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Pituitary Tumors

Acknowledgment The authors wish to thank Ira J. Rampril for work on the previous edition of this chapter. Risk 10% of diagnosed brain neoplasms Peak incidence fourth to sixth decade of life Perioperative Risks Related to specific hormone-related effects, including difficult airway management; cardiovascular complications (hypertension, coronary artery disease, cardiomyopathy); respiratory compromise (obstructive sleep apnea); and endocrine and lyte abnormalities Worry About Airway management: Difficult mask…

Pierre Robin Sequence

Risk 1:8500-14,000 live births; PRS nonsyndromic in about 40% of cases. Syndromic PRS most commonly associated with Stickler, velocardiofacial, and Treacher-Collins syndromes. Perioperative Risks Chronic airway obstruction, respiratory distress, hypoxia. Malnutrition due to feeding difficulties, GE reflux. Congenital heart defects with syndromic PRS. Worry About Airway obstruction Difficult intubation Overview An anomaly consisting of micrognathia (or retrognathia), glossoptosis (posterior displacement of the tongue), and varying degrees…

Pickwickian Syndrome

Risk Affects 5–10% of morbidly obese pts Usually associated with long-standing obesity Perioperative Risks Markedly greater risk among the morbidly obese vs. pts with normal BMI. With intraabdominal or intrathoracic procedures lasting more than 2 h, there is approximately 40% of serious morbidity. Worry About Hypoventilation Hypercarbia Hypoxemia Polycythemia, thrombophlebitis, and subsequent pulm embolism Pulm Htn Hypersomnolence Biventricular cardiac failure Overview Pickwickian syndrome, or OHS, is…

Physiologic Anemia and the Anemia of Prematurity

Risk Physiologic anemia, occurring 6–8 wk after birth, is a normal process in term infants. Anemia of prematurity is a pathologic anemia occurring in preterm infants. Extent of prematurity and comorbidities correlate with extent of anemia. Perioperative Risks Term infants with physiologic anemia tolerate minor surgery well. Premature infants must be evaluated for symptoms due to anemia that may contribute to increased risk of preop events.…

Pheochromocytoma

Risk Incidence in USA: 0.03–0.04% (∼80,000) by autopsy of nonselected individuals. Prevalence: 0.1–0.3% of individuals with sustained Htn have pheochromocytoma. At least 20% are now diagnosed when the tumor is incidentally found during abdominal MRI or CT for other reasons. Race with highest prevalence: Caucasian. Perioperative Risks In the case of emergency (life-threatening trauma, ruptured viscus), use α- and β-blockers and nitroprusside and keep pt in…

Pertussis (Whooping Cough)

Risk Increasing prevalence 1976 (lowest) vs. 2012, 1010 vs. 41,880 cases (14 deaths in infants aged <12 mo). Substantial morbidity and mortality in USA children despite high childhood vaccination rates. Incidence highest for infants <1 y of age (23% of all cases). Adolescent group 10–19 y (33% of all cases). Incidence of death highest for infants <6 mo of age (91% of all deaths). Incidence greater among…

Peripheral Vascular Disease

Risk Prevalence of PVD is 3–20%; and increases with age. Risk factors: Nonwhite race, male gender, older age, smoking, DM, Htn, hyperlipidemia, and CRI. Risk of MACE approximately 5–7% per year; correlates with the severity of PVD. Perioperative Risks Prevalence of concomitant CAD or CVD is in the range of 40–60%. Vascular surgery associated with greater cardiac morbidity (periop MI in 4–15%) and mortality (>50% of…

Pericarditis, Constrictive

Risk Dense changes in pericardium can be caused by scarring induced by a single episode of acute pericarditis or by prolonged exposure to an inflammatory process. 18% of pericardiectomies are attributed to previous cardiac surgery, which may explain the increase in number of cases of CP since the mid-1990s. Perioperative Risks Heart failure, atrial arrhythmia, MI Abnormal drug metabolism secondary to liver failure Intraop major hemorrhage…

Pericardial Effusion

Acknowledgment The authors would like to acknowledge the contributions of Drs. Terence Wallace and Bruce D. Spiess to this text in the previous edition. Risk Occurs rarely May be seen after open-heart surgery or PTCA. Blood and/or serous May be caused by infection: Viral, bacterial, or fungal May have a neoplastic etiology: Lymphoma, leukemia Can occur after acute MI, especially transmural Can be due to trauma…

Pemphigus

Acknowledgment The authors would like to acknowledge Drs. James M. Sonner and Jeffrey A. Katz for their contribution to this text in the previous edition. Risk Incidence in USA: 0.1–0.5:100,000 per y for pemphigus vulgaris (the most common form of pemphigus) Individuals from ages 40-60 y most commonly affected. Perioperative Risks Infection, sepsis Electrolyte abnormalities and dehydration, with extensive lesions Worry About Volume status with oropharyngeal…

