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Atrial Fibrillation

Risk Isolated atrial fibrillation affects >1% of those >60 y of age. Overall incidence is 0.4% of adult population. In the postcardiac surgical population, the incidence can be as high as 27-40%. No racial predominance. Prevalence increases with older age. Independent risk factor for stroke. In pts presenting for cardiac surgery, the incidence of postop atrial fibrillation increases with increasing left atrial size, as well as…

Atherosclerotic Disease

Risk Over 100 million USA adults age 20 y or older have a total cholesterol >200 mg Cardiovascular disease accounts for approximately 1 of every 3 deaths in USA (31.3%). Perioperative Risks Cardiovascular disease increases risk of periop major adverse cardiac events (cardiac death, nonfatal myocardial infarction, and nonfatal cardiac arrest). Approximately 3% of pts undergoing noncardiac surgery will experience a periop cardiac complication. Worry About…

Asthma, Acute

Risk Prevalence in USA: 25 million people; nearly 5% for persons age 5-34 y Increased prevalence and severity in African Americans, adult females, and atopic individuals Perioperative Risks Risk related to degree of preop control of symptoms and optimization of medication regimen Morbidity due to bronchospasm and laryngospasm Worry About Bronchospasm Hyperinflation of lungs Medication side effects (e.g., β-agonists causing tachycardia and hypokalemia) Adrenal insufficiency (chronic…

Aspiration, Perioperative

Risk Risk of aspiration: Approximately 3 per 10,000 anesthetics, 11 per 10,000 emergency and/or after-hours cases, and 29 per 10,000 emergency cases in ASA IV and V pts Loss of protective reflexes and sphincter function Obstructed or abnormal GI motility Increased gastric fluid volume; decreased pH Inadequate anesthesia leading to coughing and straining during airway manipulation or induction Trauma, emergency/night surgery, pregnancy, difficult airway, advanced age,…

Arnold-Chiari Malformation (Chiari Malformation Type II)

Risk Arnold-Chiari malformation (Chiari Malformation type II or CMII) is found exclusively in pts with myelomeningocele. Myelomeningocele occurs in 0.6 of 1000 live births. Perioperative Risks Vocal cord paralysis Respiratory distress Apnea Neurogenic dysphagia and pulmonary aspiration Hydrocephalus and increased ICP Congenital heart defects (37% of pts with myelomeningocele) including atrial septal defect, ventricular septal defect, anomalous pulmonary return, tetralogy of Fallot, bicuspid aortic valve, coarctation…

Appendicitis, Acute

Risk One of most common abdominal emergencies Possible at any age but most common during an individual’s teens and 20s 11 in 10,000 individuals will experience appendicitis M:F ratio 1.4:1 Most common reason for nonobstetric surgery during pregnancy; Occurs in 1 out of every 800 to 1500 pregnancies; slightly more common during second trimester; incidence of perforation highest during third trimester (70%) Perioperative Risks Risk of…

Apnea of the Newborn

Risk Full-term infants with an underlying pathology (i.e., neurologic disorders, metabolic derangements) Premature infants, with or without an underlying pathology Infants less than 60 wk post conceptual age Underweight infants <1000 g Anemia Perioperative Risks More prone to apnea during local or neuraxial anesthesia or when additionally administered IV sedative More prone to apnea after general anesthesia Worry About Unexpected apnea in recovery room Unexpected apnea…

Apert Syndrome (Acrocephalosyndactyly Type 1 and 2)

Risk 15:1,000,000 live births Equal M:F ratio Perioperative Risk Aspiration Bronchospasm Resp depression Airway obstruction Worry About Difficult mask, airway, or IV access Elevated intracranial pressure, temperature dysregulation, and seizures Corneal abrasions (due to exophthalmos) PACU and perioperative monitoring for apnea Cardiac anomalies (10% of cases) Anatomic anomalies (regional/neuraxial anesthesia) Overview Apert syndrome is a disorder identified by synostoses of the cranium, vertebral bodies, and digits.…

Aortic Stenosis

Risk Most common valvular heart disease; prevalence only 0.2% among adults aged 50-59 y, but increases to almost 10% after age 80 y. Calcific aortic stenosis: Major risk factors are increasing age, LDL, diabetes mellitus, smoking, hypertension, and bicuspid valve anatomy. Less common risk factors include disorders of calcium metabolism, renal failure, and history of mediastinal radiation. Bicuspid aortic valve is present in 1-2% of USA…

Aortic Regurgitation

Risk There are on the order of 100,000 aortic valve surgeries each year, with approximately 18,000 of them performed annually in the USA. Of aortic valves, 20% to 30% have isolated regurgitation at time of replacement. At time of replacement, 12-30% of aortic valves have combined regurgitation and stenosis. M:F ratio: 3:1. Racial predominance: None known. Perioperative Risks Left ventricular failure Right ventricular failure Subendocardial ischemia…

