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Encephalopathy, Hypertensive

Risk Chronic Htn, renal disease (particularly end-stage renal disease), malignancy, sympathomimetic drugs, and a history of transplantation and immunosuppressive therapies Perioperative Risks Increased risk of myocardial ischemia, ventricular dysrhythmias, HF, aortic dissection, cerebral hemorrhage, coma, long-term neurologic disability, renal failure, or sudden death Worry About Myocardial ischemia or infarction Aortic dissection HF Pulm edema Cerebral infarction (ischemic or hemorrhagic) or intracranial hemorrhage Acute renal failure Eclampsia…

Encephalitis

Risk Age; animal contact and occupational exposure to animals; ingestion of raw, partially cooked meat, fish, reptiles, or unpasteurized milk; insect contact; laboratory workers; healthcare workers; person-person transmission; recent vaccination and unvaccinated status; season (late summer/early fall, winter); travel and geographic exposure; immunocompromised state; transfusion and transplantation Perioperative Risks Mental status alteration: Delirium, altered level of consciousness, clinical and subclinical seizures, increased ICP, and SIADH Unpredictable…

Emphysema

Risk Incidence in USA: 4.7 million. Prevalence, incidence, and mortality increase with age. Higher in males than females. Higher in whites than nonwhites. Perioperative Risks Intraop bronchospasm N 2 O expansion of bullae Postop respiratory failure Postop pulm infection Worry About Worsening of baseline pulm function, caused by: Bronchospasm. Acute bronchitis or pneumonia. Pulm embolism. Worsening of baseline cardiac function caused by right heart failure. Most…

Eisenmenger Syndrome

Risk 8% of all CHD pts. 11% of pts with intracardiac or aortopulmonary shunt, allowing continuous exposure of pulm vasculature to systemic arterial pressure. VSD is the most common lesion. Perioperative Risks High risk of cardiovascular complications when undergoing noncardiac surgery; mortality reaching 30%. Severity of pulm Htn cyanosis, tricuspid regurgitation, and right ventricular dysfunction are important factors. Additional acquired cardiac and systemic diseases, such as…

Ehlers-Danlos Syndrome

Risk EDS has an overall incidence of 1:10,000-25,000, with no ethnic predisposition. Six major subtypes, each with slightly different and unique phenotypes. Symptoms involve skin, ligaments, joints, and vessels. Perioperative Risks Valvular abnormalities or major vessel dissection/aneurysm Unstoppable bleeding Pneumothorax from positive pressure ventilation or pneumoperitoneum Neuropathy or musculoskeletal injury from positioning Airway difficulty from atlanto-occipital instability Worry About Musculoskeletal injury from positioning. Airway damage due…

Eclampsia

Risk Incidence varies from 0.01–0.1% of pregnancies in developed countries. Occurs in 1–3% of pts with preeclampsia. Risk factors include age <20 y old, nulliparity, anemia, diabetes, and preexisting heart disease. Perioperative Risks Eclampsia is a factor in approximately 10% of all maternal deaths in developed countries. Maternal complications include adult respiratory distress syndrome, acute renal failure, cardiopulmonary arrest, and CVA. Fetal complications include respiratory distress…

Echinococcosis

Risk Men approximately equal to women. Echinococcus granulosus causes cystic echinococcosis (hydatid disease) in people exposed to feces of dogs and other canids in endemic areas of nearly every continent. E. multilocularis causes alveolar echinococcus in people exposed to feces of infected foxes living in colder regions of the northern hemisphere. Cases of alveolar echinococcus continue to expand over the past 2 decades, despite increased awareness…

Ebstein Anomaly

Risk Incidence: Rare; <1:200,000 live births Accounts for <1% of congenital heart disease Perioperative Risks Arrhythmias (approximately 20–25% incidence of accessory pathways) Intracardiac shunting Cyanosis and associated problems (e.g., polycythemia, hyperviscosity, altered vascular function, impaired cardiopulmonary performance) Ventricular volume overload Ventricular dysfunction Worry About Delayed onset of action of IV agents due to blood pooling into dilated right-sided cardiac structures Rhythm disturbances: Atrial and ventricular Conditions…

Duodenal Atresia

Risk Incidence 1:5000–10,000 live births Male to female incidence is equal Trisomy 21 in 20–30% 45% are premature infants of pregnancy complicated by polyhydramnios Incidence of polyhydramnios 32–81% Mortality 3–5%; due not to duodenal atresia but to associated CHD or prematurity Perioperative Risks Hypoxemia associated with immature lungs Hypoxemia due to CHD, persistent fetal circulation (pulm Htn) Worry About Ventilation problems associated with prematurity. Other associated…

Duchenne Muscular Dystrophy (Pseudohypertrophic Muscular Dystrophy)

