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Stephen P. Fischer, Angela M.

Bader, and BobbieJean Sweitzer

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Key Points

Preoperative Evaluation

1. The anesthesia preoperative evaluation is the clinical foundation and framework of perioperative patient management and can potentially reduce operative morbidity and enhance patient outcomes. 2. The fundamental purpose of preoperative evaluation is to obtain pertinent information regarding the patients current and past medical history and to formulate an assessment of the patients intraoperative risk and requisite clinical optimization. 3. Basic and complex medical diseases and syndromes that can potentially affect anesthesia perioperative management require the anesthesiologist to be clinically knowledgeable and current in many aspects of internal medicine. 4. Patients require preoperative diagnostic and laboratory studies that are consistent with their medical history, the proposed surgical procedure, and the potential for intraoperative blood loss. Routine preoperative testing cannot be justified and is costly and clinically inappropriate. 5. Preoperative patient education and individual discussion can significantly reduce patient anxiety and fears of the perioperative anesthesia process.

6. Under the clinical directorship of an anesthesiologist, the anesthesia preoperative evaluation clinic can enhance operating room efficiency, decrease day-of-surgery cancellations and delays, reduce hospital costs, and enhance the quality of patient care. 7. New and updated preoperative evaluation consensus and evidence-based guidelines published by multiple medical specialties have led to evaluation protocols for preparing patients for anesthesia and surgery. 8. Increasing regulatory and reporting requirements involving preoperative issues by agencies such as the Joint Commission on Accreditation of Healthcare Organizations require awareness and compliance by anesthesiologists. 9. Information technology and decision support systems in preoperative evaluation can enhance the quality of patient care and clinical management through electronic integration and standardization of patient data. 10. The anesthesiologist is the perioperative medical specialist and the only preoperative evaluation physician who can truly evaluate the risks associated with anesthesia, discuss these risks with the patient, and manage them intraoperatively.

Virtually every practicing anesthesiologist has experienced and contributed to the evolution of anesthesias involvement in perioperative care. Furthermore, the rapid transformation from admission of the patient to the hospital the night before surgery to the morning of surgery has necessitated that preoperative evaluation be conducted in a different manner. Although the historical basic concept of preoperative evaluation and an anesthesia clinic is not new to anesthesia, what has occurred in this specialty is unique, remarkable, and revolutionary. Many anesthesiologists have essentially taken back from multiple medical specialties the primary responsibility, coordination, and recognition for assessment and optimization of preoperative risk in patients being prepared for surgery.

Some anesthesiologists have evolved into perioperative medical specialists by demonstrating their unique qualification of focused knowledge and experience to evaluate and successfully manage medical complexities related to anesthesia and surgery.1,2 Anesthesia care is no longer limited to the operating room. Many departments of anesthesiology have even changed their official departmental titles to include anesthesia and perioperative care. This chapter on preoperative evaluation is intended to provide the reader with a comprehensive discussion of the basics and fundamental practice of preoperative assessment, as well as provide a review of new concepts, regulatory requirements, consensus guidelines, medical-legal responsibilities, and clinical options.
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The Evolution in Preoperative Evaluation


Preoperative evaluation of a surgical patient for anesthesia increases the practitioners awareness of the patients medical condition and becomes the foundation of the individual patients perioperative management plan. The fundamental purpose in preoperative evaluation is to obtain pertinent information regarding the patients current and past medical history and to formulate an assessment of the patients intraoperative risk. Anesthesiologists preoperatively perform focused clinical examinations, develop a plan of medical intervention and optimization, reduce the patients (and familys) anxiety and fears through education, discuss perioperative care and options for postoperative pain control, determine the appropriate laboratory tests and diagnostic studies to perform, discuss anesthesia risks, and obtain informed consent. The anesthesia preoperative evaluation can decrease surgical morbidity, minimize expensive delays and cancellations on the day of surgery, and increase perioperative efficiency. The practice of preoperative evaluation for anesthesia has changed. Fewer patients are admitted to the hospital before surgery unless their medical condition is unstable and requires optimization. Currently, approximately 80% of surgeries in the United States are performed on an outpatient or same-day admission basis, even including major neurosurgical, cardiac, and radical cancer procedures. The previous process of admitting the majority of patients to the hospital at least the day before is no longer financially supported or justified. Although patients are still assessed for the first time by the anesthesiologist just before surgery, the trend toward preparing and evaluating patients in a preoperative program or clinic before the surgical date has increased. This has been especially important in patients with multiple medical risks and comorbid conditions. In other settings, the preoperative evaluation is completed for many patients by the surgeon (or designee) or primary care physician, and only patients at highest risk are referred for consultation by an anesthesiologist. In such circumstances, the anesthesia department must interact with the surgical departments to establish general protocols for acquiring the information needed to safely perform anesthesia or there could be a potential for an increased incidence of delays or cancellations at the time of surgery to obtain additional information or evaluation. A change in the procedure and manner of preoperative evaluation requires the anesthesiologist to achieve a high level of efficiency and accuracy in assessment of the patients history, physical examination, differential diagnosis, and planning of management. It presents the anesthesiologist with a formidable challenge from both an organizational and a clinical perspective because of a decreased amount of time available to evaluate often medically complex patients. Providing consistent quality and cost-effective preoperative preparation of patients is an important issue in perioperative patient management. Both The Joint Commission (TJC) and the American Society of Anesthesiologists (ASA) have developed standards and requirements for preoperative anesthesia evaluation.3 Recent and updated preoperative evaluation guidelines published by multiple medical specialties have led to protocols for evaluation in preparing patients for anesthesia and surgery. Several of the current

practice guidelines challenge the historical manner of practicing anesthesia. These guidelines require objective review, reasonable consideration, and possibly changes in the manner of customary anesthesia practice.4 For example, the routine nothing by mouth (NPO) after midnight or 6 hours before surgery has been redefined by the ASA Task Force on Preoperative Fasting.5 The American College of Cardiologists/American Heart Association (ACC/AHA) preoperative evaluation guidelines, recently updated in 2007, recommend proceeding with elective surgery in certain patients who have experienced a myocardial infarction (MI) in terms of weeks rather than months. Both these and other changes and challenges in anesthesia practice are reviewed and the implications discussed in this chapter. If anesthesia and surgery were not associated with perioperative risk or adverse patient outcome, anesthesia preoperative evaluation and management would not be required. Although the incidence of patient morbidity and mortality has decreased in the past decades, many patients still have an abundance of fear and anxiety regarding anesthesia risk. We begin this preoperative chapter with a current review and identification of the concepts, evaluation, and goals in assessment of patient risk.

Preoperative Risk Assessment


The current ASA risk classification system was developed in 1941 by Meyer Saklad at the request of the ASA (Table 34-1). This classification was the first attempt to quantify the risk associated with anesthesia and surgery. Neither the type of anesthesia nor the location of the procedure or operation was considered in the development or as components of this risk classification. The system attempts to give a subjective and relative risk based only on the patients preoperative medical history (i.e., no consideration of diagnostic studies). ASA physical status (ASA-PS) 2
Table 34-1 American Society of Anesthesiologists Physical Status Classification ASA 1 ASA 2 Healthy patient without organic, biochemical, or psychiatric disease A patient with mild systemic disease, e.g., mild asthma or wellcontrolled hypertension. No significant impact on daily activity. Unlikely to have an impact on anesthesia and surgery Significant or severe systemic disease that limits normal activity, e.g., renal failure on dialysis or class 2 congestive heart failure. Significant impact on daily activity. Probable impact on anesthesia and surgery Severe disease that is a constant threat to life or requires intensive therapy, e.g., acute myocardial infarction, respiratory failure requiring mechanical ventilation. Serious limitation of daily activity. Major impact on anesthesia and surgery Moribund patient who is equally likely to die in the next 24 hours with or without surgery Brain-dead organ donor

ASA 3

ASA 4

ASA 5 ASA 6

E added to the classification indicates emergency surgery. Available from www.asahq.org.

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patients are at higher risk than ASA-PS 1 patients, but only if undergoing the same operation. Most importantly, there is no attempt to quantify the risk, which hampers the ability to use this risk assessment tool for communicating meaningful expectations to patients and other caregivers. Despite these limitations, some studies have corroborated an association of mortality and morbidity with ASA-PS scores. Studies have also shown a correlation between ASA-PS and unanticipated intensive care unit admissions, longer hospital stays for some procedures, and adverse cardiopulmonary outcomes. No correlation has been shown between ASA-PS class and cancellations, cost, unplanned admissions, and other perioperative complications, and traditionally, surgical risk has been considered more important than anesthetic risk. However, few studies have evaluated the effect of combining the risk inherent in the surgical procedure and the ASA-PS score. Among the first was the Johns Hopkins Risk Classification System, but this system focuses only on surgical risk. As surgery has evolved with innovations in minimally invasive and endoscopic techniques, a general anesthetic requiring instrumentation of the airway with associated significant physiologic perturbations may pose a significant and greater risk than the surgery itself to some extremely fragile individuals. Even the location of the procedure may alter the risk. A study of ambulatory surgery in Medicare beneficiaries older than 65 years found no deaths on the day of surgery when the procedure was performed in a physicians office; 2.3 deaths per 100,000 performed in a freestanding ambulatory surgical center; and 2.5 deaths per 100,000 performed at an outpatient hospital. The 7-day mortality was 35 per 100,000, 25 per 100,000, and 50 per 100,000, respectively. Age older than 85 years, significant comorbidity, and the type of procedure predicted adverse events.6 Other specialties have developed risk assessment tools for patients undergoing anesthesia and surgery. One of the first was Goldman, who further advanced risk assessment by identifying risk factors and cardiac complications in patients undergoing noncardiac surgery. Several studies followed, culminating in one of the most widely used guidelines for assessment of the common, significant perioperative complication of cardiac morbidity and mortality associated with noncardiac surgery. The joint ACC/ AHA guideline was first published in 1996 and updated in 2007.7 This guideline combines patient and surgical risk but is specific only for cardiac complications. There is no comprehensive risk assessment tool available at the time of this writing. The concept of risk associated with anesthesia (see Chapter 33) is unique in that rarely does the anesthetic itself offer benefit but merely allows others to do things that potentially offer benefit. The goals in assessing risk are to inform patients so that they can weigh their options and to identify opportunities to alter that risk. Analysis of the Australian Incident Monitoring Study (AIMS) database showed that 11.6% of reports identified inadequate or incorrect preoperative assessment (478 of 6271) or preoperative preparation (248/6271).8 Of adverse events, 3.1% (197) were indisputably related to inadequate or incorrect preoperative assessment or preparation. Of these 197 patients, major morbidity occurred in 23, and 7 patients died. The investigators concluded that patient factors contributed only 1% of the time. More than half of the incidents were preventable; an additional 21% were possibly preventable. Unpreventable events accounted for just 5% of cases. Almost a quarter of the time, communication failure was

cited as the most significant factor. Analysis of the first 2000 reports submitted to AIMS found a sixfold increase in mortality in patients who were inadequately assessed preoperatively.9 In a different study of anesthetic-related perioperative deaths, 53 of 135 deaths involved inadequate preoperative assessment and management. Many anesthesiologists perform preoperative evaluations, review diagnostic studies (chosen and ordered by someone else), discuss anesthetic risks, and obtain informed consent moments before patients undergo major, potentially life-threatening or disfiguring procedures. This choice offers little opportunity to optimize comorbid conditions or alter risk. The effects of extensive disclosure are stressful for patients and families at a time when they may be ill prepared to consider the implications rationally. An increase in preoperative anxiety probably affects postoperative outcomes because increased anxiety correlates with increased postoperative analgesic requirements and prolonged recovery and hospital stay. Anxiety impairs retention of information, with attendant medicolegal implications because of inadequate communication or discussion of the risks associated with anesthesia. Some assessment of risk is important to prepare for anesthesia and the surgical procedure. Patients have a right to be informed during the consent process of possible complications and, if possible, be given some estimate of the chance of complications occurring. Identified modifiable risk factors such as poorly controlled hypertension or unstable ischemic heart disease should be addressed. Risk assessment is useful to compare outcomes, control costs, allocate compensation, postpone surgery until interventions improve risk, or assist in the difficult decision of canceling or recommending that a procedure not be done when the risks are too high. The need for special techniques, postoperative care in the intensive care unit, and special monitoring must be considered and planned for. Yet risk assessment, at its best, is hampered by individual patient variability.

