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Improving Pain and Outcomes in the Perioperative Setting

The Growth of Unidimensional Pain Assessment Tools A subjective and personal experience, pain remains difficult to quantify within the confines of empirically based medical tradition. Regardless of this challenge, however, management still necessitates accurate and timely assessment, particularly in the perioperative patient. The promotion of pain as a fifth vital sign in the 1990s has been criticized for its potential unintended consequences, however, this initiative also…

Endocrine and Electrolyte Disorders

Introduction Perioperative electrolyte and endocrine disorders are dealt with by anesthesiologists on a daily basis. With the rising incidence of diabetes and obesity and their relation to increased morbidity in the perioperative period, it is imperative that clinicians are skilled in the management of these disorders. This chapter discusses the management of these conditions and other common endocrinological problems such as thyroid disease and the controversy…

Acute Respiratory Failure

Definition Respiratory failure occurs when the lungs fail to oxygenate the arterial blood adequately and/or fail to prevent carbon dioxide retention. Although the definition does not contain any absolute values, an arterial O 2 of less than 60 mmHg and an arterial CO 2 of more than 50 mmHg are often regarded as of consequence. However, values should be considered in the context of an individual…

Sepsis and Septic Shock

Introduction The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) recently defined sepsis as a “life-threatening organ dysfunction caused by a dysregulated host response to infection.” Sepsis is a medical emergency with mortality rates of 18% to 29% in developed countries and as high as 80% in low-income countries. In the United States alone there are reportedly 750,000 cases per year. History The oldest…

Neurosurgery

After uncomplicated neurosurgical procedures, patients are often admitted to an intensive care unit (ICU) for close observation. In the large majority of cases, this level of care is warranted as a means to monitor the patient’s neurologic function carefully and to expedite appropriate intervention if necessary. Further, observation and evaluation of postoperative neurosurgical patients may be complicated by the residual effects of the prior anesthetic and…

Multisystem Trauma

Care of patients with multisystem trauma is challenging. Although well-defined constellations of injury exist, ultimately each patient is unique in preinjury health, injury complex, and postinjury management. Because many injuries are managed nonoperatively, many patients have no postoperative phase. However, some injured patients require multiple operations, and the distinction between postoperative care and preoperative care is blurred. The fundamental principles of care of the injured patient…

Solid Organ Transplantation

Solid organ transplantation is the surgical procedure in which an organ is removed from a one body (donor) and placed into another body (recipient). Solid organs that have been successfully transplanted are liver, kidneys, pancreas, intestine, heart, and lungs. Before organ transplantation can be considered, there must be failure of the native organ. Each organ failure is associated with specific morbidities and for some organs the…

Major Orthopedic Surgery

The United States is experiencing considerable growth in its elderly population. In 2050, the population of elderly people aged 65 years and over is projected to be 83.7 million, almost double the estimated population in 2012. As a result, an increasing portion of health-care resources will be used by the “baby boomer” generation. In the United States, approximately 505,000 hip replacements and 723,000 knee replacements were…

Major Abdominal Surgery

Introduction Major abdominal surgery encompasses a broad range of operations with a wide variety of procedures that fall under this category. The perioperative management after a low-risk procedure such as a herniorrhaphy is going to be different from the management following a high-risk procedure such as a pancreaticoduodenectomy. The majority of patients undergoing major abdominal surgery often present with cancer and other medical comorbidities and are…

General Thoracic Surgery

The focus of this chapter is on concepts in the perioperative period germane to general thoracic surgery. Areas that will be covered include preoperative pulmonary reserve assessment, prevention of postoperative pulmonary complications with emphasis on smoking cessation and the current evidence for use of incentive spirometry, prevention of arrhythmia, and a comprehensive assessment of the role for enhanced recovery protocols in thoracic surgery. Although the majority…

