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Ventricular Septal Rupture (Defect), Postmyocardial Infarction

Risk Historically seen in 1–3% of MIs prior to era of acute revascularization. Incidence is 0.2% in current era of acute percutaneous intervention. Most occur within 1 wk of MI; 20–30% occur in first 24 h post-MI. Rarely occurs >2 wk post-MI. Medical management alone results in a mortality >90%. Perioperative Risks Accounts for 5% of MI-related deaths, Without surgical therapy, survival is less than 10%…

Ventricular Septal Defect (Congenital)

Risk Incidence: About 2–6:1000 live births. May be isolated or part of several complex malformations such as TOF. Perioperative Risks Mortality higher in older children; elevated PVR (>7 Wood units); surgery may be complicated by complete heart block. Worry About Worsening of L-to-R shunt with hyperventilation and increased FIO 2 Paradoxical embolization Hypothermia Post–CPB pulm Htn and RV failure Overview Small defects asymptomatic, present with murmur,…

Ventricular Preexcitation Syndrome

Risk Not all patients are symptomatic or have a prior diagnosis; 1–3% of diagnoses are made following ECG in previously asymptomatic individuals. WPW syndrome affects 0.1–0.3% of the population, is more prevalent in males, and is characterized by symptomatic arrhythmias and an ECG showing a short PR interval (<120 ms) with a widened QRS (>100 ms) and often, but not always, δ waves, representing fusion of…

Ventricular Fibrillation

Risk VFIB/VTach: Most frequent rhythm in sudden cardiac arrest and the most frequent cause of death in pts with coronary disease. Risk of VF complicating an acute MI: 4–7%; has remained unchanged for several years. 1-y mortality in survivors of near sudden death: 20–30% if nonresponsive to antiarrhythmics (20–50% of survivors). Perioperative Risks Primary VFIB associated with acute infarction may not affect prognosis if treated promptly…

Varicella-Zoster Virus

Risk Prevalence: <10% of adults seronegative Usually contracted during childhood. Perioperative Risks Minimal additional risk to pts unless immunocompromised. Risk of infection for caregivers. Worry About Encephalitis in immunocompromised pt Potential nosocomial transmission Acyclovir-induced nephrotoxicity Transmission to pregnant woman Overview Viral cause of varicella (chickenpox) and herpes zoster (shingles). Caused by both nosocomial transmission and direct contact. Development of herpes zoster is common in immunocompromised pts…

Uterine Rupture

Risk Incidence varies; 1:1500 women for all pregnancies; 1:8400 for unscarred uteri. Incidence of rupture with prior uterine scar (i.e., cesarean, myomectomy) ranges from 0.5–2% in developed countries. Maternal mortality is between 0.1–1% of cases. Risk factors: Uterine scar (e.g., prior classical cesarean, prior low transverse cesarean, previous uterine myomectomy), congenital uterine anomalies, multiparity (especially previous cesarean deliveries), fetal macrosomia, uterine instrumentation, uterine trauma, rapid progression…

Urticaria, Cold

Risk Higher incidence found in regions with colder climate Prevalent in all races and genders; most commonly seen between ages 10–40 y Perioperative Risks Can develop urticaria and/or angioedema with skin cooling and rewarming Systemic shock-like reactions can occur with whole-body cold exposure (e.g., swimming) Worry About Exposing patients to cold stimulus (e.g., cold room, cold IV or irrigation fluids, cold instruments or devices against the…

Urinary Lithiasis

Risk Annual incidence of stone disease is 16.4 per 10,000. Lifetime prevalence is 1–15%, although this varies with age, gender, race, and geography. Men are affected 2-3 times more often than women, but this varies with race. Racially, prevalence highest among Caucasians, followed by Hispanics, Asians, and African Americans. Peak incidence in fourth-sixth decades of life. Increased risk of recurrence after first stone. Perioperative Risks Morbidity…

Upper Respiratory Infections

Risk Most adults will suffer 1 URI per year; this incidence jumps to approximately 6 episodes per year in the pediatric population. Approximately 95% of the infections have a viral etiology. URIs are generally self-limiting; however, airway hyperreactivity may persist for several wk. Adults are less likely to have URIs due to larger airways enabling them to compensate with edema and increased secretions. Those with underlying…

Ulcerative Colitis, Chronic

Risk Incidence in USA and Northern countries of 35-100:100,000; incidence of 11:100,000/y with 2- to 4-fold increased frequency in Jewish populations. Mortality highest in early years of disease, or with prolonged disease due to risk of colon cancer; two peaks for age of onset: 15–30 y and 60–80 y. Male:female ratio is 1:1; smokers:nonsmokers, 0.4:1; former smokers:nonsmokers, 1.7:1. Up to 20% of pts have a positive…