Section IV Anesthesia Management

Detecting Disease in Preoperative Evaluation


Several studies have proved the utility of the history and physical examination in determining diagnoses. A study of general medical clinic patients found that 56% of correct diagnoses were made with the history alone, which increased to 73% with the addition of physical examination. In patients with cardiovascular disease, the history establishes the diagnosis two thirds of the time, and physical examination contributes to a quarter of diagnoses. Diagnostic tests such as chest radiographs and electrocardiograms (ECGs) helped with only 3% of diagnoses, and special tests (e.g., exercise ECG) assisted with 6%. In patients with respiratory, urinary, and neurologic conditions, the history has also been shown to be the most important diagnostic method. The skill of performing a clinical examination derives from pattern recognition learned by listening to and seeing patients and assimilating the stories and outcomes of their illnesses. The diagnostic acumen of the physician is a result of the ability to integrate and develop an overall impression rather than just reviewing a compilation of facts.

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Importance of the Preoperative Medical History


The variability of the medical history and the words that both patients and physicians use to describe symptoms is a common problem. Using lay language and recording symptoms in ordinary words leads to greater interobserver agreement between practitioners and can lessen communication errors, which are common obstacles in medical care. Common errors occur when diagnostic labels such as angina are written in the record when the patient actually complained of chest pain. Conversely, true angina or cardiac ischemia/infarction is rarely described by a patient as chest pain. More likely, the patient will have complaints of tightness or squeezing, often in the upper part of the abdomen, shoulder, or neck. Therefore, medical interviewers should not be surprised that patients may deny ever having chest pain if this is the only noun used when inquiring about symptoms to elicit a history, thus missing a history of angina. Obtaining the patients history is not simply asking questions but asking the right questions, frequently in a variety of ways, and interpreting and carefully recording the answers. Complete and thorough histories assist in planning appropriate and safe anesthesia care and are more accurate and cost-effective in establishing diagnoses than screening laboratory tests are.

or illicit drugs should be documented. Quantitatively documenting tobacco exposure by pack-years (number of packs of cigarettes smoked per day times the number of years of smoking) is best. For example, if one has smoked two packs of cigarettes daily for the last 10 years, this is recorded as 20pack/years of tobacco use. A history of malignant hyperthermia (MH) or a suggestion of it (hyperthermia or rigidity during anesthesia) in either a patient or family member should be clearly documented to allow appropriate arrangements to be made before the day of surgery. A personal or family history of pseudocholinesterase deficiency should be identified preoperatively. Records from previous anesthesia may clarify an uncertain history. A screening review of systems is especially useful to uncover symptoms that may lead to the establishment of previously undiagnosed conditions. During the review of systems for anesthesia purposes, special emphasis needs to be placed on airway abnormalities; a personal or family history of adverse events related to anesthesia; and cardiovascular, pulmonary, hepatic, renal, endocrine, or neurologic symptoms. Questioning the patient about snoring and daytime somnolence may suggest undiagnosed sleep apnea, which has implications for anesthesia management (see the section Preoperative Evaluation of Patients with Obstructive Sleep Apnea and Chapter 64). The presence of any two of the following increases the chance that a patient has sleep apnea: Snoring Daytime sleepiness Hypertension Obesity

Components of the Preoperative Medical History


The important components of the anesthesia history are shown in Figure 34-1. The form can be completed by the patient in person (paper or electronic version), via Web-based programs, through a telephone interview, or by anesthesia staff. The classic history of present illness, or HPI, as it relates to evaluation for anesthesia starts with the reason that the patient is having surgery and the planned procedure. Often one needs to inquire further about how the surgical condition developed and any previous therapies related to this problem. Current and past medical problems, previous surgeries and types of anesthesia, and any anesthesia-related complications need to be noted. Rarely is simply a notation of diseases or symptoms such as hypertension, diabetes mellitus, coronary artery disease (CAD), shortness of breath, or chest pain sufficient. Equally important in identifying the presence of a disease is to establish the severity, current or recent exacerbations, the stability, and previous treatment of the condition or planned interventions. The extent, degree of control, and activity-limiting nature of the problems are equally important. The patients medical problems, previous surgeries, and response to questions will elicit further inquiry to establish a complete history. Prescription and over-the-counter medications, including supplements and herbals, should be carefully recorded, along with dosages and schedules. Any recent but currently interrupted medications should be included because this may lead to recognition of important issues. It is necessary to inquire about allergies to drugs and substances such as latex or radiographic dye, with special emphasis on the specifics of the patients response to the exposure. Frequently, patients claim an allergy to a substance when in reality the reaction was a common, expected side effect (e.g., nausea or vomiting with narcotics). Use of tobacco, alcohol,

A significant history of heartburn, especially with associated reflux or after a period of fasting comparable to what will occur preoperatively, is important. Women of childbearing age need to be prompted to recall their last normal menstrual period and their likelihood of being pregnant. This history is more reliable if the woman, especially if a minor child, is questioned in privacy. Determination of the patients cardiorespiratory fitness or functional capacity is useful in guiding additional preanesthetic evaluation and predicting outcome and perioperative complications.7,10 Exercise or work activity can be quantified in metabolic equivalents of the task (METs), which refers to a measure of the volume of oxygen consumed during an activity (Table 34-2). Ones ability to exercise is two-pronged in that better fitness decreases mortality through improved lipid and glucose profiles and reductions in blood pressure (BP) and obesity. Lack of exercise increases the risk for development of cardiac disease. Conversely, an inability to exercise may be the result of cardiopulmonary disease. Patients with peripheral vascular disease (PVD) will be limited by claudication, and those with ischemic heart disease may complain of shortness of breath or chest discomfort with exertion. Patients may not volunteer this information until asked why they cannot walk more than a certain distance or climb stairs. Several studies have shown that inability to perform average levels of exercise (4 to 5 METs) identifies patients at risk for perioperative complications (see Table 34-2).7 One should inquire about chest discomfort (pain, pressure, tightness), duration of the discomfort, precipitating factors, associated symptoms, and methods of relief. One should note diagnoses, diagnostic tests, therapies, and names of treating physicians.

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Shortness of breath with exertion or when lying flat (orthopnea) or peripheral edema is important to note. Patients are asked about a history of heart murmurs and what diagnostic studies have been performed to evaluate a murmur. The cardinal symptoms of severe aortic stenosis are angina, heart failure, and syncope, although patients are much more likely to complain of a decrease in exercise tolerance and exertional dyspnea. A general examination of all organ systems needs to be performed. For example, asking patients whether they have ever had problems with their heart, lungs, kidneys, liver, or nervous system, whether they have had cancer, anemia, or bleeding problems, or whether thay have ever been hospitalized for any reason will often prompt recall of medical problems. Similarly, obtaining

a complete listing of previous surgeries can help complete the medical history. Finally, a review of records from primary care physicians, specialists, or the hospital can reveal issues that the patient may not recall.

The Preoperative Physical Examination Section IV Anesthesia Management


At a minimum, the preanesthetic examination should include vital signs (e.g., BP, heart rate [HR], respiratory rate, oxygen saturation), height, and weight. Body mass index (BMI) is calculated from height and weight and is more accurate than weight in establishing obesity. Online BMI calculators can be found at

Patients name_________________________________________________Age__________Sex__________Date of surgery__________ Planned operation ___________________________________________________Surgeon_____________________________________ Primary care doctor/phone #___________________________ Other physicians/phone #s______________________________________ 1. Please list all operations (and approximate dates) a. __________________________________________________ b. __________________________________________________ c. __________________________________________________ d. __________________________________________________ e. __________________________________________________ f. __________________________________________________

2. Please list any allergies to medicines, latex or other (and your reactions to them) a. __________________________________________________ b. __________________________________________________ c. __________________________________________________ d. __________________________________________________

3. Please list all medications you have taken in the last month (include over-the-counter drugs, inhalers, herbals, dietary supplements and aspirin) Name of Drug Dose and How Often Name of Drug Dose and How Often

a. __________________________________________________ b. __________________________________________________ c. __________________________________________________ d. __________________________________________________ e. __________________________________________________ (Please check YES or NO and circle specific problems) 4. Have you taken steroids (prednisone or cortisone) in the last year?

f. __________________________________________________ g. __________________________________________________ h. __________________________________________________ i. __________________________________________________ j. __________________________________________________ YES NO

5. Have you ever smoked? (Quantify in _______ packs/day for _______ years) Do you still smoke? Do you drink alcohol? (If so, how much?) ________________________________ Do you use or have you ever used any illegal drugs? (we need to know for your safety) 6. Can you walk up one flight of stairs without stopping? 7. Have you had any problems with your heart? (circle) (chest pain or pressure, heart attack, abnormal ECG, skipped beats, heart murmur, palpitation, heart failure [fluid in the lungs], require antibiotics before routine dental care) 8. Do you have high blood pressure? 9. Have you had any problems with your lungs or your chest? (circle) (shortness of breath, emphysema, bronchitis, asthma, TB, abnormal chest x-ray) 10. Are you ill now or were you recently ill with a cold, fever, chills, flu or productive cough? Describe recent changes ________________________________________________
Figure 34-1 Sample patient preoperative history form. Continued

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(Please check YES or NO and circle specific problems) 11. Have you or anyone in your family had serious bleeding problems? (circle) (prolonged bleeding from nosebleed, gums, tooth extractions, or surgery) 12. Have you had any problems with your blood (anemia, leukemia, sickle cell disease, blood clots, transfusions)? 13. Have you ever had problems with your: (circle) Liver (cirrhosis, hepatitis, jaundice)? Kidney (stones, failure, dialysis)? Digestive system (frequent heartburn, hiatus hernia, stomach ulcer)? Back, neck or jaws (TMJ, rheumatoid arthritis)? Thyroid gland (underactive or overactive)? 14. Have you ever had: (circle) Seizures, epilepsy, or fits? Stroke, facial, leg or arm weakness, difficulty speaking? Cramping pain in your legs with walking? Problems with hearing, vision or memory? 15. Have you ever been treated for cancer with chemotherapy or radiation therapy? (circle) 16. Women: Could you be pregnant? Last menstrual period began: ______________________ 17. Have you ever had problems with anesthesia or surgery? (circle) (severe nausea or vomiting, malignant hyperthermia (in blood relatives or self), prolonged drowsiness, anxiety, breathing difficulties, or problems during placement of a breathing tube) 18. Do you have any chipped or loose teeth, dentures, caps, bridgework, braces, problems opening your mouth, swallowing or choking? (circle) 19. Do your physical abilities limit your daily activities? 20. Do you snore? 21. Please list any medical illnesses not noted above: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 22. Additional comments or questions for nurse or anesthesiologist? ___________________________________________________________________________ ___________________________________________________________________________

YES

NO

Figure 34-1, contd

http://www.cdc.gov/nccdphp/dnpa/bmi/index.htm or http:// www.nhlbisupport.com/bmi/. Formulas for calculating BMI are as follows: English formula: Weight in pounds 703 BMI = ( Height in inches ) ( Height in inches ) Metric formula: BMI =

or BMI = Weight in kilograms 10, 000 ( Height in centimeters) ( Height in centimeters) A BMI of 40 or greater defines extreme obesity, obesity is defined as a BMI of 30 to 39.9, and an overweight person has a BMI of 25 to 29.9. An increased BMI is predictive of airway difficulties in some studies and one of many factors associated with the development of chronic diseases such as heart disease, cancer, and diabetes.11

(Height in meters) (Height in meters)

Weight in kilograms

Preoperative Evaluation 1007


Table 34-2 Metabolic Equivalents of Functional Capacity MET 1 2 3 4 5 6 7 8 9 10 11 12 Functional Levels of Exercise Eating, working at a computer, dressing Walking down stairs or in your house, cooking Walking 1-2 blocks Raking leaves, gardening Climbing 1 flight of stairs, dancing, bicycling Playing golf, carrying clubs Playing singles tennis Rapidly climbing stairs, jogging slowly Jumping rope slowly, moderate cycling Swimming quickly, running or jogging briskly Skiing cross country, playing full-court basketball Running rapidly for moderate to long distances

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From Jette M, Sidney K, Blumchen G: Metabolic equivalents (METs) in exercise testing, exercise prescription, and evaluation of functional capacity. Clin Cardiol 13:555-565, 1990. MET, metabolic equivalent of the task. 1 MET = consumption of 3.5mL O2/min/kg of body weight.

