracranial Pressure
Brainstem Lesions
Spinal Cord Lesions
Sedation Strategies
Cardiovascular Support
Cerebral Perfusion and Arterial Blood Pressure
Hypertension and Brain Injury
Inotropes and Vasodilators
Fluid and Electrolyte Support
Hypovolemia and Cerebral Perfusion
Hyponatremia, Edema, and Seizures
Routine Fluid Management
Diabetes Insipidus (DI)
Hematologic Support
Role of Anemia in Cerebral Ischemia
Thromboprophylaxis
Gastrointestinal and Endocrine Support
Glucose and Cerebral Injury
Management of Diabetes Mellitus
Nutrition
Postoperative Nausea and Vomiting
Infectious Disease
Infectious Risks of Neuraxial Devices
References
Sepsis and Septic Shock
Introduction
History
Epidemiology
Pathophysiology
Inflammation
Cardiovascular Function
Immunoactivation and Paresis
Hormonal and Metabolic Changes
Organ Dysfunction
Clinical Features
Laboratory Features
Management
Antibiotics and Infection Control
Circulatory Support
Respiratory Support
Renal Support
Nutrition
Other Organ Support and Therapeutic Strategies
Immunomodulation
Hormonal Manipulation
Other Organ Supports
Future Directions
Conclusions
References
Acute Respiratory Failure
Definition
Hypoxemic Respiratory Failure
Hypercapnic Respiratory Failure
Acute Respiratory Failure in the Perioperative Patient
Postoperative Factors
Atelectasis
Clinical Manifestations
Diagnosis
Treatment
Aspiration
Clinical Manifestations
Diagnosis
Treatment
Pulmonary Embolism
Clinical Manifestations
Diagnosis
Prophylaxis
Treatment
Acute Respiratory Distress Syndrome
Principles of Management
Summary
References
Endocrine and Electrolyte Disorders
Introduction
Endocrine Dysfunction
Diabetes Mellitus
Medically Significant Obesity
Preoperative Evaluation
Treatment with Noninvasive Ventilation
Cardiovascular Complications of Obesity
Deep Vein Thrombosis
Intraoperative Concerns
Postoperative Concerns
Recommendations
Corticosteroid Supplementation
Normal Physiology
Effect of Chronic Steroid Supplementation on the HPA Axis
Diagnosis of Adrenal Insufficiency
Incidence of Adrenal Insufficiency
Identifying patients at risk for adrenal insufficiency
Perioperative Steroid Supplementation
Corticosteroids and Sepsis
Thyroid Disease and Anesthesia
Hypothyroidism
Hyperthyroidism
Thyroid Hormone and Cardiac Surgery
Sodium
Hyponatremia
Management of Hyponatremia
Outcomes
Hypernatremia
Management of Hypernatremia
Outcomes
Potassium
Hypokalemia
Treatment
Outcomes
Hyperkalemia
Magnesium
Hypomagnesemia
Hypermagnesemia
Treatment
Phosphorous
Hypophosphatemia
Hyperphosphatemia
Calcium
Hypocalcemia
Hypercalcemia
Chloride
Hypochloremia
Hyperchloremia
Conclusion
References
Improving Pain and Outcomes in the Perioperative Setting
The Growth of Unidimensional Pain Assessment Tools
The Importance of Multidimensional Assessment
An Increased Focus on Perioperative Functional Outcomes
Future Directions: Risk Predictive Tools and Personalized Pain Medicine
Clinical Phenotyping: Cluster Analysis
Genetic Risks Predictors
Biomarkers of Risk: Cytokine Profiling
Optimization
Summary and Recommendations
References
Postoperative Cognitive Dysfunction and Delirium
Introduction
Perioperative Central Nervous System Injury or Dysfunction
Postoperative Delirium
Postoperative Cognitive Dysfunction in Cardiac Surgery
POCD Associated with Noncardiac Surgery
Pathophysiology of Neurocognitive Dysfunction after Surgery
Inflammation
Embolic Load
Cerebral Blood Flow, Autoregulation, and Oxygen Delivery
Temperature Management During Cardiac Surgery
Glucose Homeostasis During Cardiac Surgery
