Medical Blog

Preoperative Testing

Introduction

Medical consultants are generally asked to assess preoperative risk in most patients who are to undergo surgery. The focus of discussion in this article applies to healthy people who are to undergo an elective surgical procedure.

Despite a low risk of perioperative complications, the use of laboratory tests before surgery became ingrained in clinical practice not only across the United States but also across the world in the latter half of the 20th century. At that time, clinicians thought it logical to order tests to detect abnormalities that might lead to increased morbidity or mortality in the perioperative period. Despite its widespread use, however, systematic evaluations of the clinical effectiveness and cost-effectiveness of routine laboratory testing were often lacking. Read more…

Perioperative Management of the Patient With Chronic Renal Failure

Introduction

Chronic renal failure (CRF), or more appropriately chronic kidney disease (CKD), refers to a decline in the glomerular filtration rate (GFR) caused by a variety of diseases, such as diabetes, glomerulonephritis, and polycystic kidney disease. Patients with CKD have a high prevalence of hypertension. Whether hypertension is a cause or a result of CKD remains debatable. CKD may be categorized as mild (GFR of 60-89 mL/min/1.73 m2), moderate (GFR of 30-59 mL/min/1.73 m2), severe (GFR of 15-29 mL/min/1.73 m2), or end-stage renal disease (ESRD). Hemodialysis or peritoneal dialysis is typically initiated as the GFR falls to less than 15 mL/min/1.73 m2. Some patients with CKD eventually receive kidney transplantation before (a few cases) or after (most recipients) initiation of hemodialysis or peritoneal dialysis.
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Perioperative Management of the Geriatric Patient

Introduction

Advances in surgical and anesthetic techniques combined with sophisticated perioperative monitoring are factors that have contributed to an expanding number of older adults undergoing surgery. A preoperative assessment is useful to identify factors associated with increased risks of specific complications and to recommend a management plan that minimizes the risks. Each person should be assessed individually, and judgments should be based on an individual’s problem and physiologic status, not on age alone. According to estimates, 50% of older Americans will have an operation when older than 65 years. Read more…

Perioperative Management of the Female Patient

Introduction

Caring for women who are about to undergo gynecologic surgery is challenging. The current climate in medicine is fraught with issues involving quality of care, professional liability, availability of information via the Internet, patient input into her care, and dwindling health care dollars. Technological advances in laparoscopy, urogynecology, and female pelvic medicine, and the rapid introduction of surgical devices have created conflict between the surgeon’s desire to provide the most current care and rising health care costs. These issues in administering care in women are compounded by a change in this patient population, from a young healthy group to an increasingly larger group of geriatric patients, including many who have chronic diseases. Read more…

Perioperative Cardiac Management

Background

The worldwide elderly population with its associated health concerns is expanding rapidly. Globally, the proportion of individuals older than 80 years currently averages 5%. In the developed world, almost 15% of individuals will be older than 80 years in 2020; the proportion is expected to increase to 25% by 2050. This aging population has associated comorbidities; consequently, clinicians are often asked to evaluate the preoperative risk status of this high-risk population.

The cardiovascular systems of patients who undergo general anesthesia and noncardiac surgical procedures are subject to multiple stresses and complications. A previously stable patient may decompensate postoperatively, leading to significant postoperative morbidity and mortality. A substantial number of all deaths among patients undergoing noncardiac surgery are caused by cardiovascular complications.

Each year, approximately 30 million individuals in the United States undergo noncardiac surgery. Approximately one third have cardiac disease or major cardiac risk factors. Current estimated rates of serious perioperative cardiac morbidity vary from 1-10%. The incidence of perioperative myocardial infarction (MI) is increased 10- to 50-fold in patients who have had previous coronary events.
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Perioperative Anticoagulation Management

Definition of Problem

In performing noncardiac surgery on patients on anticoagulation, the major concern is when it is safe to perform surgery without increasing the risk of hemorrhage or increasing the risk of thromboembolism (eg, venous, arterial) after discontinuing treatment. In treating patients on long-term coumadin perioperatively, consider the risks of hemorrhage or thromboembolism versus the benefit from the operation. When considering noncardiac surgery, these factors and the need to weigh the risk of hemorrhage against that of thromboembolism must analyzed on an individual patient basis. Certain procedures (eg, oncologic procedures, threats to limb or life) are easy analyses. More complex discussions must be had for such cases as hernia repair of other elective nonurgent operations. Read more…