Not infrequently, patients will have increased BP during the preoperative visit, even without a history of hypertension. This may be due to anxiety or missing doses of drugs because patients often do not take their medications before an appointment or procedure. This reading is probably not reflective of their usual control. Repeating the BP measurement, especially after the administration of anxiolytics if this is planned, obtaining previous readings from either medical records or asking patients what their usual BP measurements are, can be informative. Inspection of the airway may be the single most important component of the physical examination from an anesthesiologists perspective. Without specialized training in airway evaluation and management, including advanced techniques such as fiberoptic intubation, it is unlikely that nonanesthesiologists will be capable of performing an adequate assessment. See Box 34-1 for components of the airway examination. All patients should have thorough documentation of an airway examination, whether in a preoperative evaluation clinic or immediately before surgery (see Chapter 50). The Mallampati classification is performed by having patients open the mouth widely and protruding the tongue completely forward. A tongue depressor is not used. In class I, the soft palate, fauces, entire uvula, and pillars are visualized; in class II, the soft palate, fauces, and a portion of the uvula; in class III, the soft palate and base of the uvula; and in class IV, the hard palate only. The evaluation should also document the status of teeth, range of motion of the neck, neck circumference (increasing size predicts difficulty with laryngoscopy), thyromental distance, body habitus, and pertinent deformities.12 Because of the relatively high incidence of dental injuries during anesthesia, thorough documentation of preexisting tooth abnormalities is useful. A good time to discuss with patients variant options of airway management or techniques other than general anesthesia when applicable and prepare patients for possible awake fiberoptic intubation is after examination of the airway. When challenging airways are identified,

advance planning ensures that the necessary equipment and skilled personnel are available. Evaluation of the heart, lungs, and skin is necessary, as well as further focus on the organ systems involved with disease as reported by the patient. Auscultation of the heart and, when indicated, inspection of the pulses and peripheral and central veins and assessment for the presence of edema in the extremities may aid in developing a perioperative plan. One should auscultate for murmurs, rhythm disturbances, and signs of volume overload. Physical findings should focus on examination for third or fourth heart sounds, rales, jugular venous distention, ascites, hepato megaly, and edema. Observing whether the patient can walk up one to two flights of stairs can predict a variety of postoperative complications, including pulmonary and cardiac events and mortality, and aid in decisions regarding the need for further specialized testing such as pulmonary function tests (PFTs) or noninvasive cardiac stress testing.13 This is frequently not practical, and a report by the patient is often sufficient. The pulmonary examination should include auscultation for wheezing and decreased or abnormal breath sounds and notation of cyanosis or clubbing, use of accessory muscles, and effort of breathing. A basic neurologic examination to document deficits in mental status, speech, cranial nerves, gait, and motor and sensory function may be indicated, depending on the surgical procedure and patients history. For selective patients (e.g., those with deficits or disease or undergoing neurosurgery), a more extensive or focused neurologic examination is necessary to document specific preexisting abnormalities that may aid in diagnosis or interfere with positioning. Establishing a baseline allows comparison postoperatively for evaluation of new deficits and can aid in defense of potential malpractice claims of adverse events. Obesity, hypertension, and large neck circumference (>17 inches in men, >16 inches in women, or >60cm in anyone) predict an increased incidence of obstructive sleep apnea (OSA).14 These same neck measurements also predict difficulty with mask ventilation and intubation. Intravenous access sites should be

Section IV Anesthesia Management

Box 34-1 Components of the Airway Examination Length of the upper incisors Condition of the teeth Relationship of the upper (maxillary) incisors to the lower (mandibular) incisors Ability to protrude or advance the lower (mandibular) incisors in front of the upper (maxillary) incisors Interincisor or intergum (if edentulous) distance Tongue size Visibility of the uvula Presence of heavy facial hair Compliance of the mandibular space Thyromental distance with the head in maximum extension Length of the neck Thickness or circumference of the neck Range of motion of the head and neck

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noted. If this is limited, one should discuss possible central line placement with the patient or arrange for assistance from interventional radiology. Auscultation for bruits is important in patients with a history of head and neck irradiation, stroke, or transient ischemic attack.

Preoperative Evaluation of Patients with Coexisting Disease


Many of these concerns and conditions, including intraoperative and postoperative anesthesia management, are discussed in greater detail in other chapters of this text. This section briefly reviews specific medical conditions that are commonly seen in preoperative evaluation and for which preoperative assessment and intervention are important. Identification of patients with these comorbid conditions often presents an opportunity for the anesthesiologist to intervene to lower risk. The following conditions are best managed before the day of surgery, which allows ample time for thoughtful evaluation, consultation, and planning of anesthesia care.

Cardiovascular Disease
Cardiovascular complications are the most common serious perioperative adverse event (see Chapter 33). It is estimated that cardiac morbidity will occur in 1% to 5% of unselected patients undergoing noncardiac surgery. In specific circumstances, perioperative interventions have been shown to modify cardiovascular morbidity and mortality.7,15-17 Hypertension Hypertension, defined as two or more BP readings greater than 140/90mmHg, affects 1 billion individuals worldwide and increases with age. In the United States, 25% of adults and 70% of patients older than 70 years have hypertension, less than 30% are adequately treated, and 30% are undiagnosed. The degree of end-organ damage and morbidity and mortality correlate with the duration and severity of hypertension. Ischemic heart disease is the most common type of organ damage associated with hypertension. Each 20mmHg incremental elevation in systolic BP or 10mmHg incremental elevation in diastolic BP above 115/75 doubles the lifetime risk for cardiovascular disease in individuals 40 to 70 years of age. The odds ratio for an association between hypertension and perioperative cardiac risk is 1.31.7,18 However, there is little evidence of an association between a preoperative BP reading of less than 180/110mmHg and perioperative cardiac risk. Heart failure, renal insufficiency, and cerebrovascular disease are common in hypertensive patients. Preoperative evaluation identifies causes of hypertension, other cardiovascular risk factors, end-organ damage, and therapy. Paroxysmal hypertension or hypertension in young individuals should prompt a search for causes such as coarctation, hyperthyroidism, pheochromocytoma, or even illicit drug use such as cocaine, amphetamines, or anabolic steroids. (See the section Pheochromocytoma for further evaluation guidelines.) Physical examination focuses on the cardiovascular system, pulses, vital signs (BP needs to be repeated and previous records obtained to

establish long-term values), the thyroid gland, and signs of volume overload. Asking about episodic tachycardia, palpitations, and syncope, measuring BP in both arms, listening for bruits, and assessing the pulses in both the upper and lower extremities are necessary if there is concern the patient may have more than essential hypertension. Testing should be determined by the history and physical examination. Patients with long-standing, severe (often based on the number and dosages of prescribed antihypertensive medications), or poorly controlled hypertension need an ECG and determination of blood urea nitrogen (BUN) and creatinine, depending on the surgical procedure. Those taking diuretics should have an evaluation of electrolytes. Patients with significant left ventricular hypertrophy (LVH), especially those with a strain pattern on the ECG, which is indicative of chronic ischemia, should have a careful assessment of symptoms and other risk factors for CAD. In the presence of heart failure or dyspnea of unknown origina, an echocardiogram may provide additional information that will modify management. LVH independently increases the risk for perioperative cardiac morbidity. Patients suspected of having hyperthyroidism require thyroid function tests. It is generally recommended that elective surgery be delayed for severe hypertension (diastolic BP >115mmHg, sys tolic BP >200mmHg) until BP is less than 180/110mmHg. If severe end-organ damage is present, the goal should be to normalize BP as much as possible before surgery.18 A careful history and physical examination to determine cardiac, neurologic, or renal disease is important (see appropriate sections of this chapter). Effective lowering of risk may require 6 to 8 weeks of therapy to allow regression of vascular and endothelial changes, but too rapid or extreme lowering of BP may increase cerebral and coronary ischemia; therefore, the benefits of delaying surgery for treatment must be weighed against the risks. The Antihypertensive and Lipid Lowering Treatment to Prevent a Heart Attack Trial (ALLHAT) showed that effective treatment of hypertension is not simply a matter of decreasing BP.19 Thus, if surgery cannot be postponed, the goal is to not decrease chronically increased BP too rapidly. Severely elevated BP should be lowered over a period of several weeks. Studies suggest that hypotension intraoperatively is far more dangerous than hypertension.18 For a BP lower than 180/110mmHg, there is no evidence to justify cancellation of surgery, although interventions preoperatively are appropriate. It is important to identify patients who have undiagnosed hypertension (although typically three separate occasions of increased BP in nonstressful situations are required to diagnosis true hypertension) and differentiate those who have poorly controlled hypertension from those who have episodic increased BP because of pain, anxiety, or stress. Because the perioperative period is an excellent opportunity to alter the long- and short-term consequences of diseases, appropriate referral for future management is vital. Guidelines suggest that cardioselective -blocker therapy is the best treatment preoperatively because of a favorable profile in lowering cardiovascular risk, although the Perioperative Ischemia Evaluation (POISE) trial has recently questioned the safety of starting these agents acutely.7 The optimal time to start -blocker therapy to achieve its benefit while minimizing risk is unknown. Even though diuretics are first-line therapies in most circumstances, starting them in the preoperative period is not generally a good idea because of the alterations in potassium (both hypokalemia and hyperkalemia) that may occur and the need for close moni-

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toring and replacement. Calcium channel blockers (e.g., amlodipine, 5 to 10mg daily) can be very effective. Frequently, anxiety increases BP, and therefore antianxiolytics can be used as adjunctive therapy. BP should not be lowered too rapidly. Continuation of antihypertensive treatment preoperatively is critical. Ischemic Heart Disease The goals of preoperative evaluation are to Identify the risk for heart disease based on risk factors (Fig. 34-2, Box 34-2) Identify the presence and severity of heart disease from symptoms, physical findings, or diagnostic tests Determine the need for preoperative interventions Modify the risk for perioperative adverse events The basis of cardiac assessment is the history, physical examination, and ECG. Risk factors for CAD are as important or more important than symptoms of ischemia because CAD is not diagnosed in 40% of men and 65% of women before an acute coronary syndrome (unstable angina, acute MI, or sudden death) occurs. The traditional risk factors for CAD, such as smoking, hypertension, age, male gender, hypercholesterolemia, and family history, are not the same risk factors that are associated with an

Box 34-2 Revised Cardiac Risk Index High-risk surgery (intraperitoneal, intrathoracic, or suprainguinal vascular procedures)* Ischemic heart disease (by any diagnostic criteria) History of congestive heart failure History of cerebrovascular disease Diabetes mellitus requiring insulin Creatinine >2.0mg/dL
*This risk factor is not considered a clinical predictor in the ACC/AHA 2007 guidelines for perioperative cardiac evaluation for noncardiac surgery.7 This risk factor has been changed to simply diabetes mellitus in the ACC/AHA 2007 guidelines for perioperative cardiac evaluation for noncardiac surgery.7 From Lee TH, Marcantonio ER, Mangione CM, etal: Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 100:1043-1049, 1999.

Section IV Anesthesia Management

increased incidence of perioperative cardiac events (see Fig. 34-2 and Box 34-2). However, traditional risk factors are important in assessing the significance of chest pain, dyspnea, or an abnormal ECG. The Revised Cardiac Risk Index (RCRI; Box 34-2) has been validated in several studies as the best scoring system to predict

Step 1: Emergency Surgery Step 2: Active Cardiac Conditions Unstable coronary syndromes (unstable or severe angina, recent Ml) Decompensated HF (new onset, NYHA class IV) Significant arrhythmias (Mobitz II or 3rd-degree heart block, SVT or AF with rapid ventricular rate, symptomatic ventricular arrhythmia or bradycardia, new VT) Severe valvular disease (severe AS or MS) Step 3: Low-Risk Surgery (risk<1%) Superficial or endoscopic Cataract or breast Ambulatory Step 4: Functional Capacity Good: 4 METs (can walk flight of stairs without symptoms) Step 5: Clinical Predictors Ischemic heart disease Compensated or prior HF Cerebrovascular disease (stroke, TIA) Diabetes mellitus Renal insufficiency No clinical predictors Vascular surgery 12 clinical predictors Intermediate-risk surgery 3 clinical predictors Vascular surgery

Proceed to surgery with medical risk reduction and perioperative surveillance

Postpone surgery until stabilized or corrected

Proceed to surgery

Proceed to surgery

Proceed to surgery Proceed to surgery with HR control or consider noninvasive testing if it will change management Consider testing if it will change management

Figure 34-2 Simplified cardiac evaluation for noncardiac surgery. AF, atrial fibrillation; AS, aortic stenosis; HF, heart failure; HR, heart rate; METs, metabolic equivalents of the task; MI, myocardial infarction; MS, mitral stenosis; NYHA, New York Heart Association; SVT, supraventricular tachycardia; TIA, transient ischemic attack; VT, ventricular tachycardia. (From Fleisher LA, Beckman JA, Brown KA, et al: ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol 50:e159-e241, 2007. Available at http://www.acc.org/qualityandscience/clinical/guidelines/Periop_ / Accessed September 28, 2007.)