Anxiety Disorders

Risk Lifetime prevalence approximately 30% in USA Gender: Female (2× more likely compared with male) Environmental: Traumatic or stressful events Age: Often develop in childhood and early adulthood; however, may occur any time after a stressful event Medical conditions: Chronic mental or physical illness Genetics: Family psychiatric history Perioperative Risks Generalized anxiety disorder leads to chronic autonomic hyperactivity with increased risks for CAD and Htn. Uncontrolled…

Antithrombin III Deficiency

Risk Incidence in USA: 1:2000-5000 (may be higher) Men and women equally affected and no racial or ethnic difference Perioperative Risks Risk of postop thromboembolic phenomena; 40% to 70%, most common (in descending order): DVT, pulm embolus, mesenteric thrombosis, cerebral venous, and retinal thrombosis; highest risk in those with antithrombin III (AT III) levels <50% of normal Risk of pregnancy-related venous thromboembolism may be >50% in…

Anticoagulation, Preoperative

Risk Pts with mechanical heart valves, atrial fibrillation, pulm embolism, or recent venous thrombosis. Oral anticoagulant therapy (warfarin, oral Xa inhibitor-rivaroxaban, apixaban, and edoxaban) and direct thrombin inhibitor (dabigatran) and use of low-molecular-weight heparin, fondaparinux may increase potential risks in elective or emergency surgery. Other populations include pts who receive heparin IV before vascular or cardiac surgery and pts undergoing cardiac surgery with extracorporeal circulation. Perioperative…

Anorexia Nervosa

Risk Primarily in white adolescent females from middle- or upper-class families; 4% to 10% males. More common in models, ballet students, and professions demanding high achievement. Occurs in 5-10 per 100,000 population; mortality rate 5-10%. Bimodal peak age of onset: 14 and 18 y. Perioperative Risks Predisposing conditions include: CV dysfunction (bradycardia, hypotension, and dysrhythmias). Acid-base abnormalities (both metabolic acidosis and alkalosis are possible), lyte abnormalities…

Anomalous Pulmonary Venous Drainage

Risk One percent of all congenital heart defects. TAPVD, the severe form, or PAPVD, the less severe form, exists when pulm veins drain into the venous circulation. M:F 4:1 in infradiaphragmatic type. Perioperative Risks Rapid CV deterioration secondary to hypercapnia and resultant acidosis Sudden pulm Htn and RHF during hypoventilation Periop mortality: 2-20% depending on preop status Worry About Air bubbles entering the venous circuit Endocarditis…

Ankylosing Spondylitis

Risk 1:2000 incidence in Caucasians; rare in non-Caucasians M:F 10:1; more severe in males 18-50% incidence in Native Americans Perioperative Risks Difficult airway and atlantoaxial instability “Bamboo spine” with potential for fracture during airway manipulation Rigid chest with difficult ventilation Myocarditis and myocardial conduction defects Increased blood loss due to abnormal chest structure or mechanics Worry About Inability to intubate, spine fracture, arrhythmia, inability to ventilate,…

Anhidrosis (Congenital Anhidrotic Ectodermal Dysplasia)

Risk Rare: 1:125,000,000 Clusters in Japan and Israel Perioperative Risks Impaired thermoregulation (risk of fatal hyperpyrexia in infants) Postop chest infections Worry About Absence of sweat leads to impaired thermoregulation. Insensitivity to superficial and deep painful stimuli with intact tactile perception; still require considerable amounts of inhalational or IV anesthetics to maintain hemodynamic stability and obtund stress response to airway manipulation. Overview Innervation of the eccrine…

Angina, Chronic Stable

Risk Incidence in USA: 3 million. Annual rates per 1000 new episodes of angina for non-African American men are 28.3 for ages 65–74, 36.3 for ages 75–84, and 33.0 for age 85 and older. For non-African American women in the same age groups, the rates are 14.1, 20.0, and 22.9, respectively. For African American men, the rates are 22.4, 33.8, and 39.5, and for African American…

Anemia, Megaloblastic

Risk Prevalence: Estimates ranging from 1.7-3.6%. Most common cause is vitamin deficiency: 65% vitamin B12; 12% combined folate/vitamin B12; 6% folate. Pernicious anemia is less common: 1 in 7500 people in USA develops pernicious anemia each year. Prevalence increases with advanced age and in countries with higher rates of malnutrition. Perioperative Risks Risk of severe anemia and coagulopathy. Risk of coronary, cerebral ischemia secondary to severe…

Anemia, Hemolytic

Risk Autoimmune disorders (SLE, RA, scleroderma, cold agglutinin disease). Lymphoproliferative disorders (CLL, NHL). Prosthetic heart valves (ball-and-cage, and bileaflet valves). Usually subclinical, but can be severe in up to 15% of pts. Family history of hemoglobinopathies or RBC membrane defects (thalassemia, sickle cell disease, G6PD deficiency, spherocytosis). Exposure to drugs (cephalosporins, penicillins, NSAIDs) or other chemicals (naphthalene, fava beans). Infection ( Clostridium perfringens , Haemophilus influenza…