Risk X-linked recessive; 1:3500 live male births; few known cases in females. Often undiagnosed until age 3–5 y; periop complications can occur before diagnosis. Deterioration through puberty to death usually before age 25 y. Periop risks may be present in female carriers. Perioperative Risks Respiratory failure, prolonged mechanical ventilation Cardiac failure (CHF or arrhythmias) Hyperkalemia and rhabdomyolysis Worry About Poor cardiac contractility, dilated cardiomyopathy, cardiac arrhythmias,…

Drug Overdose, Rat Poison (Warfarin Toxicity)

Risk Major risk is hemorrhage, especially CNS or GI. Incidence: Risk of hemorrhage in 1–7.4% of pts chronically anticoagulated. Risk is dose-related and proportional to PT prolongation. Risk of hemorrhage doubles as INR increases from 2.0–2.9 to 3.0–4.4. It further quadruples as INR increases from 3.0–4.4 to 4.5–6.9. Age is associated with increased sensitivity to warfarin and increased incidence of bleeding complications. Rx for DVT, cerebral…

Drug Abuse, Lysergic Acid Diethylamide

Risk “Hallucinogen” with primary effects of heightened or distorted mood, thought, and sensory perception. The hallucinogen class includes LSD, mescaline, phencyclidine, and psilocybin. These drugs cause tolerance and psychological drug dependence but not physical drug dependence or withdrawal. Initially marketed as an anesthetic agent; people began using it for recreational and spiritual purpose in the 1960s. LSD is still illegally used as a major hallucinogen worldwide.…

Down Syndrome

Risk Trisomy 21 is the most common autosomal aneuploidy; approximately 1:1000 live births. 80% of children with this condition survive beyond 1 y; average life expectancy 60 y. Increased incidence in mothers >35 y, but most are born to younger mothers, owing to higher fertility rates. Incidence decreased by elective termination of pregnancy from prenatal screening: high beta-hCG, low AFP, cell-free DNA, thickened nuchal fold, abnormal…

Double Aortic Arch

Risk Vascular rings account for <1% of cardiovascular malformations that require surgical correction. Double aortic arch is the most common form of complete ring that encircles both the trachea and the esophagus. Race/gender predilection: None. Perioperative Risks Recurrent respiratory infections often aggravate chronic airway obstruction. Baseline dynamic tracheal compression can progress to complete airway obstruction upon induction and muscle relaxation. Persistent postop airway obstruction requiring prolonged…

Do Not Resuscitate Orders

Risk Violation of pt autonomy and self-determination if DNR orders are not reconsidered and honored for the periop period. Increasing numbers of pts have some form of advance directive. Approximately 15% of surgical pts have DNR orders. Perioperative Considerations Resuscitation preferences can change based on pt status and prognosis. DNR orders do not become automatically suspended or continued when a pt goes to surgery. Intraop arrests…

Diverticulosis

Risk More prevalent in developed countries; common in the UK and other parts of northern Europe, North America, Australia, and New Zealand, but uncommon in southern Africa, the Middle East, the Far East, and the Pacific Islands. Prevalence in developing countries between 5–45%, depending on age of population and method of diagnosis; African and Asian countries with prevalence approximately 0.2%. Prevalence increases with age. In USA,…

Disseminated Intravascular Coagulation

Risk Most common coagulopathy in the ICU. 1% of all hospital admissions. Evidence of a coagulopathy in the DIC spectrum approaches 90% in cases of severe sepsis. The most important initiator of DIC is sepsis, along with trauma (hypovolemic shock, extensive tissue damage, fat embolism, head injury); surgery (neurosurgery, CPB); obstetric emergencies (hemorrhage, preeclampsia, retained products, amniotic fluid embolism); malignancy (acute promyelocytic leukemia, disseminated metastases); and…

Diphtheria

Risk Approximately 0.001 cases per 100,000 population in USA since 1980 (<5 cases a year). Endemic in developing countries. Still common in countries where mass immunization programs are not enforced. After political changes in Eastern Europe and Central Asia at the end of the 20th century, a resurgence in many vaccine-preventable diseases, including diphtheria, was reported across these countries. Risk factors for diphtheria outbreaks: older age…

Dilated Cardiomyopathy

Risk DCM is a largely irreversible form of heart muscle disease, with an estimated prevalence of 1:2500; it is the third most common cause of CHF and most frequent cause for heart transplantation. DCM leads to progressive CHF, ventricular and supraventricular arrhythmias, conduction system abnormalities, thromboembolism, and sudden or heart failure–related death. Marked limitation of exercise capacity is a reliable predictor of mortality. Perioperative Risks Increased…

DiGeorge Syndrome

Risk 1:4000 births with variable penetrance Worry About Cardiac anomalies Immunodeficiency and poor wound healing Palatal anomalies Hypocalcemia Seizures Difficult mask/intubation Overview Chromosome deletion 22q11.2. Classic triad: Conotruncal cardiac anomalies, hypoplastic thymus, and hypocalcemia. Clinical phenotype varies with mild-to-severe forms of immunodeficiency. Most cases are diagnosed in infancy, but Dx in adulthood is not uncommon. Etiology Heterozygous versus homozygous deletion of 22q11.2 Usually inherited from maternal…