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perioperative cardiac risk in patients undergoing noncardiac surgery.20 The most important risk factors for adverse events are a history of ischemic heart disease, heart failure, diabetes, cerebrovascular disease, and renal insufficiency; advanced age; and high-risk surgery, especially open vascular procedures. One should inquire about chest discomfort (pain, pressure, tightness), the duration of the discomfort, precipitating factors, associated symptoms, and methods of relief. Regardless of symptoms, the most important prognostic indicators of heart disease and perioperative adverse events are risk factors. Shortness of breath with exertion is a common angina-equivalent. Dyspnea is nonspecific and can be a result of deconditioning, pulmonary disease, or heart failure. Dyspnea in patients with risk factors for CAD (see Fig. 34-2 and Box 34-2) may necessitate an investigation for ischemic heart disease. Women are particularly likely to have atypical symptoms of ischemic heart disease. One should note diagnoses, diagnostic tests, therapies, and names of treating physicians. Patients with risk factors for CAD or symptoms suggestive of ischemia, including atypical ones such as dyspnea, need an ECG. Tait and colleagues suggested that routine preoperative ECGs are not indicated in patients without a history of cardiovascular disease and no significant risk factors.21 An abnormal ECG is found in 62% of patients with known cardiac disease, in 44% of those with strong risk factors, but in only 7% of individuals younger than 50 years with no risk factors. Additionally, the specificity of an abnormality on the ECG in predicting postoperative cardiac adverse events is only 26%, and a normal ECG does not exclude cardiac disease.22 An ECG should not be ordered simply because of advanced age (see Chapter 71). Recommendations for age-based testing are derived from the high incidence of abnormalities found with advancing age. The frequency of Q-wave infarctions found only by ECG in men 75 years or older is about 0.5%. In an ambulatory surgical population, 43% of patients had an abnormal ECG, but only 1.6% had an adverse perioperative event and the preoperative ECG was of potential value in just half of those who had a complication. Only certain abnormalities on the ECG are important in preoperative assessment (e.g., Q waves, especially if recent; conduction abnormalities and arrhythmias), and one study found that just 2% of patients had one or both if a previous ECG did not show these abnormalities. Establishing a baseline for comparison is the most important reason to obtain an ECG preoperatively. However, if the rate of probable events is infrequent or the ECG is likely to be normal preoperatively, the yield lessens. If a previous ECG is available and there has been no change in symptoms or risk factors and no new physical findings, it is unlikely that a repeat ECG will be useful. The 2007 ACC/AHA guidelines on perioperative cardiovascular evaluation provide additional recommendations for preoperative resting ECGs (Box 34-3).7 Review of medical records and previous diagnostic studies, especially stress tests and catheterization results, should be performed if possible. In our experience, many patients are unaware of abnormalities or results not requiring revascularization. Frequently, a phone call to the primary care physician or cardiologist will yield important information and obviate the need for further testing or consultation. Consultation initiated by the preoperative physician should seek specific advice regarding diagnosis and status of the patients condition. Asking specific questions such as Does this patient have CAD? or Is this patient optimized for planned radical nephrectomy? is the first step. Letters or notes

Box 34-3 Recommendations for Preoperative Resting 12-Lead Electrocardiogram Class I A preoperative resting 12-lead ECG is recommended for patients with at least one clinical risk factor* who are undergoing vascular surgical procedures A preoperative resting 12-lead ECG is recommended for patients with known congestive heart failure, peripheral arterial disease, or cerebrovascular disease who are undergoing intermediate-risk surgical procedures Class IIa A preoperative resting 12-lead ECG is reasonable in persons with no clinical risk factors who are undergoing vascular surgical procedures Class IIb A preoperative resting 12-lead ECG may be reasonable in patients with at least one clinical risk factor who are undergoing intermediate-risk operative procedures Class III Preoperative and postoperative resting 12-lead ECGs are not indicated for asymptomatic persons undergoing low-risk surgical procedures Class I recommendations: the procedure should be performed; class IIa: it is reasonable to perform the preocedure; class IIb: the procedure may be considered; class III: the procedure should not be performed because it is not helpful.
*Clinical risk factors are listed in Box 34-2. Adapted from Fleisher LA, Beckman JA, Brown KA, etal: ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol 50:e159-e241, 2007. Available at http://www.acc.org/qualityandscience/clinical/ guidelines/Periop_Fulltext_2007.pdf/ Accessed September 28, 2007.

stating cleared for surgery are not sufficient to design a safe anesthetic plan. A letter summarizing the medical problems and therapies, along with the results of diagnostic tests, should be requested. The goal is to identify patients with heart disease who are at high risk for perioperative cardiac morbidity or mortality or those with modifiable conditions or risk. The guidelines for cardiac evaluation before noncardiac surgery published by the ACC/AHA have become the national standard of care. These guidelines were recently revised with a marked reduction in recommendations for preoperative noninvasive stress testing and revascularization.7 Step 1 in this guideline algorithm is to determine the urgency of the surgery. If emergency surgery does not allow further assessment, the focus needs to be placed on perioperative surveillance (e.g., serial ECGs, enzymes, monitoring) and risk reduction (e.g., HR control, statins, pain management). Clinical predictors, functional or exercise capacity, and level of surgical risk guide further diagnostic and therapeutic interventions. Step 2 is to determine whether the patient has an active cardiac condition, such as acute MI, unstable or severe angina, decompensated heart failure, severe valvular disease (e.g., severe

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aortic stenosis), or significant arrhythmias (e.g., ventricular tachycardia or atrial fibrillation with a rapid rate), that warrants postponement of all except lifesaving emergency procedures (e.g., ruptured aneurysms). After evaluating and treating these conditions according to the AHA/ACC guidelines, surgery may be considered if the benefits outweigh the risks. Traditionally, patients who experienced an MI within 3 to 6 months were considered high risk and surgery was delayed. More recent evidence and the ACC/AHA guidelines suggest that acute MI, defined as occurring within the past 7 days, should still be considered high risk and elective surgeries postponed. A recent MI, defined as occurring within the past 30 days (but more than 7 days) with evidence of myocardium at risk (generally based on persistent symptoms or results of stress testing), is also a high-risk condition. However, a recent (8 to 30 days previously) MI without evidence of myocardium at risk is considered an active cardiac condition and equivalent to any history of CAD. Step 3 involves determination of the surgical risk or severity. Patients without active cardiac conditions who are undergoing low-risk surgery (reported cardiac risk generally <1%; endoscopic or superficial procedures, cataract, breast, or ambulatory surgeries) can proceed to surgery without further cardiac testing other than an ECG within 3 months. Step 4 assesses the patients functional capacity (see Table 34-2). Asymptomatic patients who are highly functional can proceed to surgery. The 2007 ACC/AHA guidelines use the RCRI (see Box 34-2) derived from a cohort study showing an incidence of major cardiac events of 0.4%, 0.9%, 7%, and 11% in patients with zero, one, two, or three risk predictors, respectively.20 The RCRI medical conditions have been confirmed in independent studies as valid predictors of risk.15 Step 5 is the last and most complicated determination for patients with poor or indeterminate functional capacity. The presence and number of clinical predictors as shown in Box 34-2 drive the recommendations for and probable benefit of further cardiac testing. Patients with no clinical predictors proceed to surgery. Those undergoing vascular surgery with three or more clinical risk factors are the group most likely to benefit from further testing, but the ACC/AHA guidelines recommend further testing only if it will change management. Patients with one or more clinical predictors undergoing intermediate-risk surgery (1% to 5% risk for cardiac complications, including orthopedic, intraabdominal, and intrathoracic procedures) or those with one or two risk factors undergoing vascular surgery can either proceed to surgery with HR control or undergo noninvasive testing if it will change management. Chronic inflammatory conditions (e.g., rheumatoid arthritis, systemic lupus erythematosus [SLE]), chronic steroid use, and chest irradiation) increase the risk for CAD but have not been shown to be significant predictors of perioperative cardiac complications.23,24 The substantial pullback of ACC/AHA recommendations advocating noninvasive stress testing and coronary revascularization before noncardiac surgery is due to the general lack of definitive benefit and risk reduction with this approach. The only randomized prospective study of revascularization (coronary artery bypass grafting [CABG] or percutaneous coronary intervention [PCI] with stenting) versus medical management failed to show a difference in outcome. This study was performed in intermediate- to high-risk patients with known CAD undergoing major vascular surgery.25 Numerous retrospective and observational studies have failed to show a benefit of coronary

revascularization before noncardiac surgery. Noncardiac surgery soon after revascularization (CABG or PCI with or without stents) is associated with high rates of perioperative cardiac morbidity and mortality.26 Factors to consider are the urgency of the noncardiac surgery (e.g., patients with cancer) and the potential long-term benefits of revascularization. Patients who need noncardiac surgery within the next year are not good candidates for implantation of drug-eluting stents, and if revascularization is absolutely necessary, these patients need to be considered for either CABG or PCI without stenting or with a bare metal stent.27 See the section on recent coronary stents and antiplatelet agents. Stress testing identifies CAD and its severity, but the positive predictive value for perioperative cardiac complications is generally only 5% to 25%.28 The negative predictive value of noninvasive tests for predicting perioperative events generally approaches 100%, so these tests are typically more informative about a patient who will not have an event than one who will. However, studies of the predictive value of noninvasive testing predated the era of drug-eluting stents and the risk of perioperative acute thrombosis with these stents. Cardiac catheterization, which some consider the gold standard for evaluation of coronary lesions, does not absolutely risk-stratify patients.29 This lack of prognostic value is partly due to the approximately 50% incidence of plaque rupture (with intermediate-sized plaque of 40% to 70% being most vulnerable to rupture) as the causative event during the perioperative period combined with the hypercoagulable state and the typical withdrawal of antiplatelet agents. Exercise treadmill testing can be ordered for patients with normal ECGs who can exercise and are likely to achieve an adequate HR response (68% to 81% sensitivity and 66% to 77% specificity for finding ischemia).7 Prognostic information such as functional capacity and the workload at which ischemia occurs predict outcome. The test result is adequate when the patient can exercise to at least greater than 85% of the target HR (the target HR is defined as 220 age). The individuals ability to exercise and symptoms that limit activity, such as dyspnea, have long-term prognostic implications, even in those without evidence of ischemia. Pharmacologic tests such as dobutamine echocardiography or nuclear perfusion imaging are necessary for patients unable to exercise, those with pacemakers or significant bradycardia, or those taking high-dose -adrenergic blockers.7 A combination of exercise and imaging can be used in patients able to exercise who have significant abnormalities on the ECG that may interfere with the interpretation of ischemia via the ECG (e.g., LVH with a strain pattern, ST-T wave changes, or left bundle branch block [LBBB]). Exercise combined with perfusion imaging in patients with LBBB results in a high incidence of false-positive tests because of septal perfusion defects not caused by CAD.7 For most patients, the choice of which pharmacologic test is immaterial. Dobutamine uncovers ischemia by increasing contractility, HR, and BP and may therefore not be the best test in patients with pacemakers, significant bradycardia, aortic or cerebral aneurysms, or poorly controlled hypertension. Adenosine radionucleotide imaging (one of the most common methods of nuclear stress testing) uses the vasodilatory properties of adenosine (stenotic vessels are maximally vasodilated at rest) and uptake of the radioisotope by viable myocardium. This type of test is not dependent on the HR response but may exacerbate bronchospasm in patients taking theophylline or reduce preload,

