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Carotid and Intracranial Surgery

Anesthesia for Carotid Surgery In the United States, each year approximately 795,000 people experience a new or recurrent stroke. Approximately 610,000 of these were first attacks and 185,000 were recurrent attacks. In 2016 the age-adjusted death rate for stroke as an underlying cause of death was 37.3 per 100,000. The risk of stroke in the hyperacute period after the index TIA in patients with 50%–99% carotid…

Prevention and Treatment of Postoperative Pulmonary Complications

Introduction What Are Postoperative Pulmonary Complications (PPC)? PPC have been defined in a variety of ways, reflecting the lack of consensus. At its broadest, PPC may refer to almost any pulmonary (respiratory) complication that follows surgery. Complications related to the airway that occur during or directly after surgery and anesthesia (such as laryngospasm) tend not to be included. Combining a diverse range of events into a…

Perioperative Management of Renal Failure and Renal Transplant

Introduction Safely guiding the patient with renal failure through the perioperative period presents a challenging set of problems such as the substantial comorbidity associated with chronic kidney disease (CKD), the risk of acute kidney injury (AKI), management of perioperative dialysis, and altered pharmacology. Patients presenting with renal failure fall into two distinct classes: acute renal failure or chronic renal failure (CRF). Although acute and chronic renal…

Evaluation and Treatment of Acute Oliguria

* Previous edition author. Oliguria is a one of the commonest clinical problems encountered by critically ill patients. The prevalence of the problem has been difficult to establish because of a wide variety of definitions used in the literature. Some studies have estimated that up to 18% of intensive care unit (ICU) patients with intact renal function exhibit episodes of oliguria. Furthermore, 69% of ICU patients…

Preservation of Renal Function

Introduction A rapid decline in glomerular filtration evidenced by the accumulation of nitrogenous waste products (blood urea nitrogen and creatinine) reflects acute kidney injury (AKI), a common major medical problem that occurs in 7%–18% of hospitalized patients including 50%–60% of those admitted to intensive care units. AKI manifesting in the early postoperative phase is particularly common after some surgeries, complicating up to 20%–70% of cardiac, vascular,…

Perioperative Fluid Management

Overview The approach to perioperative fluid therapy has changed markedly over the last 40 years. This has followed the change in approach by surgeons recognizing that by reducing primary injury and blood loss during surgery the physiological impact for the patient is reduced, resulting in reduction in complications and improved outcomes. The establishment of minimal invasive surgery as a reproducible way of performing complex colorectal resections…

Prevention and Management of Perioperative Dysrhythmias

Introduction Cardiac dysrhythmias are quite common in the general population. In fact, approximately 33 million people worldwide experience atrial fibrillation, and the leading cause of sudden cardiac death is ventricular tachyarrhythmias. From 2003 to 2015, there were approximately 312.6 million surgeries performed in 66 countries, and the average patient in the United States will have approximately nine surgeries during their lifetime. Its significance is detailed in…

Perioperative Management of Valvular Heart Disease

Preoperative Assessment Valvular heart disease (VHD) is frequently observed in patients undergoing surgery. As the medical and minimally invasive management of coronary artery disease increases, the number of patients with untreated advanced valvular disease is likely to supersede the number of patients with advanced coronary disease. Similarly, the rapidly expanding use of percutaneous transcatheter aortic valve replacement for high- and intermediate-risk patients with aortic stenosis (AS),…

Treatment of Perioperative Ischemia, Infarction, and Ventricular Failure in Cardiac Surgery

Perioperative Myocardial Ischemia and Infarction Definition Perioperative myocardial ischemia is difficult to define, as it represents a continuum with clinically irrelevant events at one end of the spectrum and myocardial infarction (MI) leading to complete ventricular failure at the other end. The diagnosis of perioperative myocardial ischemia and/or infarction is challenging in the setting of cardiac surgery, specifically because of the elevation of cardiac enzymes that…

Prevention of Ischemic Injury in Noncardiac Surgery

Introduction Perioperative myocardial infarction (MI) is the most common cause of death in the early postoperative period. Perioperative ischemia can be caused by either acute coronary thrombosis or by a mismatch between myocardial oxygen supply and demand. While the inflammatory response to surgery itself may be responsible for precipitating acute plaque rupture and MI, other hemodynamic disturbances, including hypertension/hypotension, tachycardia, acute blood loss, and anemia, may…

