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Is There an Optimal Perioperative Hemoglobin?

## Blood transfusions remain the most common procedure performed in hospitals in the United States. With recent trial evidence supporting the use of restrictive transfusion thresholds and the rise of patient blood management programs, however, red blood cell transfusion rates have been declining since 2008. Approximately 10.7 million units of red blood cells were transfused in the United States in 2017. It is estimated that 30%…

What Is the Best Strategy for Prevention of Postoperative Nausea and Vomiting?

INTRODUCTION Postoperative nausea and vomiting (PONV) are among the most common side effects associated with anesthesia and surgery. Currently, the overall incidence of PONV for all surgeries and patient populations is estimated to be 25% to 30%. Furthermore, PONV can lead to a delay in postanesthesia care unit (PACU) discharge, unanticipated hospital admission, or both, thereby increasing medical costs. Symptoms of PONV are also among the…

What Are the Benefits of Different Ventilatory Techniques?

INTRODUCTION A broad variety of techniques and modes of mechanical ventilation are now available to physicians, thanks to improvements in technology. For the most part, the design of these techniques is based on sound physiologic principles. Nevertheless, there is limited evidence that ventilatory techniques and modes affect hard outcomes. Additionally, the existing randomized controlled trials (RCTs) do not indicate the superiority of any specific mode; they…

Does the Choice of Fluid Matter in Major Surgery?

INTRODUCTION Intravenous (IV) fluid therapy is known to have a major impact on surgical outcomes and, as a result, has been the focus of many clinical studies. The overall aim is to maintain normal intravascular volume, tissue fluid, and electrolytes but avoid fluid and sodium overload. The first use of IV fluid therapy dates back to the 1831 European cholera epidemic when attempts were made by…

When Should Perioperative Glucocorticoid Replacement Be Administered?

INTRODUCTION Glucocorticoids have been used as adjunctive therapy in the perioperative period for decades. They have immunosuppressant and antiinflammatory effects, improve cardiovascular sensitivity to catecholamines, restore adrenal cortical function, and maintain intravascular volume. Therefore steroids may be particularly beneficial in patients with sepsis, relative adrenal insufficiency caused by exogenous corticosteroid administration, acute respiratory distress syndrome (ARDS), and those undergoing cardiac surgical procedures. Perioperative steroid replacement remains…

What Is the Role of Ketaminein Perioperative Management?

INTRODUCTION Over 40 years ago during the Vietnam War, ketamine, a nonbarbiturate phencyclidine derivative, was considered an ideal “battlefield anesthetic” because it did not alter hemodynamics and had sedative, hypnotic, analgesic, and amnestic properties. , Over time, its popularity waned because of an undesirable side effect profile: hallucinations, delirium, lacrimation, tachycardia, and the potential for an increase in intracranial pressure (ICP) and coronary ischemia. Nevertheless, reports…

When Are Platelet and Plasma Transfusion Indicated?

INTRODUCTION Perioperative management of hemostasis is an important topic. Both prophylactic and therapeutic replacement of coagulation factors are frequently required to minimize the risk for spontaneous or perioperative bleeding, the need for intraoperative transfusion of allogenic blood products, and the associated complications of both bleeding and transfusion. Over the last decades, there has been an emphasis on targeted replacement of coagulation factors rather than the administration…

Emergency Laparotomy

INTRODUCTION Emergency laparotomy is a common surgical procedure with high morbidity and mortality. There is a diverse range of underlying causes and surgical treatment for emergency laparotomy (excluding trauma and major vascular procedures), but the commonest underlying causes are intestinal obstruction and perforation. A large proportion of patients who require emergency laparotomy have deranged physiology relating to the underlying pathology, with one large prospective study of…

Aspiration: Understanding the Risks and Optimizing Management

INTRODUCTION Pulmonary aspiration is a recognized risk for patients undergoing anesthesia and surgery and for patients with a variety of underlying medical conditions. For the surgical patient, although aspiration can occur at any time during the perioperative period, the risk for aspiration is greatest when the patient is rendered unconscious and unable to protect the airway as occurs during deep sedation or general anesthesia. A variety…

Does Anesthetic Choice Affect Surgical and Recovery Times?

INTRODUCTION One of the most common concerns of physicians and patients is the potential adverse effects of anesthesia on recovery times after surgical procedures. Although mortality rates for anesthesia have continued to decrease over the years, postoperative complications continue to pose a risk for patients and providers. Scientific literature shows continued interest in anesthetic techniques shown to decrease poor outcomes. Traditionally an investigation of these techniques…

Do Inhalational Agents Have Beneficial Effects on Cardiac Ischemia-Reperfusion Injury?

