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Diarrhea, Acute and Chronic

Risk Incidence in USA: 200–300 million new cases/y of acute, with >900,000 hospital admissions Chronic: 1–5% of population; increasing with age; female at greater risk than male Acute: Male and female equivalent Perioperative Risks Hypovolemia with hemodynamic instability Electrolyte abnormalities, especially hypokalemia Acid-base abnormalities: May be non–anion gap acidosis or alkalosis, depending on underlying cause Worry About Chronic Underlying disease, especially iatrogenic (e.g., infection with antibiotic-induced…

Diaphragmatic Hernia (Congenital)

Risk Occurs in approximately 1 in 2500–5000 births; 12–25% have associated anomalies, in particular cardiac (20%), chromosomal (5–16%), and neurologic. Parents who have one child with isolated defect have 2% chance with next child. Usually left sided (90%) due to defect in foramen of Bochdalek and are more common in boys. Morgagni hernias (2–5%) located anterior are more common in girls. Remainder through esophageal hiatus. Perioperative…

Diabetic Ketoacidosis

Risk Typically seen in pts with type I diabetes mellitus; can occur in pts with ketosis-prone type II diabetes. Stress related to acute infection, trauma, surgery, MI, pulm embolism, pancreatitis, alcohol abuse, stroke, emotional trauma, or drugs (steroids, thiazides, sodium-glucose transporter-2 inhibitors) can precipitate DKA in diabetic pts. Poor compliance with insulin therapy or inadequate outpatient insulin regimen. Perioperative Risks CV collapse secondary to severe dehydration…

Diabetes Insipidus

Risk Hereditary/familial (rare): Nephrogenic DI due to mutations in the AVP receptor gene, with X-linked recessive transmission; or AQP2, usually with autosomal recessive transmission, but autosomal dominant transmission also occurs; overall, males at greater risk than females Central (hypothalamic) DI due to mutations of the AVP gene; usually manifests in childhood; males equal risk as females May also be part of developmental syndromes (Wolfram syndrome, Laurence-Moon-Biedl…

Diabetes, Type III (Gestational Diabetes Mellitus)

Risk Incidence of GDM approximately 5–6% of all pregnancies. Increased in African American, Hispanic, Asian, Native American, or Pacific Islander women. Risk factors: Maternal age >25 y. Previous delivery of macrosomic infant. Glucosuria. History of polycystic ovarian syndrome. Previous unexplained fetal demise. Previous pregnancy with GDM. Strong immediate family history of NIDDM or GDM. Obesity. Dx: Two-step approach: 1. Fasting glucose >95 mg/dL or a glucose…

Diabetes, Type II (Noninsulin Dependent)

Risk Incidence in USA more than 25 million Highest prevalence: Hispanics and Native Americans Gender predominance: None Metabolic syndrome associated with obesity and sedentary lifestyle Perioperative Risks Increased risk 5–10 times if end-stage renal disease, CV, CHF, or autonomic neuropathy; without renal, CV disease, or autonomic dysfunction, risk is 1–1.5 times normal. Metabolic abnormalities increased with perioperative insulin Rx. Unclear if same risks as for type…

Diabetes, Type I (Insulin-Dependent)

Risk Incidence in USA: 1.25 million. Perioperative Risks Risk of requiring a CABG is increased 5–10 times in presence of ESRD, CHF, or autonomic neuropathy; without these conditions, the risk is 1-1½ times that of a normal person. Worry About Autonomic neuropathy, gastroparesis, and sudden postop death. Painless myocardial ischemia. Atlantooccipital joint immobility. Tight glucose control might be indicated in pregnant pts and those difficult to…

Dextrocardia

Risk Birth prevalence of approximately 1:10,000; equal sex distribution 25% have PCD, an autosomal recessive disorder Perioperative Risks Increased risk of cardiac decompensation, pulm Htn, resp failure, airway obstruction, sepsis, raised intracranial pressure, and death Increased likelihood of emergent open-heart or abdominal surgery Worry About Heterotaxy syndrome (approximately 40% have dextrocardia) PCD (approximately 50% have dextrocardia) Distinguish from dextroposition—right cardiac displacement by extracardiac causes (lung, diaphragm,…

Dermatomyositis

Risk Prevalence in USA: 3000–10,000. Group, demographics with highest prevalence include females, 2:1 relative to men, with a peak onset between 30–60 y of age. Perioperative Risks Increased risk of respiratory failure and infections postop Worry About Most case reports absolutely avoid depolarizing muscle relaxants and are careful with medications that have effects on muscle strength. Monitor muscle relaxant dosing and recovery. Valvular heart disease and…

Depression, Unipolar

Acknowledgment I wish to thank Dr. Ian Yuan for his work on this chapter in the earlier edition of this book. Risk Affects 2–4% of population; equal occurrence by gender; highest in 25–44 y. Lifetime risk 10–25% for women and 5–12% for men; at any point in time, 5–9% women and 2–3% of men suffer from this. Approximately 15% of pts with major depression commit suicide.…