Prevention of Ischemic Injury in Cardiac Surgery

The development of the heart-lung machine by John and Mary Gibbon over a half-century ago ushered in the modern era of cardiac surgery. Prior to 1953, the emerging field of heart surgery was limited primarily to brief operations conducted on the aorta, great vessels, pericardium, and cardiac surface, all of which were performed without interrupting cardiac function; valvular repairs were often performed with a blind sweep…

Hematologic Risk Assessment

Hematologic risk assessment (HRA) involves evaluating and managing needs for red blood cell (RBC) transfusion as well as the integrity of a patient’s coagulation ability, including intrinsic bleeding disorders or coagulopathies and anticoagulant or antiplatelet medications. HRA is an essential component of preoperative assessment for virtually all patients undergoing surgery, but it is particularly critical for those refusing blood and blood products, in patients for whom…

Pulmonary Risk Assessment

Introduction Postoperative pulmonary complications (PPCs) have undeniable clinical relevance because they are frequent and impose a significant burden of perioperative morbidity and mortality. The reported incidence of PPCs varies considerably among studies, from 2% to 40%, with several risk factors identified ( Table 9.1 ). Ambiguities in the definition of PPCs and lack of systematic studies have created more challenges to the perioperative pulmonary risk evaluation.…

Risk Assessment and Perioperative Renal Dysfunction

All patients undergoing surgery—from simple surgery to an extremely complex operative procedure—suffer some perturbation in oxygen delivery to the kidneys. Postoperative acute kidney injury (AKI) portends an increase in overall morbidity, mortality, and hospital resource use. Thus the identification of patients with an increased risk for postoperative AKI is critical. The prognosis of postoperative AKI for a particular patient scheduled for a specific operative intervention may…

Central Nervous System Risk Assessment: Preventing Postoperative Brain Injury

Perioperative complications involving the central nervous system (CNS) are common. However, these issues have generally received little attention in the presurgical assessment process. New data allow us to better guide physicians and patients regarding perioperative CNS risk and ways to mitigate that risk ( Fig. 7.1 ). Open full size image Fig. 7.1 Recommendations for management of at-risk central nervous system (CNS) conditions. CSF, Cerebrospinal fluid;…

Cardiovascular Risk Assessment in Cardiac Surgery

Despite significant advancements in surgical and perioperative technology, cardiac surgery remains associated with significant risk of morbidity and mortality. Over the last 30 years, at least 20 risk models have been developed to account for variations in patient comorbidities, operations subtypes, and statistical techniques. The utility of risk models is intimately related to the characteristics of the population used to generate them. Therefore, currently accepted and…

Perioperative Cardiac Risk Assessment in Noncardiac Surgery

Introduction Anesthesia has become increasingly safer. According to the Anesthesia Quality Institute’s National Anesthesia Clinical Outcomes Registry, comprising over 30 million cases, perioperative mortality has significantly decreased in high-income countries despite a population increasingly burdened by severe comorbidities. Nevertheless, cardiac complications are still common after noncardiac surgery, with myocardial infarction (MI) being the single most common cause of death. Annually, 4% of the world’s population will…

The Value of Preoperative Assessment

Describing the value of preoperative assessment resembles the fable of six blind men trying to describe an elephant: Each comes across different parts and creates his own version of reality from that limited experience and perspective. Therefore, a clear definition of both value and preoperative assessment is necessary to inform the following discussion. Value The pursuit of value in health-care is an increasingly important focus of…

The Coagulation Cascade in Perioperative Organ Injury

Significance of Perioperative Organ Injury Although anesthesia-related complications have decreased in the last two decades, perioperative mortality has not. The leading precursor to death after surgery is acute organ injury progressing to single-organ or multiorgan failure. The failure of two or more vital organs has been termed “multiorgan dysfunction syndrome” (MODS). The common trigger for development of organ dysfunction or acute organ injury is the systemic…

The Inflammatory Response to Surgery

Introduction Tissue damage after surgery triggers a complex inflammatory response termed sterile inflammation characterized by the release of intracellular molecules into the extracellular environment leading to receptor-mediated immune signaling cascades. A key feature of this inflammatory response involves removing necrotic cells and launching a program of tissue repair. Patients may not only respond differently to a similar sterile insult because of genetic differences, but also as…