Depression
Genetic Factors
Anesthesia, Surgery and Alzheimers Disease
Systems-Level Mechanisms of Postcardiac Surgery Cognitive Dysfunction
Future Interventions to Prevent or Treat Postoperative Cognitive Dysfunction and/or Delirium
Conclusions
References
Role of Palliative Care
Defining Palliative Care
The Multidisciplinary Team
Palliative Care and Hospice
Primary versus Specialist Palliative Care
Advance Care Planning
Symptom Management
End-of-life Care
Impact on Outcomes
Palliative Care for the Surgical Patient
Disease-Specific Palliative Care
Cancer
Palliative Care for Non-cancer Patients
Congestive Heart Failure (CHF)
Chronic Obstructive Pulmonary Disease (COPD)
Neurodegenerative Disease and Dementia
End-Stage Renal Disease (ESRD)
Human Immunodeficiency Virus (HIV)
Pediatrics
Conclusions
References
PART V CONFLICTING OUTCOMES VALUE BASED CARE
Economic Analysis of Perioperative Optimization
Health-Care Interventions as Investments
Costs and (We Hope) Benefits
The Agency Problem-Providers as Fiduciaries
Health-Care Economic Studies Offer Challenges
The Point of View Must Be Clear and Consistent
Our Goal Is to Know What Works and How Much It Costs
Barriers to Doing the Right Thing
Costs-What Exactly Do We Mean?
Direct Costs
Indirect Costs
Intangible Costs
Costs versus Charges
Cost-Estimation Techniques
Skewness in Cost Data
Future Costs Need to Be Discounted to Present Values
Good News about Costs: Marginal Costs and the Learning Curve
Benefits: Clinical Effectiveness and Utility
Increased Utility (Quality and Duration of Life)
Benefit
Types of Economic Analysis
Cost-Identification (or Cost-Minimization) Analysis
Cost-Effectiveness Analysis (Which Includes Cost-Utility Analysis)
Cost-``Benefit´´ Analysis
Decision Trees
Sensitivity Analysis
Conclusion
References
Improving Health-Care Quality Through Measurement
What Is Quality in Health-Care?
Why Improve Quality?
Framework for Measuring Quality
Development and Endorsement of Quality Measures
NQF Measure Applications Partnership
Uses of Quality Measures
Quality Improvement
Quality Improvement Methodologies
Accreditation and Verification
Hospital Accreditation: The Joint Commission
Health Plan Accreditation: The National Committee for Quality Assurance (NCQA)
Surgical Specialty Verification: Trauma Care
Public Reporting and Transparency
Value-Based Health-Care and Paying for Performance
Redefining Quality and Cost to Transition to Value
From Pay-for-Reporting to Pay-for-Performance
Clinical Care Model Redesign and Health Information Technology
Legislation to Promote Value-based Care
Patient Protection and Affordable Care Act (ACA)
The Quality Payment Program (QPP)
MIPS
APMs
Challenges in Implementing Value-Based Care and the Path Forward
Value Is Defined by Payers
Excessive Burden With Lack of Valid and Meaningful Measures
Challenges in Measuring Cost Alongside Quality
Lack of Interoperable Meaningful Data
Conclusions
References
Delivering Value Based Care: The UK Perspective
Introduction: Rising Demand and Resource Constraint
The Cost and Value of Surgery
Shared Decision Making
Preoperative Optimization
Comorbidity
Prehabilitation and Behavioral Change
Intraoperative Care
Postoperative Care and Recovery
Conclusions
References
Transitions From Hospital to Home
Paths from Hospital to Home
Factors Associated with Nonhome Discharge
Planning for Transitions
Costs of Failed Transitions
Ensuring the Transition
Putting it all Together
References
Index
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