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Protein C Deficiency

Risk Congenital deficiency. Homozygote is estimated at 1:500,000-750,000 live births. Occurs when gene coding for protein C on both chromosomes #2 is affected. Heterozygote ∼0.2–0.4% of healthy population; 2–5% in pts with DVT. Acquired deficiency also seen. Perioperative Risks Pts with protein C deficiency are at risk for venous thrombosis and pulm embolism (immobility, endothelial damage, and decreased blood flow during periop period may be triggers).…

Preterm Infant

Risk Births at less than 37 post conceptual wk (PCW) rose sharply from 1990 to 2006 in USA due to the increase in assisted reproductive technology and multiple gestation. It has been slowly declining in the ensuing years. In 2013, 11.4% of all live births were <37 PCW; 3.4% were <34 PCW. 67% of all infant deaths occur among the premature. Babies born at less than…

Pregnancy-Induced Hypertension

Risk Although the true incidence of PIH remains unknown, it is believed to complicate about 6–10% of pregnancies, contributing to one of the major causes of maternal, fetal, and neonatal mortality and morbidity. Perioperative Risks Short-term maternal risks: CNS dysfunction, hepatocellular injury/hemorrhage, thrombocytopenia, acute DIC, oliguria, pulmonary edema, cerebrovascular events (hemorrhage, encephalopathy), placental abruption, acute renal failure, progression to PEC, or EC and death. Short-term fetal…

Pregnancy, Maternal Physiology

Risk Estimated 6.4 million pregnancies in USA, resulting in 4.1 million live births per year. Pregnancy rate is 102 pregnancies per 1000 women between the ages of 15–44 y. Perioperative Risks Maternal mortality rate is 28 deaths per 100,000 live births in USA, with 210 deaths per 100,000 live births in the world. Hemorrhage, hypertension, and embolic disorders are leading causes of maternal deaths. Risks of…

Pregnancy, Intra-Abdominal

Risk Incidence in USA: 11:100,000 live births and 9:1000 ectopic pregnancies. Higher incidence in African Americans, Asians, and immigrant populations from third-world countries. Risk factors include PID, tubal damage, intrauterine contraceptive devices, assisted reproductive techniques, previous ectopic, and previous pelvic surgery. Maternal mortality 100 times that of intrauterine pregnancy. Perinatal mortality ranges from 40–95%. Perioperative Risks Misdiagnosis prior to delivery is not uncommon, and a high…

Pregnancy, Ectopic

Risk Implantation of a fertilized oocyte outside the uterine cavity. 1.3–2.4% of all pregnancies, but rate is increasing due to risk factors and better diagnostic methods. Risk factors: High-tubal surgery, prior ectopic pregnancy, use of an IUD, interutero exposure to diethylstilbestrol, moderate assisted reproductive technologies, pelvic inflammatory disease, smoking, tubal pathology; maternal age >40 y. Fallopian “tubal” pregnancy is most common (97–99%). Perioperative Risks Leading cause…

Preeclampsia

Risk 2–8% of all pregnancies Nulliparous, or multiparous with previous preeclampsia/eclampsia Hx, advanced maternal age Increased with Hx of obesity, chronic htn, diabetes, renal disease, SLE, thrombophilia Perioperative Risks Increased risk of fetoplacental or maternal deterioration necessitating (often operative) delivery. Increased risk of fetal death. Preeclampsia and eclampsia account for about 15% of maternal and perinatal deaths. Worry About Hypertensive crisis leading to intracerebral bleed or…

Prader-Willi Syndrome

Risk Prevalence: 1:25,000 Incidence: 1:10,000-15,000 Racial prevalence: None Gender predominance: Similar frequency in both sexes and all races Most common syndromic form of obesity, affects 350,000–400,000 individuals worldwide Annual death rate is 3% versus 1% in the general population, primarily due to respiratory arrest Perioperative Risks Infantile hypotonia, hypoventilation, and breathing difficulty Potential for difficult intubation and aspiration risk Worsening of obstructive/central sleep apnea and abn…

Posttransplant Lymphoproliferative Disorder

Risk Cumulative incidence over 5 y: 1–2% in liver, 1–3% in kidneys, 2–6% in heart, 2–9% in lung, and 11–33% in intestinal or multiorgan transplants Major risk factors: EBV positive serology in the recipient (multisystem PTLD) EBV negative recipient and EBV-positive donor (PTLD limited to allograft tissue) The degree of T-cell immunosuppression (induction with OKT3, ATGAM, thymoglobulin, and maintenance with tacrolimus) Additional risk factors: Time after…

Postoperative Encephalopathy, Metabolic

Risk Pts undergoing any surgical procedure are at risk. It is especially of concern following brain or cardiac surgery or interventional neuroradiology procedures and in pts with COPD, cancer, renal or hepatic failure, and those with lyte abnormalities. Post–liver transplant. No gender predominance. Perioperative Risks Aspiration, fluid and lyte imbalances, circulatory failure, hypoxia, insulin use You’re Reading a Preview Become a Clinical Tree membership for Full…