Cardiac Surgery

Each year, more than 500,000 cardiac surgery procedures are performed in the United States, and, until recently, this number continued to grow annually. Cardiac surgical patients are routinely admitted to the intensive care unit (ICU) for monitoring of recovery from anesthesia and surgery, optimization of hemodynamics, weaning from ventilatory support, and monitoring for possible complications. The ICU has emerged as the dominant area where the complex…

Preservation of Fetal Viability During Noncardiac Surgery

Caring for the pregnant patient who requires a surgical procedure is challenging. The effects of anesthetics on the developing fetus continues to evolve and issues concerning the pregnant patient have changed. The most important point to remember when performing anesthesia on the pregnant patient requiring surgery is that this procedure will involve caring for two patients with the mother being the primary patient and the fetus…

Perioperative Protection of the Pregnant Woman

Introduction Maternal safety surrounding nonobstetrical surgery, labor, and delivery has been seen as one of the greatest triumphs of 20th century medicine. Within living memory, nearly 1% of women in the United States died during or in the immediate aftermath of childbirth. As recently as 1900, maternal mortality was six to nine per 1000 live births, and of those 1000 births, 100 infants died before the…

Prevention of Perioperative Surgical Site Infection

Introduction Surgical site infections (SSIs) are now the most common cause of hospital-acquired infections (HAIs), accounting for approximately 20% of all HAIs in hospitalized patients. Approximately 160,000–300,000 SSIs occur each year in the United States and 2%–5% occur in patients undergoing inpatient surgery. SSIs are associated with worse outcomes, including a 2- to 11-fold increase in the risk of mortality. Although most patients recover from an…

Perioperative Management of Bleeding and Transfusion

Introduction Transfusion therapy is necessary and can be lifesaving in surgical patients. However, despite being the standard of care for blood loss and anemia, it has never undergone the rigorous, randomized testing required of a new therapeutic agent, including assessment of adverse events and risk assessment. Since the outbreak of acquired immunodeficiency syndrome (AIDS) in the 1980s, it has become apparent that the full extent of…

Prevention and Management of Deep Vein Thrombosis and Pulmonary Embolism

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common, preventable perioperative complication occurring in up to 5% of noncardiac surgical patients. Even when treated, DVT can lead to long-term consequences, including chronic edema, dermatitis, venous stasis ulcers, and post-thrombotic syndrome. Another complication of DVT, pulmonary embolism, carries 15% mortality, and acute phase survivors may develop pulmonary hypertension. Prevention and treatment…

Prevention and Treatment of Gastrointestinal Morbidity

Undergoing general anesthesia for an elective operation has become exceedingly safe and is now rarely associated with mortality. With the improvements in perioperative screening, risk reduction, and intraoperative management, we can now focus on and improve the quality of postoperative recovery. For example, gastrointestinal morbidity is frequent after elective surgery. In the past decade, there has been a vast increase in the understanding of the risk…

Perioperative Management of Acute Central Nervous System Injury

Introduction Neural function is essential to human existence. Thus, loss of any neural element in the course of a critical illness represents a major loss to a given individual. Neurons or supporting elements may be lost in a small, virtually unnoticeable manner, perhaps manifest as cognitive or behavioral deficit, or there may be widespread selective neuronal loss or tissue infarction with more apparent and disabling deficits.…

Preservation of Spinal Cord Function

Introduction Acute spinal cord injury (SCI) is a devastating medical condition because of the impact of permanent disability produced by paraplegia or quadriplegia. Treatment of the initial injury and reintegration of the injured patient into society place a large burden on health-care systems and society as a whole. Furthermore, acute SCI is particularly taxing from an emotional standpoint, because the patient often remains fully aware of…

Protecting the Central Nervous System During Cardiac Surgery

Introduction Multiple advances in perioperative techniques, especially the maturation of cardiopulmonary bypass, have allowed the practice of cardiac surgery to develop rapidly. Despite these advances that have enabled contemporary cardiac surgery to address a diverse range of cardiac pathologies, neurological injury, ranging from delirium to stroke, has persisted as a relatively common and important complication after cardiac surgery. As a result, extensive research has explored the…