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which may be dangerous in patients with severe aortic stenosis, hypertrophic cardiomyopathy (HCM), or carotid stenosis. Echocardiography, combined with exercise or a pharmacologic agent, is used to look for wall motion abnormalities. Abnormalities present at rest (baseline) indicate scar tissue from previous infarction. Areas of myocardium that are normal at rest but show abnormalities with increased isotropy and chronotropy are consistent with stenotic lesions and limited blood flow. Similarly, nuclear imaging perfusion abnormalities at rest are consistent with infarction. Normal coronary arteries vasodilate with adenosine or exercise, and uptake of isotope is normal. Myocardium with limited blood flow will be normal at rest but show decreased uptake of isotope with exercise or administration of adenosine. Perioperative cardiac risk increases with increasing amounts of at-risk myocardium. If a patient has undergone a specific test in the past, it is most useful to obtain the same test for comparison. Patients with ischemic heart disease require a complete blood count (CBC), and transfusion for anemia should be considered. In nonoperative settings but in populations with critical illness or chronic disease states associated with known CAD or risk factors for CAD, hemoglobin levels higher than 13.5 g/dL are associated with adverse outcomes.30 A recent study suggests that even mild preoperative anemia increases postoperative mortality and cardiac morbidity in men but not in women.31 Individuals

with preoperative hematocrits between 39% and 51% had the lowest risk of adverse outcomes in this Veterans Administration surgical population. A thorough discussion of the optimal perioperative medical treatment of patients with ischemic heart disease can be found in Chapter 35. In brief, patients already taking statins and -blockers need to have these drugs continued without interruption throughout the perioperative period. Those already taking -blockers need their dosages adjusted to achieve an HR lower than 70 beats/min if at all possible. The optimal use of -blockers in patients who are at significant risk for perioperative cardiac events and are currently not taking them in accord with national guidelines is controversial and discussed more fully in Chapter 35. Strong consideration should be given to continuing aspirin perioperatively or discontinuing for the shortest duration possible if used for secondary prevention of vascular events (Fig. 34-3). By applying the ACC/AHA recommendations or using the predictive value of the RCRI and developing practice guidelines as shown in Figure 34-2, anesthesiologists in preanesthetic clinics are well positioned to risk-stratify patients, thus obviating the need for cardiac consultation. The preoperative period is an opportunity to identify patients with CAD who will benefit from long-term risk modification with statins, aspirin, exercise, and diet adjustment. Patients with symptoms consistent with ischemia (but without a diagnosis of CAD) or significant risk factors

Patients with aspirin (75150 mg/day)

Patients with aspirin (75150 mg/day)+ clopidogrel (75 mg/day)

Primary prevention

Secondary prevention after MI, ACS, stent, stroke, PAD

High-risk situations: <6 weeks after MI, PCI, BMS, stroke <12 months after DES High-risk stents*

Low-risk situations**

Intracranial neurosurgery

All surgery

Only vital surgery Risk of bleeding in closed space***

All surgery

Stop 7 days before operation as needed

Operation under continuous treatment

Stop clopidogrel Maintain aspirin

*High-risk stents: long (>36 mm), proximal, overlapping, or multiple stent implantation, stents for chronic total occlusions, stents in small vessels or bifurcated lesions. **Examples of low-risk situations: >3 months after BMS, stroke, uncomplicated MI, PCI without stenting. ***Risk of bleeding in closed space: intracranial neurosurgery, intra-medullary canal surgery, posterior eye chamber ophthalmic surgery. In these situations, the risk/benefit ratio of upholding vs withdrawing aspirin must be evaluated for each case individually; in case of aspirin upholding, early postoperative re-institution is important. Figure 34-3 Algorithm for preoperative management of patients receiving antiplatelet therapy. ACS, acute coronary syndrome; BMS, bare metal stent; DES, drug-eluting stent; MI, myocardial infarction; PAD, peripheral arterial disease; PCI, percutaneous coronary intervention. (From Chassot P-G, Delabays A, Spahn DR: Perioperative antiplatelet therapy: The case for continuing therapy in patients at risk of myocardial infarction. Br J Anaesth 99:316-328, 2007. Available at http://bja.oxfordjournals.org.)

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without medical management such as statins and aspirin may benefit from evaluation by a cardiologist regardless of whether they are having surgery. Preoperative evaluation should not simply focus on perioperative risk. Heart Failure Heart failure affects 4 to 5 million people (2% of the population) in the United States and is a significant risk factor for postoperative adverse events (see Chapter 60).32 One in 100 individuals between 50 and 59 years of age has a 5% to 7% risk of perioperative cardiac complications, but those with decompensated failure have a 20% to 30% incidence. Heart failure may be due to systolic dysfunction (decreased ejection fraction because of abnormal contractility), diastolic dysfunction (elevated filling pressure because of abnormal relaxation but normal contractility and ejection fraction), or a combination. Diastolic failure accounts for almost half of all cases, but there is little science to guide perioperative care of these individuals. Hypertension is a cause of diastolic dysfunction, and LVH on an ECG should raise suspicion. Ischemic heart disease is the most common cause of systolic dysfunction in the United States (50% to 75% of cases). Cardiomyopathies occur from a variety of causes, including infectious causes (human immunodeficiency virus [HIV], coxsackievirus, influenza virus, adenovirus, Chagas or Lyme disease), ischemia, stress, toxins, alcohol, the peripartum period, drugs (doxorubicin [Adriamycin], cocaine), muscular dystrophies, and idiopathic causes, which can be familial and inherited in an autosomal dominant or X-linked autosomal recessive pattern. The preoperative evaluation history and physical examination focus on identifying and minimizing the effects of heart failure. Recent weight gain, complaints of shortness of breath, fatigue, orthopnea, paroxysmal nocturnal dyspnea, nocturnal cough, peripheral edema, hospitalizations, and recent changes in management are all significant. Patients with decompensated heart failure feel as though they are suffocating or have air hunger.33 Angina or a history of CAD may indicate heart failure. The physical examination focuses on finding third or fourth heart sounds, tachycardia, a laterally displaced apical pulse, rales, jugular venous distention, ascites, hepatomegaly, or peripheral edema. Classifying the patients medical status according to the New York Heart Association (NYHA) categories is useful.34 NYHA Classification Class I: no limitation of physical activity; ordinary activity does not cause fatigue, palpitations, or syncope Class II: slight limitation of physical activity; ordinary activity results in fatigue, palpitations, or syncope Class III: marked limitation of physical activity; less than ordinary activity results in fatigue, palpitations, or syncope; comfortable at rest Class IV: inability to perform any physical activity without discomfort; symptoms at rest Decompensated heart failure is considered a high-risk cardiac condition, and elective surgery should be postponed (see Fig. 34-2).7 Brain naturetic peptide (BNP), which is released from the ventricles of the heart, can be useful in evaluating patients suspected of having decompensated heart failure.35 In an emergency room study of patients with dyspnea, a plasma BNP level higher than 100pg/mL diagnosed heart failure with a sensitivity,

specificity, and predictive accuracy of 90%, 76%, and 83%, respectively. The plasma concentration of BNP correlated with NYHA functional class, with BNP levels ranging from 244 to 817pg/mL corresponding to classes I to IV.36 In patients undergoing noncardiac surgery, preoperative BNP levels predict cardiac complications and death.37 An N-terminal pro-BNP level elevated to greater than 450pg/mL in patients younger than 50 years and to greater than 900pg/mL in patients 50 years or older is highly sensitive and specific for the diagnosis of acute failure. An N-terminal pro-BNP level less than 300pg/mL has a 99% negative predictive value for acute heart failure. A study of patients undergoing vascular surgery showed that preoperatively elevated levels of N-terminal pro-BNP predicted cardiac events and mortality.38 A preoperative ECG plus determination of electrolytes, BUN, creatinine, and possibly BNP is indicated in all patients with or suspected of having heart failure. Digoxin levels should not be routinely measured unless toxicity under treatment or noncompliance is suspected. One should determine trough levels of digoxin, which is not always possible in a preoperative evaluation setting. Paroxysmal atrial tachycardia with a 2:1 atrioventricular (AV) block is pathognomonic of digoxin toxicity. Junctional tachycardia, ventricular ectopic beats, bigeminy, second-degree AV block, nausea, lethargy, altered color perception, and mental status changes or agitation are symptoms of digoxin toxicity. Chest radiography is useful in those suspected of pulmonary edema or decompensation. An objective measure of the left ventricular ejection fraction (LVEF), ventricular performance, and diastolic function with echocardiography is helpful if not previously performed, especially in patients with NYHA class III or IV heart failure. Normal LVEF is greater than 50%, mildly diminished is 41% to 49%, moderately diminished is 26% to 40%, and severely diminished is less than 25%. In patients with class III or IV heart failure, cardiology consultation would be useful before the patient undergoes general anesthesia or any intermediate- or high-risk procedure. Minor procedures under monitored anesthesia care may proceed as long as the patients condition is stable. Medical therapy, including -blockers, hydralazine, nitrates, and digoxin, needs to be optimized and continued preoperatively. Angiotension-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), diuretics (including aldosterone antagonists such as spironolactone), and anticoagulants may be beneficial, even on the day of surgery. Selectively continuing or discontinuing these drugs depends on the volume and hemodynamic status of the patient, the degree of cardiac dysfunction, and the anticipated surgery and volume challenges. Continuing all medications for patients with severe dysfunction who are scheduled for minor procedures is probably best. The other extreme occurs when patients with well-compensated NYHA class I failure are scheduled for lengthy high-risk procedures with projected significant blood loss or fluid requirements; in this case it is best to discontinue potent diuretics on the morning of surgery. Shortacting calcium channel antagonists depress left ventricular function, worsen symptoms, and increase the risk for death. Some patients will have pacemakers or implantable cardiac defibrillators, which have special considerations perioperatively (see the section on devices for management of cardiac rhythm for recommendations and Chapter 43). Unless truly an emergency and life preserving, surgery should be postponed in patients with decompensated or untreated heart failure. There is no consensus on how long after an acute

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exacerbation patients remain at risk. Severely affected individuals or those with decompensation are best managed in concert with a heart failure specialist and may benefit from preoperative hospitalization for interventions designed to improve function. Murmurs and Valvular Abnormalities The quandary in the preoperative clinic is to determine the cause of cardiac murmurs and to distinguish between significant murmurs and clinically unimportant ones (see Chapter 60).39 Functional murmurs occur as a result of turbulent flow across the aortic or pulmonic outflow tracts. These benign murmurs occur with high-outflow states such as hyperthyroidism, pregnancy, or anemia. However, noncardiologists or even cardiologists often cannot distinguish benign from pathologic murmurs. In elderly patients and those with risk factors for heart disease, other abnormal heart sounds, a history of rheumatic fever or anorectic drug use, evidence of volume overload, pulmonary disease, cardio megaly, or an abnormal ECG, echocardiography should be considered (Box 34-4).40 Although echocardiography may be useful in the diagnosis of many of these murmurs, the evaluation may not be required preoperatively if the information will not change management. Diastolic murmurs are always pathologic and require further evaluation. Regurgitant disease is tolerated perioperatively much better than stenotic disease is. Heart failure in concert with any valvular disease is associated with a 20% risk of decompensation in the perioperative period. Murmurs are graded according to loudness: grade I, a faint murmur that can be heard with difficulty; grade II, faint but easily heard; grade III, moderately loud without a thrill; grade IV, loud with a palpable thrill; grade V, very loud but still needs a stethoscope (thrill present); and grade VI, murmur heard without a stethoscope. However, the usefulness of this distinction is debatable because severe lesions can be associated with soft murmurs and vice versa. The location of the murmur and changes in intensity with maneuvers guide diagnosis (Table 34-3). A Valsalva maneuver decreases filling of the right and left heart chambers and reduces the intensity of most murmurs, except those associated with mitral valve prolapse (MVP) and HCM. Standing will also increase the intensity of murmurs of MVP and HCM. Squatting increases venous return and afterload and therefore increases most murmurs, except those related to MVP and HCM. Asking the
Table 34-3 Descriptions of Murmurs Associated with Cardiac Abnormalities Lesion Aortic stenosis Aortic insufficiency Mitral stenosis Mitral regurgitation Mitral valve prolapse Hypertrophic cardiomyopathy Location Second parasternal interspaces Third and fourth parasternal interspaces Apex Apex Apex Apex, lower left sternal border Timing Midsystolic Holodiastolic Mid-diastolic Holosystolic Late systolic Midsystolic

Box 34-4 ACC/AHA Guideline SummaryEchocardiography in Asymptomatic Patients with Cardiac Murmurs* Class IThere is evidence or general agreement (or both) that echocardiography is useful in asymptomatic patients with the following cardiac murmurs: Diastolic murmurs Continuous murmurs Late systolic murmurs Murmurs associated with ejection clicks Murmurs that radiate to the neck or back Grade 3 or louder systolic murmurs Class IIaThe weight of evidence or opinion is in favor of the usefulness of echocardiography in asymptomatic patients with the following cardiac murmurs: Murmurs associated with other abnormal physical findings on cardiac examination Murmurs associated with an abnormal electrocardiogram or chest radiograph Class IIIThere is evidence or general agreement (or both) that echocardiography is not useful in asymptomatic patients with the following murmurs: Grade 2 or softer midsystolic murmurs considered innocent or functional by an experienced observer
*These are indications for general evaluation but do not necessarily need to be performed preoperatively. From Bonow, RO, Carabello, BA, Chatterjee, K, etal: ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients with Valvular Heart Disease). J Am Coll Cardiol 48:e1, 2006.

patient to repeatedly perform a handgrip will increase HR and afterload (increases BP) and will augment murmurs of mitral regurgitation and stenosis and aortic insufficiency but decrease aortic stenosis and HCM murmurs. All patients with murmurs require an ECG. In patients with significant abnormalities found by history, physical examination, or ECG, further evaluation by echocardiography or by a cardiologist should be considered (see Box 34-4).

