Chronic pain is a major health issue throughout the world and is an increasingly challenging preoperative issue for anesthesiologists. Throughout the 1990s, the health care system in the United States began to encourage more routine assessment of pain in patients, leading to the emergence of pain as the “fifth vital sign.” This resulted in the release of new pain management standards for hospitals by The Joint…
Introduction Cancer is the second leading cause of death in the United States, exceeded only by heart disease. The lifetime risk of developing cancer is estimated to be one in three for both men and women. The lifetime risk of dying from cancer is one in five. About 90% of patients with cancer require surgery for reasons both related and unrelated to the cancer diagnosis. Furthermore,…
Introduction The human immune system is traditionally divided into two pathways: innate immunity and adaptive (also known as acquired) immunity. Each is comprised of a series of unique components, all of which function to protect the host against invading microorganisms. The innate immune response is rapid and nonspecific (i.e., recognizes targets that are common to many pathogens and requires no prior exposure to a target antigen).…
Unknown illness … single infection … community spread … contagion … epidemic … pandemic. The recent year has demonstrated in full force that infectious diseases remain a major health concern. Infectious diseases jeopardize patient outcomes throughout the healthcare delivery system as well as in the perioperative sector. Additionally, new emerging infectious diseases stemming from special and novel pathogens pose great threats to the health and safety…
Skin diseases Skin disease can have significance for the anesthesiologist due to the skin manifestations itself, the underlying medical condition, or the potential worsening by anesthetic interventions. Examples of skin diseases in which the anesthetic implications are mainly due to the skin lesion itself include Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), either of which can result in significant fluid losses through the skin and…
Disease states related to erythrocytes include anemia and polycythemia. Anemia is characterized by a decrease in the red cell mass, with the main adverse effect being a decrease in the oxygen-carrying capacity of blood. Polycythemia (erythrocytosis) represents an increase in hematocrit (Hct). Its consequences are primarily related to an expanded red cell mass and a resulting increase in blood viscosity. Physiology of anemia Anemia is a…
Diabetes mellitus Normal glucose physiology requires a balance between glucose utilization and endogenous production or dietary delivery ( Fig. 22.1 ). The liver is the primary source of endogenous glucose production via glycogenolysis and gluconeogenesis. Approximately 70% to 80% of glucose released by the liver is metabolized by insulin-insensitive tissues such as the brain, gastrointestinal tract, and red blood cells. Following a meal, plasma glucose level…
Introduction The kidney plays a key homeostatic role in the tight regulation of extracellular fluid volume, blood pressure, solute transport and electrolyte concentrations, pH, and excretion of drug metabolites. Knowledge of how the kidneys perform these important functions aids in understanding the clinical presentation, signs and symptoms, and treatment of renal diseases. The kidneys are retroperitoneal organs located at the T12 to L4 levels, with the…
Alterations of water, osmolal, and electrolyte content and distribution as well as acid-base disturbances are common in the perioperative period and rarely happen in isolation because they are inherently interrelated. They both affect and are affected by the function and stability of several organ systems. Central nervous system (CNS) impairment, cardiac dysfunction, and neuromuscular changes are especially common in the presence of water, osmolal, electrolyte, and…
Malnutrition can be caused by either an insufficient consumption of essential nutrients or an overconsumption of poor nutrients. Currently the most prevalent nutritional disease worldwide is obesity. About two-thirds of the world’s population live in countries where being overweight and obese kills more people than being underweight. In the United States, obesity is considered a national epidemic and a serious public health threat. The prevalence of…
Inborn errors of metabolism manifest as a variety of metabolic defects that may complicate the management of anesthesia ( Table 18.1 ). In some instances, these defects are clinically asymptomatic and become manifest only in response to specific triggering events, such as ingestion of certain foods or administration of certain drugs, including some anesthetic drugs. TABLE 18.1 Selected Inborn Errors of Metabolism Porphyria Purine metabolism disorders…
The principal function of the gastrointestinal (GI) tract is to provide the body with a supply of water, nutrients, and electrolytes. Each division of the GI tract—esophagus, stomach, small and large intestines—is adapted for specific functions such as passage, storage, digestion, and absorption of food. Impairment of any part of the GI tract may have significant effects on a patient coming for surgery. Procedures to evaluate…
Epidemiology Nearly 4.5 million people in the United States are living with chronic liver disease, while more than 40,000 deaths annually are attributed to chronic liver disease. Liver dysfunction affects multiple organ systems and increases the risk of perioperative morbidity and mortality. While the prevalence of chronic viral infections has decreased due to improvements in medical treatments, the prevalence of alcohol-associated liver disease (ALD) and nonalcoholic…
Introduction The peripheral nervous system consists of nerve elements outside the brain and spinal cord. It contains both peripheral nerves and elements of the autonomic nervous system. Disorders of the autonomic nervous system can result in significant hemodynamic changes as well as abnormal responses to drugs that work via adrenergic receptors. Diseases affecting peripheral nerves often have perioperative implications, including choice of muscle relaxants and management…
Anatomy of the vertebral column and spinal cord The vertebral column consists of 24 individual vertebrae (7 cervical, 12 thoracic, and 5 lumbar), in addition to the sacrum and coccyx. Basic anatomy of individual vertebrae and the vertebral column is illustrated in Fig. 14.1 . Briefly, the anterior section of vertebrae consists of a body and adjacent vertebral bodies that are separated in intervertebral disks. Posteriorly,…
Cerebral physiology Cerebral blood flow, blood volume, and metabolism Cerebral blood flow (CBF) is modulated by cerebral metabolic rate, cerebral perfusion pressure (CPP, the difference between the mean arterial pressure [MAP] and intracranial pressure [ICP]), and arterial blood carbon dioxide (Paco 2 ) and oxygen (Pao 2 ) tensions. Various drugs and intracranial pathologies can also impact CBF. During normal physiologic conditions, CBF is autoregulated over…
Diseases of the thoracic and abdominal aorta Aneurysms, dissections, and occlusive disease are the main pathologies that can affect arterial vessels. Whereas occlusive disease is more likely to occur in peripheral arteries, the aorta and its major branches are affected by two abnormalities that may be present simultaneously or occur at different stages of the same disease process—aneurysms (more common) and dissections ( Fig. 12.1 and…
Introduction Pericardial diseases have a varied clinical presentation, ranging from chronic or subacute to acute and potentially life threatening. These pathologies often present urgently to the operating room, and their perioperative management poses unique challenges for the anesthesiologist. The hemodynamic compromise resulting from some of these conditions (e.g., tamponade) often requires emergent management. Routine perioperative interventions, such as positive pressure ventilation, may have an adverse impact…
Heart failure Definition The ability of the left ventricle to function as one of the body’s two main pumping chambers depends on how efficiently it ejects and subsequently fills with oxygenated blood. This implicit duality indicates that heart failure may occur either when the left ventricle is unable to eject blood at a rate sufficient to meet tissue metabolic requirements or when it cannot fill completely…
Systemic hypertension In 2017, the American College of Cardiology/American Heart Association (ACC/AHA) redefined hypertension as a sustained systolic blood pressure above 130 mm Hg and/or a diastolic pressure above 80 mm Hg. This new definition arose in response to the results of the Systolic Blood Pressure Intervention Trial (SPRINT), which found a significantly lower rate of fatal and nonfatal cardiovascular events in nondiabetic hypertensive patients with…