Tuberculosis

Risk Incidence in USA in 2014 was 2.96 cases per 100,000 persons; worldwide, incidence is over 9 million cases per year. There were 1.5 million TB-related deaths worldwide in 2014. Incidence in USA has been decreasing every year since 1992. Risk is higher among homeless, elderly, Asian, and Latin American immigrants, minorities, and prisoners. Also, immunosuppression (e.g., HIV infection, transplant recipients, chronic renal insufficiency) increases TB…

Truncus Arteriosus

Risk Uncommon congenital heart defect; <3% of all congenital heart defects No gender predilection Perioperative Risks CHF. Volatile agents may depress myocardial contractility and lower SVR. Inadvertent hyperventilation resulting in reduced PVR, excess PBF, and worsening CHF. Infective endocarditis. Risks of CPB. Worry About Difficult intubation due to assoc with velocardiofacial syndrome (e.g., DiGeorge) Air embolus (VSD almost always present) Hyperoxia and hyperventilation resulting in pulm…

Trigeminal Neuralgia (Tic Doloureux)

Risk Has an incidence of 12–27:100,000 More common in women and pts >50 y. 1–5% of pts with MS have TN, and 2–4% of pts with TN have tumors or vascular malformations in the posterior fossa. There is an association with Charcot-Marie-Tooth disease. Perioperative Risks Evaluate comorbidities with pts with MS, tumors. Liver enzyme induction with use of antiepileptic drugs. Difficulties with mastication might lead to…

Tricuspid Atresia

Risk Uncommon; occurs in 0.056:1000 live births. Perioperative Risks Hypoxia caused by limited pulm blood flow. Reliable systemic and pulm blood flow in these pts depends on existence of an unobstructed atrial level right to left shunt, an unobstructed left to right ventricular septal defect, and intact pulm artery. There is obligatory mixing of systemic venous blood return to the heart from the vena cavas (lower…

Treacher Collins Syndrome

Risk Incidence of 1:25,000–50,000 live births. Perioperative Risks Difficult airway management Worry About Difficult mask ventilation and intubation Acute airway obstruction Hx of obstructive sleep apnea and cor pulmonale Overview Also known as mandibulofacial dysostosis and Franceschetti-Zwahlen-Klein syndrome. Clinical features include various degrees of mandibular hypoplasia, high arched or cleft palate, malar hypoplasia, ophthalmic abn (downward slant of palpebral fissures, lower lid coloboma, partial to total…

Transverse Myelitis

Risk Incidence: 1–8 cases per million per y. Age distribution: Bimodal peaks between ages of 10–19 y and 30–39 y. Perioperative Risks Data scarce Autonomic disturbances (hypertension, hypotension, arrhythmias) Delayed gastric empting Anesthetic induced worsening unclear; causative role described Worry About Risk of aspiration due to gastroparesis Autonomic dysfunction: Acute: Spinal shock (hypotension) Chronic: Autonomic dysreflexia (hypertension, bradycardia) Potential worsening of neurologic symptoms Hyperkalemia from succinylcholine…

Transposition of the Great Arteries

Risk Incidence: 2.7-3.2:10,000 live births Relatively common; represents >5% of all congenital cardiac malformations One of the most common causes of newborn cyanosis Male predominance of 2.25-fold increased risk Relatively low risk (12%) of coexisting syndromes/noncardiac malformations Perioperative Risks Newborn: Hypoxemia, acidemia, low cardiac output syndrome, and death. Risk of inadequate mixing of pulm and systemic circulations to allow oxygen uptake and delivery. Closure of ductus…

Transfusion-Related Acute Lung Injury

Risk Can occur in any pt receiving blood or blood products, including platelets, plasma, cryoprecipitate, and rarely, IVIG. Overall incidence probably <1%; increasing awareness of the syndrome has resulted in improved recognition. Use of leukodepleted blood has decreased the incidence of packed red cell-related lung injury. Perioperative Risks Noncardiogenic pulm edema, usually within 6 h of transfusion. Mortality reported as 5–10%. Worry About O 2 toxicity…

Tracheoesophageal Fistula (Congenital)

Risk Incidence of EA + TEF: 1:3500. EA/TEF in twins is 2.6 times higher than in singletons. Perioperative Risks Respiratory distress Stomach distention, rupture (1%) possible Dehydration and hypoglycemia Worry About Respiratory status Congenital heart disease (23%): PDA, VSD, TOF, ASD, right-sided aortic arch Location of fistula (typically unknown) Fluid and metabolic status Prematurity Low birth weight (common) Overview Association with vertebral abnormalities (17%), anal and/or…

Thyroid Neoplasms

Risk Incidence in USA is 23,500 new thyroid cancer cases/y, but incidence is increasing. Account for approximately 1% of new cancer diagnoses each y. Hispanics, African Americans, lower rate; Caucasians, moderate rate; Japanese, Chinese, Hawaiian, Filipinos, higher rate. Overall incidence 3× higher in women than in men; peaks in third and fourth decades of life. Perioperative Risks Large thyroid mass may produce airway compression, deviation, or…