Description Crescendo-decrescendo, radiates to the carotids; S3, S4; Valsalva and sustained handgrip exercise decrease intensity Decrescendo, blowing, high pitched, radiates to the carotids; Austin-Flint rumble at the apex; squatting, handgrip exercise, and leaning forward increase intensity Opening snap; low-pitched rumble radiates to the axilla; squatting and handgrip exercise increase intensity High pitched, blowing, radiates to the axilla; loud S3; standing decreases intensity; squatting and handgrip exercise increase intensity Crescendo, midsystolic click; Valsalva and standing increase intensity; squatting decreases intensity S4, single S2; Valsalva and standing increase intensity; squatting, passive leg raising, and handgrip exercise decrease intensity

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Aortic Stenosis Aortic stenosis, the most common valvular lesion in the United States, affects 2% to 4% of adults older than 65 years; severe stenosis is associated with high risk for perioperative complications.7 Once considered a degenerative lesion associated with age or a congenital bicuspid valve, aortic stenosis is now thought to have much in common with ischemic heart disease and is an independent marker of CAD.41 In patients with bicuspid valves, stenosis typically develops at a younger age (fourth and fifth decades of life); those with stenosis of the tricuspid valves are usually older than 60 years, but there is overlap. Aortic sclerosis, which also causes a systolic ejection murmur similar to that of aortic stenosis, is present in 25% of people 65 to 74 years of age and in almost half of those older than 84 years.41 Aortic sclerosis is associated with a 40% increase in risk for MI and a 50% increase in risk for cardiovascular death in patients without a history of CAD.42 There is no hemodynamic compromise with aortic sclerosis. The cardinal symptoms of severe aortic stenosis are angina, heart failure, and syncope, although patients are much more likely to complain of a decrease in exercise tolerance and exertional dyspnea. Aortic stenosis causes a systolic ejection murmur, best heard in the right upper sternal border and often radiating to the neck. There is delayed carotid upstroke and a paradoxically split S2, and exercise will increase HR and decrease an aortic stenosis murmur. Patients with a previously undiagnosed murmur need an ECG, and an echocardiogram should be considered in patients with an abnormality on the ECG (see Box 34-4). Such abnormalities may consist of LVH, often with a strain pattern (ST-T wave changes), left axis deviation, or LBBB. Aortic stenosis severity is based on the mean transvalvular pressure gradient and valve area (Table 34-4). The pressure gradient falls if the left ventricle begins to fail. Current guidelines recommend echocardiography annually for patients with severe aortic stenosis, every 2 years for moderate stenosis, and every 5 years for mild stenosis.40 Patients with aortic stenosis are at risk for sudden death from arrhythmias, heart failure, and myocardial ischemia and infarction from concomitant CAD (high incidence) or a supply-demand mismatch. Patients with aortic sclerosis or stenosis need evaluation for CAD regardless of other risk factors. Those with severe or critical stenosis should not undergo noncardiac surgery (unless emergency and lifesaving) without a cardiology evaluation and careful consideration of risks or until valve replacement. Patients with moderate to severe aortic stenosis have an increased risk of bleeding (especially from gastrointestinal angiodysplasia). The cause appears to be an acquired von Willebrand syndrome resulting from mechanical disruption of von Willebrand multimers during turbulent blood flow through a narrowed valve. See the section von Willebrands Disease for

more details. An activated partial thromboplastin time (aPTT) is indicated. Prophylaxis for infective endocarditis in patients with aortic stenosis is no longer recommended.43 Aortic Insufficiency Insufficiency of the aortic valve occurs with true valvular disease affecting the leaflets, from aortic root dilation, or as a result of both. Rheumatic heart disease, a bicuspid valve, collagen vascular diseases, and endocarditis can all lead to valvular disease. Aortic root dilation can complicate ankylosing spondylitis, osteogenesis imperfecta, syphilis, hypertension, age-related degeneration, Marfans syndrome, and collagen vascular diseases. Acute insufficiency with pulmonary edema and hypertension can occur with trauma, infection, or aortic dissection and is an emergency. The murmur of aortic insufficiency is described in Table 34-3. The intensity of the murmur does not correlate with the severity of regurgitation.44 Patients typically have a widened pulse pressure (normal or elevated systolic BP and low diastolic BP) manifested as Corrigans or water-hammer pulses (bounding carotid pulse with a rapid downstroke). de Mussets sign is a head bob with each heartbeat, Duroziezs sign is a systolic and diastolic bruit heard over the femoral artery when it is partially compressed, Quinckes pulses are capillary pulsations in the fingertips or lips, and Mllers sign is systolic pulsations of the uvula. An ECG is needed and an echocardiogram should be considered if finding could change management (see Box 34-4); a chest radiograph may be useful. LVH with ST- and T-wave changes as a result of volume overload or underlying chronic ischemia may be present. Left atrial hypertrophy and left axis deviation along with premature atrial and ventricular contractions are not uncommon. Generally, chronic insufficiency is well tolerated in the perioperative period. Patients with good functional status and preserved left ventricular systolic function have a low risk of complications with anesthesia. Prophylaxis for infective endocarditis is no longer recommended.43 Mitral Stenosis Mitral stenosis is much less common than aortic stenosis and is usually associated with a history of rheumatic heart disease. It can occur with aortic valvular disease or mitral regurgitation. A normal mitral valve has an area of 4 to 6cm2; stenosis is mild when the mitral valve area is 1.5 to 2.5cm2, moderate with an area of 1.1 to 1.5cm2, and critical when the area is 0.6 to 1.0cm2. A resting mean transvalvular gradient greater than 10mmHg also denotes severe stenosis. Symptoms typically occur 10 to 20 years after acute rheumatic fever and are often precipitated by pregnancy or illness. Unrecognized mitral stenosis is included in the differential diagnosis of pulmonary edema. Preoperative evaluation includes determining whether the patient has a history of dyspnea, fatigue, orthopnea, pulmonary edema, and hemoptysis. These findings result from elevated left atrial pressure and decreased cardiac output. Atrial fibrillation can be due to a dilated left atrium, which can acutely precipitate failure and chronically cause thrombosis. Patients with atrial fibrillation require anticoagulation to avoid a left atrial thrombus. Tachycardia decreases cardiac output. Pulmonary hypertension and right heart failure may occur with significant stenosis. A loud S2 suggests pulmonary hypertension. The characteristics of the murmur are described in Table 34-3. Sustained handgrip exercise increases HR and BP and may increase the murmur. Examination should look for rales and signs of right heart failure such as

Section IV Anesthesia Management

Table 34-4 Severity of Aortic Stenosis Velocity of Aortic Jet (m/sec) <3 3-4 4-4.5 >4.5 Mean Pressure Gradient (mmHg) <25 25-40 40-50 >50 Valve Area (cm2) 1.5 1.0-1.5 0.7-1.0 <0.7

Grade Mild Moderate Severe Critical

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jugular venous distention, peripheral edema, hepatomegaly, right ventricular heave, and ascites. A preoperative ECG is necessary and an echocardiogram should be considered if it will change management (see Box 34-4). A chest radiograph should also be considered. -Blockers are used to control HR, and antiarrhythmics prevent or control atrial fibrillation. These medications have to be continued preoperatively because HR needs to be controlled before surgery. Anticoagulation is managed in conjunction with the treating cardiologist and surgeon. Prophylaxis for infective endocarditis is no longer recommended.43 Mitral Regurgitation Mitral regurgitation can be acute in the setting of ischemia or infarction or can be chronic and associated with mitral stenosis, mitral valve prolapse, collagen vascular diseases, or cardiomyopathies. The course is typically very gradual, and symptoms develop late and only after the development of left ventricular dysfunction. Preoperative symptoms are vague and often attributed to other causes. Fatigue, dyspnea, and atrial fibrillation can be present. Description of murmurs is presented in Table 34-3. A loud murmur associated with a thrill (grade 4) has a specificity of 91% for severe regurgitation but a sensitivity of 24%.44 Severe regurgitation is rarely present with a grade 1 to 2 murmur; however, there is a wide range of severity with a grade 3 murmur. Chronic mitral regurgitation is generally well tolerated perioperatively unless other valvular lesions (e.g., mitral or aortic stenosis) or left ventricular dysfunction coexist. Prophylaxis for infective endocarditis is no longer recommended.43 Mitral Valve Prolapse Also known as click-murmur or floppy valve syndrome, mitral valve prolapse is commonly diagnosed in young women during evaluation for atypical chest pain, palpitations, or syncope. Whether these symptoms are truly related is questionable. Interestingly, men older than 55 years with mitral valve prolapse are more likely to have regurgitation complications and are at greatest risk for infective endocarditis. The important issue preoperatively is to differentiate patients with clinically significant mitral valve degeneration and regurgitation from those with an incidental finding of prolapse or a click, which does not warrant further evaluation or change in management. Patients taking -blockers for control of palpitations or atypical chest pain continue these medications perioperatively. Prophylaxis for infective endocarditis is no longer recommended.43 Tricuspid Regurgitation Tricuspid regurgitation is a relatively common abnormality, but because it is usually asymptomatic and not audible on physical examination, it is most commonly noted by echocardiography performed for other reasons. A small degree of tricuspid regurgitation is present in approximately 70% of normal adults. Tricuspid regurgitation is most commonly caused by dilatation of the right ventricle and the tricuspid annulus. Right ventricular dilatation is caused by conditions that directly involve the right ventricle (ischemia, cardiomyopathy) or is due to pulmonary hypertension and elevated right ventricular systolic pressure. Tricuspid and mitral regurgitation often occurs together. Tricuspid regurgitation is less often due to processes that directly affect the tricuspid valve, such as Ebsteins anomaly (a congenital malformation), infective endocarditis, rheumatic fever, carcinoid

syndrome, connective tissue disorders (Marfans syndrome), myxomatous degeneration or prolapse (occurs in as many as 40% of patients with mitral valve prolapse), or injury from a pacemaker, central line, or implantable cardioverter-defibrillator (ICD) lead. Drugs such as the anorectics fenfluramine and phentermine and the dopamine agonist pergolide may cause tricuspid regurgitation by a mechanism similar to that seen with carcinoid syndrome. The aforementioned drugs are no longer available in the United States. Tricuspid regurgitation is classically associated with a holosystolic murmur that is best heard at the right or left midsternal border or at the subxiphoid area. When the right ventricle is very enlarged, the murmur may even be appreciated at the apex. There is usually little radiation of the murmur, and a thrill is not palpable. However, the murmur of tricuspid insufficiency is often soft or absent, even when regurgitation is severe. Interventions that result in an increase in venous return (leg raising, exercise, hepatic compression) will augment the murmur of tricuspid regurgitation. The murmur may also become louder after a premature beat and prolonged diastole. In contrast, reducing venous return (by standing or with amyl nitrate) will diminish the intensity of the murmur. In patients with pulmonary hypertension, the intensity of the murmur may change with alterations in pulmonary artery pressure and therefore the right ventricle. Patients with (or suspected of having) pulmonary hypertension need to be managed in conjunction with a pulmonary hypertension specialist (see the section Pulmonary Hypertension). Prophylaxis for infective endocarditis is no longer recommended.43 An echocardiogram should be considered if it will change management. Hypertrophic Cardiomyopathy Previously known as hypertrophic obstructive cardiomyopathy and before that as idiopathic hypertrophic subaortic stenosis, HCM can be familial. Patients with hypertrophic obstructive cardiomyopathy are often young and male and may be asymptomatic without murmurs. An ECG and echocardiogram should be considered if there is a personal or family history of syncope with exertion or sudden death or when a murmur consistent with this disorder is detected. Characteristics of the murmur are described in Table 34-3. A maneuver that decreases diastolic volume or increases contractility increases the intensity of the murmur. Passive leg raising and squatting decrease the intensity, and a Valsalva maneuver increases it. In an otherwise healthy nonhypertensive patient with LVH and ST-segment and T-wave abnormalities on an ECG, an echocardiogram should be considered. Patients are at risk for sudden cardiac death probably from arrhythmias (see Box 34-4). Holter monitoring may be useful in some patients. Many patients are treated with -blockers to decrease contractility; these medications are continued perioperatively. ICDs may be in place to prevent sudden death; see discussion in the appropriate section of this chapter. Prophylaxis for infective endocarditis is no longer recommended.43 Prosthetic Heart Valves In patients with prosthetic valves, the most important issues preoperatively are determination of the underlying condition requiring replacement, the type of prosthesis, the need for anticoagulation, and the planned management of such patients in the perioperative period. Occasionally, patients will have valve-related hemolysis. The risk for thrombosis is greatest with multiple prosthetic