Delirium (Postanesthetic) and Dementia

Risk Risk factors for the development of POD can be categorized as pt or procedure related. Pt-related factors: Age >75 y. Preexisting cognitive dysfunction or depression. Male sex. Preexisting severe illness. Polypharmacy (>3 medications) and use of psychoactive medications. History of substance abuse. Laboratory abnormalities (anemia, hypoalbuminemia, sodium, potassium, glucose). Procedure-related factors: Cardiac, orthopedic, and vascular procedures associated with highest incidence. Emergent or urgent procedures. Poorly…

Degenerative Disk Disease

Risk Risk factors determined by spinal level Cervical spine: C3 and C4 most common; 10% of degenerative disk disease Thoracic: uncommon; can be related to trauma or tumor; 0.2–1.8% of disk disease Lumbar; very common; 85–90% of disk disease; third most common cause of chronic pain in USA Perioperative Risks Difficult airway Spinal cord injury from airway manipulation or positioning Positioning injury from prone position Ischemic…

Deep Vein Thrombosis

Risk Incidence in USA: 170,000–200,000 new cases; 90,000–100,000 recurrent cases. VTE is the third most frequent acute cardiovascular syndrome after MI and CVA. Half of all episodes are associated with recent surgery or hospitalization. VTE is recognized as the leading cause of preventable death in hospitalized pts. Perioperative Risks Modified Caprini risk model can be used to predict risk in general surgical pts. Without prophylaxis, DVT…

De Morsier Syndrome

Risk For live births: 1:10,000; equal male to female prevalence Associated with younger maternal age May not be identified until later in life Perioperative Risks Reduced cortisol stress response in undiagnosed or untreated pts. Hormone tests may be normal in nonstress conditions. Treatment of one hormone deficiency (e.g., hypothyroidism, or hypothyroidism and adrenal insufficiency) may unmask another or others (e.g., adrenal insufficiency, DI). Worry About Unrecognized…

Dandy-Walker Syndrome

Risk Multiple genetic factors; mostly sporadic with limited familial inheritance Range: 1:10,000-30,000 newborns Perioperative Risks Variable phenotypic expression and organ involvement Increased incidence of additional developmental abnormalities Depend upon severity of disease and comorbidities, which may include elevated ICP; craniofacial, cardiac, and renal malformation; seizure disorder; respiratory depression; nausea; and vomiting Worry About Hydrocephalus with elevated ICP and possible seizures Pt’s ability to cooperate and follow…

Cytomegalovirus Infection

Risk Seroprevalence increases with age and low socioeconomic status in USA: From 58.9% in those aged ≥6 y to 90.8% in those ≥80 y. Also higher in non-Hispanic blacks, Mexican Americans, and women. Severe disease from CMV is rare in immunocompetent individuals. Risk for CMV disease in transplant recipients: 10–40% with preventive measures. Risk for CMV disease in HIV-positive pts: 20–30% (increased risk with low CD4…

Cystic Fibrosis

Acknowledgment The authors wish to acknowledge the contributions to the previous edition of this chapter by Daniel Roke and John Algren. Risk Prevalence ranges from 1:2500 births in white population to 1:17,000 in African Americans; prevalence growing faster than incidence as median survival is increasing. For pts with CF, 50% of are older than 18 y of age; 30,000 affected in USA; 3000 affected in Canada;…

Cyanide Poisoning

Risk Potent rapid-onset toxin, especially with inhalation of HCN (volatile liquid). May be absorbed through mucous membranes; CN ingestion results in slower onset. Diffuses rapidly through body with high intracellular fixation to cytochrome aa 3 in cellular mitochondria to paralyze aerobic metabolism. Perioperative Risks Main target organs: CNS and heart. Animal experiments: Apnea precedes cardiac collapse. Worry About If CN toxicity resulted from fire or smoke…

Cushing Syndrome

Risk Onset generally occurs in third and fourth decades. Approximately 3–5 times more common in women than men. 5-y mortality rate from adrenal carcinomas has been estimated to be >70%. Perioperative Risks Lyte abnormalities Consequences of untreated Htn Hyperglycemia Cardiovascular disease more common Worry About Challenges related to obesity, including airway management and IV access. Significant osteopenia secondary to impaired calcium absorption, making positioning difficult. Htn…

Cryptococcus Infection

Risk In general population: 0.4–1.3 cases per 100,000; AIDS pts: 2–7 cases per 1000. Impact of cryptococcosis: Approximately 625,000 deaths each year worldwide. Underlying immunocompromised conditions and risk factors: AIDS, systemic lupus erythematous, prolonged treatment with corticosteroids, organ transplantation, advanced malignancy, hematologic malignancy, diabetes, sarcoidosis, cirrhosis, idiopathic CD4 lymphocytopenia, or use of immune-modifying monoclonal antibodies (alemtuzumab, infliximab, etanercept, or adalimumab). More and more pts with cryptococcosis…