Portal Hypertension

Risk Hepatic cirrhosis has a prevalence of about 1–3:1000. At the time of diagnosis of cirrhosis, 50% of pts will already demonstrate sequelae of portal hypertension. Also, in the setting of schistosomiasis (mainly in developing countries), portal vein thrombosis, Budd-Chiari syndrome, or congestive hepatopathy may be seen in pts with congestive heart failure. Perioperative Risks Multifactorial increase in risk of coagulopathy: Risk of thrombocytopenia caused by…

Pompe Disease

Risk Combined incidence (infantile vs. late-onset): 1:40,000. Infantile form has higher incidence in African-American and Chinese populations. Late-onset disease has a higher incidence in the Netherlands. Perioperative Risks Respiratory insufficiency Aspiration pneumonia Pulm edema Myocardial ischemia Worry About Respiratory insufficiency, which may require prolonged mechanical ventilation Myocardial ischemia Arrhythmias, sudden death GE reflux, aspiration pneumonia Difficult extubation and ventilator dependence Overview Only glycogen storage disease that…

Polymyositis

Risk Annual incidence in USA: 5.5:1,000,000, most prevalent among black women Annual incidence around the world: 1.9-7.7:1,000,000, although comprehensive epidemiologic data are lacking Perioperative Risks Delayed recovery from muscle relaxation Aspiration pneumonitis Cardiac arrhythmias CHF Worry About Increased risk of aspiration Respiratory muscle and/or diaphragmatic weakness Hyperkalemia following succinylcholine use; sensitivity to NMB Interstitial lung disease, progressive fibrosis, and/or difficulty with ventilation/oxygenation Cardiomyopathy with heart failure…

Polycythemia Vera

Risk Prevalence: 22:100,000; twice as high among men as women. Higher prevalence in Jewish people of European origin. Prevalence increases with advancing age (rare in those <30 y). Perioperative Risks Risk of deep venous thrombosis, pulmonary emboli Risk of coronary, cerebral thrombosis/ischemia Increased histamine release and prostaglandin production Worry About Hyperviscosity from increased Hct Preop treatment should include phlebotomy to Hct of ≤45% Increased plt count…

Poliomyelitis

Risk Acute disease eradicated in USA and most of Europe owing to effective vaccination (last USA case reported in 1979 and last case in the western hemisphere in Peru in 1991). Small parts of Africa and Asia still have areas of endemic wild-type poliovirus with less than 200 cases reported globally in 2014. Hundreds of thousands of survivors still live in USA with varying degrees of…

Pneumonia, Ventilator-Associated

Risk Incidence of VAP is 1.2–8.5:1000 ventilator days; occurs in 9–27% of intubated mechanically ventilated pts Risk greatest in the first 5 d of mechanical ventilation Increased risk: Male sex; admission for trauma; underlying disease severity; surgery; previous antibiotic exposure Perioperative Risks Intraop decrease in FRC can worsen the severity of hypoxemia. Preop high levels of PEEP can lead to decreased preload and hypotension. Worry About…

Pneumonia, Community-Acquired

Risk Incidence of CAP requiring hospitalization is 24.8:10,000 individuals. Incidence is 9 times higher among those 65 y of age or older (compared with age group 18–49). Incidence is 25 times higher among those 80 y of age or older (compared with age group 18–49). Perioperative Risks Intraop decrease in FRC could worsen the severity of hypoxemia. Prolonged mechanical ventilation. Worry About Irritable airway at increased…

Pneumocystis jirovecii Pneumonia

Risk PJP is a respiratory infection seen in immunocompromised pts, usually associated with a CD4 cell count <500 Can affect pts with both acquired and congenital immunodeficiency syndromes. Seen in both males and females and all age groups. Often associated with chronic HIV infection, particularly if not treated with HAART. Perioperative Risks Respiratory failure often necessitating mechanical ventilatory support with high airway pressures even when ventilating…

Plagiocephaly

Risk Obstetric factors: Primigravidy, assisted delivery, low birth weight, preterm birth Infant factors: Limited neck ROM, male sex, larger CSF spaces, preference to sleep with head turned to one side. Infant care factors: Spends most time in supine position without variable head positions, firmer mattress, less time in prone position and/or upright, exclusively bottle-fed. Observed in 5–48% of healthy newborns. Perioperative Risks Minimal risk if plagiocephaly…

Placenta Previa

Risk Incidence: 1:200-250 pregnancies Highest incidence with multiparity, repeat C-section or other uterine surgery, prior placenta previa, advanced maternal age, tobacco use, cocaine use, male fetus Perioperative Risks Maternal mortality is <1%. Fetal complications: Prematurity (45% of deliveries at <37 wk); mortality increased 3 to 4 times. Life-threatening hemorrhage of mother or fetus. Fetal hypoxia. Worry About Blood loss, hypovolemia. Increased risk of aspiration due to…