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valves, followed by valves in the mitral position and then aortic valve replacements. Caged-ball valves (Starr-Edwards) have the highest risk, single tilting-disk valves (Bjrk-Shiley, MedtronicHall, Omnicarbon) have an intermediate risk, and the lowest risk is seen with bileaflet tilting-disk prostheses (St. Jude, CarboMedics, Edwards Duromedics). Bioprosthetic valves such as Carpentier-Edwards (porcine heterograft or pericardial) or Hancock (porcine) brands generally do not require long-term anticoagulation. The decision to stop anticoagulants, the duration off anticoagulants, and the need to bridge with a shorter-acting drug and the type of bridging agent (intravenous heparin or lowmolecular-weight heparin [LMWH]) need to be made in conjunction with the treating cardiologist and surgeon. See the section on anticoagulation for a discussion of bridging. Rhythm Disturbances and Electrocardiographic Abnormalities Arrhythmias and conduction disturbances are common in the perioperative period (see also Chapter 42). Supraventricular and ventricular arrhythmias are associated with a greater risk of perioperative adverse events because of the arrhythmia itself and because they are markers for cardiopulmonary disease. Uncontrolled atrial fibrillation and ventricular tachycardia are high-risk clinical predictors, and elective surgery should be postponed until evaluation and stabilization are complete.7 New-onset atrial fibrillation, symptomatic bradycardia, or high-grade heart block (second or third degree) identified in the preoperative clinic warrant consideration of postponement of elective procedurest and referral to cardiology for further evaluation. First-degree AV block is defined as a PR interval longer than 0.20msec with an HR of 50 to 100 beats/min and is generally benign. Second-degree heart block occurs when the PR interval is prolonged greater than 0.20msec, and eventually the atrial beat is blocked, which results in a dropped or missing QRS complex after a P wave. Two types of second-degree block exist. A Mobitz type I or Wenckebach block is more benign, rarely progresses to complete heart block, and responds to atropine. It is characterized by a progressive lengthening of the PR interval until the dropped beat occurs and is usually due to AV nodal delay. Mobitz type II results from an infranodal block, can progress to complete heart block, and is generally treated with a pacemaker unless secondary to a reversible cause such as ischemia or drugs. It is characterized by a fixed, prolonged PR interval that does not change before the dropped QRS complex. Third-degree or complete heart block is complete dissociation between the atrial and ventricular beats (P waves and QRS complexes) and requires a pacemaker unless a reversible source is identified. The ventricular beats in a patient with complete heart block are independent of the atria and should not be depressed. Two general factors are considered when determining the need for a pacemaker: an arrhythmia associated with symptoms and the location of the conduction abnormality. Syncope or near syncope associated with bradycardia or conduction delays is generally an indication for placement of a pacemaker. Disease below the AV node, in the His-Purkinje system, is more ominous and is suggested by a normal or minimally prolonged PR interval, a Mobitz type II block, and QRS abnormalities (bundle branch block, fascicular block, or both). Because disease in the HisPurkinje system is generally less stable, permanent pacemaker placement is likely to be beneficial. The indications for a pacemaker perioperatively are the same as those in nonsurgical patients (Box 34-5).45

Box 34-5 Indications for a Pacemaker Class I Indications Sinus bradycardia with symptoms clearly related to the bradycardia (usually with a heart rate <40 beats/min or frequent sinus pauses) Symptomatic chronotropic incompetence Complete (third-degree) AV block* Advanced second-degree AV block (block of 2 consecutive P waves) Symptomatic Mobitz I or II second-degree AV block Mobitz II second-degree AV block with a widened QRS or chronic bifascicular block, regardless of symptoms Class II Indications Sinus bradycardia (heart rate <40 beats/min) with symptoms suggestive of bradycardia but without a clear association between bradycardia and symptoms Sinus node dysfunction with unexplained syncope Chronic heart rates <30 beats/min in an awake patient Class I conditions are those in which permanent pacing is definitely beneficial and effective, provided that the condition is not due to a transient cause. Class II conditions are those in which permanent pacing may be indicated but there is conflicting evidence or divergence of opinion (or both).
*Controversy exists concerning complete atrioventricular (AV) block without symptoms. The current ACC/AHA guidelines classify asymptomatic third-degree AV block with average awake ventricular rates of 40 beats/min or greater as a class IIa indication, although others recommend definite pacemaker placement. From Gregoratos, G, Abrams, J, Epstein, AE, etal: ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices: Summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/NASPE Committee to Update the 1998 Pacemaker Guidelines). Circulation 106:2145-2161, 2002.

Section IV Anesthesia Management

Bundle branch blocks are complete or incomplete and either right (RBBB) or left (LBBB). They result from aging or fibrosis of the conducting system, ischemia, pulmonary disease, radiation, or cardiomyopathies or can be normal variants. Traditionally, LBBB has been considered more ominous and has been shown to be associated with CAD and heart failure.46,47 LBBB is strongly associated with CAD, and in a patient with a recent onset or no previous evaluation of LBBB, stress testing or cardiology consultation may be warranted. Obtaining a previous ECG for comparison can establish the stability. RBBB is likely to be congenital, a result of calcification and degeneration of the conduction system or secondary to pulmonary disease. Brugadas syndrome is a congenital disease characterized by RBBB with ST-segment elevation in the right precordial leads and is associated with a risk for sudden death and lethal arrhythmias. If the history and physical examination do not suggest significant pulmonary, congenital, or ischemic heart disease or Brugadas syndrome, no further evaluation is warranted because of an isolated RBBB. An RBBB in a patient with pulmonary symptoms (including pulmonary hypertension) may be suggestive of severe respiratory or vascular compromise and may warrant pulmonary evaluation and echocardiography if intermediate- or high-risk surgery is planned. If congenital heart disease, pulmonary hypertension (see the appropriate section in this chapter), or Brugadas

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syndrome is suspected, cardiology consultation is indicated. LVH and ST-segment depression on a preoperative ECG are associated with a greater risk for MI and cardiac death perioperatively.48 LVH may be associated with diastolic dysfunction and poorly controlled hypertension. Prolonged QT intervals should prompt an evaluation of electrolytes, magnesium, and calcium and a search for potentiating drugs. In a patient with a prolonged QT interval and syncope, near syncope, or a family history of sudden death, further evaluation should be considered. Atrial Fibrillation Atrial fibrillation occurs in elderly patients and those with thyrotoxicosis, valvular disease, and ischemic heart disease. It can be intermittent (paroxysmal), persistent (able to be cardioverted), or permanent (unable to be converted). Evidence suggests that rate control is more important than rhythm control. Patients with rapid ventricular rates (>100 beats/min) require control before elective surgery.7 Patients with slow ventricular rates not caused by rate-controlling medications are at risk for sick sinus syndrome, need a careful history to uncover syncopal or near-syncopal episodes, and may need a Holter monitor. Most patients with atrial fibrillation will require long-term anticoagulation, which becomes an issue in the perioperative period. If they are being treated with only prophylactic therapy (no history of emboli or left atrial thrombi), bridging perioperatively is not cost-effective. Patients with atrial or ventricular thrombi or a previous history of thromboembolic events are at higher risk, and anticoagulant therapy is managed on a case-by-case basis in concert with the treating physician. -Blockers, digoxin, and calcium channel blockers taken chronically to control rate or rhythm need to be continued perioperatively. Supraventricular Arrhythmias Supraventricular tachycardias result from rapidly firing ectopic atrial foci with rapid conduction via the AV node or from a reentry mechanism via accessory pathways. With a reentry mechanism the cycle self-perpetuates because conduction occurs down one pathway and up the other, with both the AV nodePurkinje system and the accessory pathway or pathways being involved. Various degrees of AV block may slow the ventricular rate. WolffParkinson-White (WPW) syndrome is a classic supraventricular tachycardia with an accessory pathway but unique in that impulses can travel both retrograde and antegrade. Antegrade conduction over the accessory pathway results in a short PR interval (<0.12msec) and slurring of the upstroke of the QRS, termed a delta wave. AV nodalblocking drugs such as -blockers, calcium channel blockers, and digoxin can paradoxically increase conduction over the accessory pathway and cause ventricular fibrillation. Lidocaine and procainamide are the preferred drugs to slow the tachycardia in patients with WPW syndrome. Certain patients may require ablation for long-term management of WPW syndrome, and this should be performed before elective surgery. Ventricular Arrhythmias Ventricular ectopics can be differentiated from atrial ectopics by a widen QRS (>0.12msec) and lack of a P wave. The traditional grading system of Lown, organized by morphology (unifocal or multifocal), frequency (less than or greater than 30 beats/min), and other characteristics (couplets, R on T phenomenon), is limited in its ability to stratify risk. Classifying ventricular arrhythmias according to the type of rhythm disturbance and the pres-

ence of coexisting heart disease better predicts the risk for sudden death. Benign: isolated ventricular premature beats (VPBs) without heart disease No need for further evaluation No risk of sudden cardiac arrest Potentially lethal: greater than 30VPBs/hr or nonsustained ventricular tachycardia with underlying heart disease Requires cardiology evaluation with possible echocardiography, stress testing, catheterization, or electrophysiologic testing Moderately high risk of sudden cardiac arrest; may benefit from an ICD Lethal: sustained ventricular tachycardia, ventricular fibrillation), syncope, or hemodynamic compromise associated with VPBs with underlying heart disease and often depressed cardiac function Requires cardiology evaluation with possible stress testing, echocardiography, catheterization, or electrophysiologic testing High risk of sudden cardiac arrest; likely to benefit from an ICD Preoperative evaluation focuses on reversible causes such as hypokalemia, ischemia, acidosis, hypomagnesemia, drug toxicity, and endocrine dysfunction, which should be further evaluated and treated. Patients taking amiodarone are at risk for hypothyroidism and require thyroid function tests before surgery. Antiarrythmics should be continued perioperatively. Cardiac Rhythm Management Devices: Pacemakers and Implantable Cardioverter-Defibrillators More than 100,000 new cardiac rhythm management devices are implanted yearly in the United States. A complete discussion of the perioperative management of these devices can be found in Chapter 43. Peripheral Vascular Disease Also called peripheral arterial disease, PVD refers to aneurysmal or occlusive arterial disease of the extremities, visceral organs, head, neck, and brain. Many of these patients have disease secondary to tobacco abuse, diabetes, hyperlipidemia and hypertension, or combinations of these causes. Patients with Marfans or Ehlers-Danlos syndrome may have aneurysmal disease without other risk factors. Renal insufficiency and cerebrovascular disease are frequent in this cohort of patients. Up to 75% of patients with PVD have CAD. In a study of 1000 consecutive patients scheduled for major vascular surgery, almost 60% had critical stenosis in at least one major coronary vessel. In addition, undiagnosed PVD (e.g., patients who smoke, are of increased age, have diabetes, or have cerebrovascular disease) should be considered when assessing patients scheduled for major surgery. Because claudication often limits functional capacity, symptoms of ischemic heart disease are often not apparent. Determination of BP in both upper extremities and the presence or absence of peripheral pulses is important. Listening for bruits over the abdomen and femoral arteries or palpating for abdominal masses is part of the vascular examination but is rarely necessary preoperatively. BUN and creatinine should be determined before procedures involving injection of radiocontrast dye

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(see the section Contrast-Induced Nephropathy for management to reduce risk). Many patients take aspirin or dipyridamole, a vasodilator with some antiplatelet effects that are reversible on discontinuation; its elimination half-life is approximately 10 hours. Therefore, stopping this drug 48 hours before surgery eliminates the antiplatelet effect. However, because dypyridamole is often combined with aspirin (Aggrenox), this drug must be stopped 5 to 7 days before surgery if complete reversal of its antiplatelet effects is desired, although the risks related to stopping antiplatelet medications must also be considered.