Patent Foramen Ovale

Risk Incidence: 25–30% at autopsy. Atrial septal aneurysm (a deformity of the septum that results in deviation of the septum more than 15 mm into either atrium) is associated with at least 50% of PFOs and is considered an additional risk factor for stroke. Perioperative Risk Unclear if a PFO increases the risk of stroke or cognitive dysfunction in the periop period. Worry About R-to-L shunting…

Patent Ductus Arteriosus

Risk Full-term infants: 1:2000 Preterm infants: 8:1000 Highest in preterm and low–birth-weight infants Female-to-male ratio: 2:1 Associated with congenital rubella infection and genetic defects, including trisomy 21, CHARGE, and a familial recurrence rate of 3% Perioperative Risks Surgery: Hemorrhage; hemodynamic instability, especially in premature and low–birth-weight neonates; single-lung ventilation resulting in hypoxia, atelectasis, and pneumothorax; injury to the recurrent laryngeal nerve; chylothorax; ligation of the incorrect…

Paroxysmal Atrial Tachycardia

Risk May be seen in ICU pts and is indistinguishable from paroxysmal SVT Digitalis toxicity, acute lyte or acid-base imbalance Incidence of 2% in the periop period (excluding AF) No racial prevalence and all age groups May be seen with mitral valve prolapse, especially in females Perioperative Risks Rapid heart rate impairs LV filling and may adversely affect LV function in pts with LV failure, hypertrophic…

Parkinson Disease (Paralysis Agitans)

Risk Advanced age 1% of population >65 y No difference in distribution by gender Perioperative Risks Hemodynamic instability, hypotension, arrhythmias Aspiration and upper airway obstruction from poor coordination of upper airway muscles Laryngospasm Postop confusion and hallucinations Worry About Exacerbation of PD symptoms triggered by dopamine antagonists such as metoclopramide; also phenothiazines, butyrophenones Potential drug interactions: MAOIs; meperidine Overview Pathophysiology: Symptoms result from the loss of…

Papillomatosis

Risk Incidence of recurrent respiratory papillomatosis (RRP) in USA estimated at 4.3:100,000 among children and 1.8:100,000 among adults. Vertical transmission during delivery is believed to be the major mode of transmission for juvenile-onset recurrent respiratory papillomatosis (JORRP). Case reports show malignant transformation of RRP to squamous cell carcinoma. Children diagnosed with JORRP at <3 y of age tend to have more aggressive disease. Adult-onset recurrent respiratory…

Pancreatitis

Risk Incidence of AP varies from 4.9–73.4 cases per 100,000 worldwide. Prevalence of CP has recently been estimated at 12–45 cases per 100,000, although its true prevalence is unknown. Perioperative Risks Most mortality occurs with surgery for complications of severe pancreatitis: 10–30% Risk of nonpancreatic surgery probably dependent on severity of attack Worry About Severe hypovolemia secondary to sequestration of fluid in the retroperitoneal space Lyte…

Paget Disease

Risk Second most common bone disorder after osteoporosis. Most common in individuals of Anglo-Saxon descent; men > women Prevalence increases with age and can be as high as 9–15% in people >80 y; average age at diagnosis in USA is 58. Within USA, prevalence is highest in the Northeast and lowest in the South. Perioperative Risks Bleeding Cardiovascular disease CNS structures at risk Worry About Excessive…

Pacemakers

Risk In USA, over 3 million people have an implantable cardiac PM, and more than 400,000 PMs are implanted annually. In addition to a right atrial and right ventricular lead, some PM pts with cardiomyopathy also have left ventricular pacing capability via a transvenous coronary sinus or epicardial lead (this configuration is called CRT-P). Because all conventional ICDs provide antibradycardia pacing, that section of this book…

Otitis Media

Risk Age: Highest incidence occurs between 6–24 mo of age; incidence subsequently declines, except for an increase at the time of school entry (between 5–6 y of age). Day care attendance. Tobacco smoke and air pollution. Other factors: Poor social/economic conditions, cooler seasons (fall and winter), altered host defenses, and diseases with associated craniofacial abnormalities (cleft palate and Down syndrome). Perioperative Risks Active or concurrent disease:…

Osteoporosis

Risk Most common metabolic bone disease in USA All elderly pts of European descent considered at risk Non-Hispanic white women and Asian women at highest risk Estimate is that over 200 million people worldwide are at risk. Approximately 30% of all postmenopausal women in USA and Europe have osteoporosis. At least 40% of these women and 15–30% of men will sustain one or more fragility fractures…