INTRODUCTION Experimental evidence has indicated that inhalational anesthetics have protective effects against the consequences of cardiac ischemia-reperfusion injury. These protective properties have been related to pharmacologic pre- and postconditioning effects but also to a modulation of the inflammatory response. Although quite a number of underlying pathways have been identified, the exact mechanisms still remain to be fully elucidated. It is beyond the scope of this chapter…

Is There a Best Approach for Patients With Difficult Airways: Regional Versus General Anesthesia?

INTRODUCTION Regional and general anesthesia techniques can individually offer advantages to a patient with a known difficult airway. The superiority of one technique over the other is hotly debated, and the complexities of study design, as well as potential ethical dilemmas, mean finding a definitive answer regarding the best approach is difficult. Multiple factors influence the choice of anesthesia provided and its outcome, including patient comorbidities…

Is There an Optimal Timing for Smoking Cessation?

INTRODUCTION Cigarette smoking is the number-one cause of avoidable death within the United States. Thirty-four million Americans smoke cigarettes and half of them will die of this, contributing 480,000 deaths annually. Medical costs attributable to smoking in the United States are estimated at $170 billion per year. Passive smoking is also harmful and begins in utero with the premature birth of small babies, which can affect…

Do Checklists Improve Emergency Management?

INTRODUCTION The use of cognitive aids in health care, specifically in the field of anesthesiology, is becoming increasingly popular. Cognitive aids are tools that help users complete a specific task, and checklists are a type of cognitive aid that detail the specific, necessary steps. Emergency manuals are collections of cognitive aids that can be used during critical events. Before we discuss the history of how crisis…

Does the Airway Examination Predict Difficult Airway Management?

INTRODUCTION Over the past few decades, advancements such as the laryngeal mask airway (LMA), the flexible intubation scope (FIS), and video-assisted laryngoscopy (VAL) have revolutionized the field of airway management. Nevertheless, difficulty with airway management still poses a challenge to anesthesia practitioners. A recent study analyzing claims in the Anesthesia Closed Claims Project database demonstrated that in the period from 2000 to 2012, adverse respiratory events…

Are Alpha-2 Agonists Effective in Reducing Perioperative Renal Injury?

INTRODUCTION Despite advances in anesthesia care over the past decades, perioperative organ injury remains the leading precursor to death after surgery. Perioperative renal injury is one of the most common postoperative complications and leads to increased health care expenditure, prolonged hospital stay, and increases in short- and long-term mortality. , It is difficult to determine the true incidence of perioperative acute kidney injury (AKI). Because of…

How Should Beta-Blockers Be Used Perioperatively?

INTRODUCTION The use of perioperative beta-blockade (PBB) for the reduction of cardiac risk in patients undergoing noncardiac surgery came to prominence in the late 1990s, and continued excitement remained strong during the first decade of the twenty-first century. Support for its initial interest came from several early successful trials and the nearly 50 years of research from the cardiology literature documenting the cardioprotective effects of beta-blockers.…

Best Strategy for Perioperative Angiotensin-Converting Enzyme-Inhibitor (ACE-I) and Angiotensin II Receptor Blocker (ARB) Therapy Prior to Noncardiac Surgery

INTRODUCTION It is estimated that more than 280 million surgeries take place globally each year. More than one-third of patients presenting for surgery have hypertension and are taking either an angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB). Since the introduction of ACE-I/ARB therapy in the early 1980s, clinicians remain uncertain as to the perioperative management of these drugs. The decision to withhold or continue…

Should All Antihypertensive Agents Be Continued Before Surgery?

INTRODUCTION Hypertension affects approximately 45% of the United States (U.S.) population and is a leading cause of mortality both nationally and globally. In light of the high prevalence of hypertensive heart disease, the American College of Cardiology and American Heart Association (ACC/AHA) updated prior guidelines for the prevention, detection, and treatment of high blood pressure in adults. These guidelines define blood pressure as either normal, elevated,…

What Are the Role and Management of Percutaneous Coronary Intervention for Noncardiac Surgery?

INTRODUCTION Percutaneous coronary intervention (PCI) has revolutionized the management of coronary artery disease (CAD), initially with balloon angioplasty (BA) and subsequently with coronary stenting, both with bare-metal stents (BMSs) and with drug-eluting stents (DESs). Historically, the high incidence of coronary restenosis from neointimal coronary endothelial growth plagued success rates for BA and prompted the clinical development and introduction of BMSs. Although a significant therapeutic advance, BMSs…