A preoperative chest radiograph is necessary only for evaluation of infections or pneumothorax. Bronchodilators, inhaled and oral steroids, and antibiotics (if taken) need to be continued on the day of surgery. -Agonists are the most useful prophylactic intervention to lower the risk for bronchospasm on induction of anesthesia. A short course of steroids (20 to 60mg of prednisone daily for 3 to 5 days) preoperatively may be useful in any patient who is not at baseline and surgery must proceed. Chronic Obstructive Pulmonary Disease COPD includes chronic bronchitis and emphysema and is characterized by obstruction to airflow that is not fully reversible. It is often due to exposure to pollutants such as cigarette smoke or substances in the environment (air pollution, allergens, grain, dust, and coal), 1-antitrypsin deficiency, chronic infections, and long-standing asthma. Chronic bronchitis is the presence of symptoms on most days for at least 3 months for 2 successive years or recurrent excessive sputum that severely impairs expiratory airflow. Dyspnea, coughing, wheezing, and sputum production are common features. An acute exacerbation is defined as an increase in symptoms that requires a change in management. The preoperative history and physical examination for patients with COPD are similar to that for patients with asthma, but with additional emphasis on the change in amount of sputum, color, or other signs of infection. A barrel chest and pursed-lip breathing suggest advanced disease. Typically, FEV1 is reduced because of obstructed airflow, but FVC is increased because of reduced airflow, loss of elasticity, and overexpansion. Diffusing capacity (Dlco) is typically decreased, and its severity often correlates with the degree of hypoxia and hypercapnia, which in turn can predict the presence of pulmonary hypertension. However, PFTs have not been shown to predict perioperative outcome. Determination of oxygen saturation by pulse oximetry is appropriate to establish a baseline. Patients found to be hypoxic or using oxygen may benefit from further testing, including arterial blood gas determination. A chest radiograph is useful only when infection is suspected. An ECG may demonstrate right axis deviation, RBBB, or peaked P waves, which suggest pulmonary hypertension and possibly right ventricular changes in response to the chronic lung disease (see the section Pulmonary Hypertension). Restrictive Pulmonary Disorders Restrictive lung disease is distinguished by a reduction in total lung capacity. Both pulmonary and extrapulmonary conditions cause restrictive disease. Pulmonary conditions include idiopathic interstitial pneumonia, interstitial lung disease related to connective tissue disease, lung resection, and pulmonary fibrosis. Extrapulmonary disorders are caused by chest wall limitations (kyphoscoliosis, obesity, ankylosing spondylitis), muscle dysfunction (muscular dystrophies, myasthenia gravis, paralyzed diaphragm), or pleural disease (mesothelioma, effusion, pneumothorax). The preoperative medical history of associated diseases or symptoms prompts the directed evaluation. A chest radiograph and PFTs may be indicated to establish a diagnosis or evaluate acute or progressive worsening but are not routinely necessary preoperatively. FEV1 and FVC are reduced proportionally, so the ratio is normal. These patients are at risk for pulmonary hypertension, which may not be diagnosed or communicated to caregivers because of overlapping symptoms with restrictive lung disease. See the section Pulmonary Hypertension for more details.

Section IV Anesthesia Management

Pulmonary Disorders (See Chapter 59)


Asthma Asthma is a chronic inflammatory disease characterized by obstruction of the airways that is partially or completely reversible with treatment or spontaneously.49 Bronchoconstriction is precipitated by irritants (smoke), allergens, infections, medications, or instrumentation of the larynx, trachea, or bronchi. Asthma is classified as intermittent (mild) or persistent (mild, moderate, or severe) based on how frequently symptoms occur and whether they are sporadic or constant. Patients with mild, well-controlled asthma have no greater risk associated with anesthesia and surgery than normal individuals do. Reporting of asthma should prompt further questioning about shortness of breath, chest tightness, coughing (especially nocturnal), recent exacerbations, therapy (especially the use of steroids, particularly within the previous year) or oxygen use, hospitalizations, and intubations. The patients best exercise level is important information for assessment of risk. A history of previous exacerbations with anesthesia should be elicited. Patients with asthma are quite good at estimating their current status and breathing capacity when asked about what percentage they are presently at (100% being normal). Adequate and appropriate medical therapy must be determined. The quality of breath sounds, quantity of air movement, and degree of wheezing are important. The degree of wheezing does not always correlate with the severity of bronchoconstriction. With severe obstruction, airflow is dangerously restricted and wheezing diminishes. Observing the degree of accessory muscle use often gauges the severity of the bronchoconstriction. Determination of oxygen saturation by pulse oximetry is useful. Arterial blood gas analysis is not generally necessary unless the patient is having a severe acute exacerbation. Patients taking oral steroids need blood glucose checked and may require perioperative steroid supplementation. Wheezing is a common symptom in asthmatics but is not specific for this disease. Patients with chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease, vocal cord dysfunction, tracheal or bronchial stenosis, cystic fibrosis, allergic bronchopulmonary aspergillosis, and heart failure may wheeze. Spirometry is the preferred diagnostic test, but a normal result does not exclude asthma. A methacholine challenge test or a trial of bronchodilator therapy is indicated if spirometry is normal but there is still a strong suspicion of asthma. PFTs have no perioperative predictive value but in rare instances may be useful to gauge the severity of disease or the adequacy of therapy. Typical findings on PFTs are reduced forced expiratory volume in 1 second (FEV1) and normal to increased functional residual capacity (FVC).

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Dyspnea Dyspnea is a subjective experience of breathing discomfort. It is a symptom of deconditioning, obesity, and disorders of ventilation, cardiac function, perfusion, and oxygen delivery. Dyspnea is associated with cardiac, pulmonary, hematologic, and neuromuscular diseases. Patients with an insidious onset may not seek attention until quite late, and frequently they and their caregivers assume that the dyspnea is due to being out of shape, although this should be a diagnosis of exclusion. The majority of patients with chronic dyspnea of unclear etiology have one of four diagnoses: asthma, COPD, interstitial lung disease, or cardiac dysfunction. The important facts to determine are the onset, progression, precipitating factors, type and level of provocative activity, associated symptoms (chest pain, leg edema, syncope or near syncope, fatigue), other conditions (arthritis, connective tissue disease, cardiac disease, smoking), and drug or toxin exposure. Asking about the quality of dyspnea can differentiate causes. Dyspnea secondary to deconditioning is usually described as heavy breathing, and one can often determine that the patient is actually describing fatigue more than true dyspnea. The bronchoconstriction in exacerbations of asthma is more commonly described as tightness or air hunger, whereas patients with COPD complain of not being able to take a deep breath or an increased effort to breathe. Patients with heart failure feel as though they are suffocating or have air hunger.33 Orthopnea (dyspnea while recumbent) suggests heart failure or sleep apnea. Coughing can be a symptom of heart failure, asthma, or COPD. Angina or a history of CAD may indicate heart failure. Anorexic drugs can cause pulmonary hypertension or valvular abnormalities. Connective tissue disease is associated with interstitial lung disease. On physical examination one should look for pallor, cyanosis, a barrel chest, rales, wheezing, crackles, murmurs, abnormal heart sounds or rhythms, an enlarged heart, tachycardia, jugular venous distention, joint involvement, clubbing, fibrotic skin changes, and edema. Patients with severe airflow obstruction may have pursed lips and a slow deep breathing pattern, and those with interstitial fibrosis or kyphoscoliosis typically have rapid shallow breathing. The preoperative history and physical examination lead to accurate diagnoses in two thirds of cases. Initial testing may include an ECG, hematocrit (to exclude anemia), arterial blood gas analysis, thyroid function tests, a chest radiograph, spirometry, and oximetry at rest and while walking several feet. BNP levels may be useful. Most dyspnea patients with heart failure have BNP values higher than 400pg/mL, whereas left ventricular dysfunction without exacerbation, pulmonary embolism, and cor pulmonale should be considered in dyspnea patients with plasma BNP concentrations between 100 and 400pg/mL. Other testing depends on findings on these tests and is directed by the history and physical examination. Computed tomography scans and cardiopulmonary exercise testing are rarely necessary but can be useful if the aforementioned tests are not diagnostic. Patients with Risk Factors for Postoperative Pulmonary Complications Postoperative pulmonary complications develop in 5% to 10% of patients undergoing nonthoracic surgery and in 22% of high-risk patients. As many as one in four deaths occurring within a week of surgery are related to pulmonary complications, thus making it the second most common serious morbidity after cardiovascular adverse events.50,51

Established risk factors for an increased risk for pulmonary complications include the following52: History of cigarette use (current or >40 pack-years) ASA-PS scores higher than 2 Age >70 years COPD Neck, thoracic, upper abdominal, aortic, or neurologic surgery Anticipated prolonged procedures (>2 hours) Planned general anesthesia (especially with endotracheal intubation) Albumin less than 3g/dL Exercise capacity of less than two blocks or one flight of stairs BMI greater than 30

Surprisingly absent predictors in this list are asthma and results from arterial blood gas analysis or PFTs. The risk for complications is surprisingly low in patients with well-controlled asthma or those treated preoperatively with corticosteroids.53 The risk is greater in asthmatics with recent exacerbations or a history of postoperative pulmonary complications or recent hospitalization or intubation for asthma. Arterial blood gas analysis is useful in predicting pulmonary function after lung resection surgery but does not predict risk for complications. The degree of airway obstruction, measured by FEV1, is not predictive of pulmonary complications.54 PFTs, arterial blood gas analysis, or chest radiographs should not be used routinely to predict the risk for postoperative pulmonary complications. PFTs may be indicated to diagnose disease (dyspnea caused by lung disease or heart failure?) or to assess management (can dyspnea or wheezing be improved further?) but should not be used as a risk assessment tool or to deny a beneficial procedure.54 Laboratory results and patient- and procedure-related determinants of risk for perioperative pulmonary complications have recently been reviewed in the literature.55 Some of these factors can be modified to alter risk. The pulmonary status of patients with recent exacerbations or infections should be improved whenever possible. Prescriptions for antibiotics, bronchodilators, and steroids, referral to pulmonologists or internists, and postponing surgery are important in patients at high risk. Training patients preoperatively in lung expansion maneuvers, such as deep-breathing exercises and incentive spirometry, reduces pulmonary complications more than training postoperatively does. Additionally, a change in perioperative management, including altering the planned surgical procedure if possible, discussing alternatives to general anesthesia, especially when peripheral nerve blocks are an option, and educating the patient about the benefits of epidural pain management, may provide effective measures to decrease pulmonary complications.56 Patients Scheduled for Lung Resection Most patients scheduled for lung resection surgery have underlying lung disease, and PFTs may be useful in predicting risk or excluding patients who may not have adequate pulmonary reserve after resection. This topic is covered more fully in Chapter 59. Pulmonary Hypertension Pulmonary hypertension may occur in isolation or with associated medical conditions and is classified into five groups (Box 34-6) according to the World Health Organization. Idiopathic

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Box 34-6 Classification of Pulmonary Hypertension Pulmonary Arterial Hypertension Primary pulmonary hypertension Sporadic Familial Associated with Collagen vascular disease Congenital shunts Portal hypertension Human immunodeficiency virus infection Drugs/toxins Persistent pulmonary hypertension of the newborn Pulmonary Venous Hypertension Left-sided heart disease Extrinsic compression of central pulmonary veins Pulmonary veno-occlusive disease Pulmonary Hypertension Related to Lung Disease or Hypoxemia Chronic obstructive pulmonary disease Interstitial lung disease Sleep-disordered breathing Neonatal lung disease Chronic exposure to high altitude Pulmonary Hypertension Caused by Chronic Thromboembolic Disease Pulmonary thrombosis or embolism Sickle cell disease Pulmonary Hypertension from Disorders Directly Affecting the Pulmonary Vasculature Schistosomiasis Sarcoidosis
Available from http://www.who.int/ncd/cvd/pph.html.

Dyspnea). Near syncope or syncopal episodes suggest severe disease. Hypoxia, hypercapnia, vasoconstrictors, and increased sympathetic tone (even from anxiety) increase pulmonary vascular resistance and lead to acute decompensation with right heart failure. Patients with pulmonary arterial hypertension have a high rate of perioperative morbidity and mortality.57 Mild pulmonary hypertension rarely affects anesthetic management, but moderate to severe disease increases the risk for right heart failure. Signs and symptoms of disease severity include58 Dyspnea at rest Metabolic acidosis Hypoxemia Right heart failure (peripheral edema, hepatomegaly, jugular venous distention) History of syncope

Section IV Anesthesia Management

pulmonary arterial hypertension, formerly called primary pulmonary hypertension, is rare, but other forms are more common and occur with a variety of diseases, including cardiac, pulmonary, liver, thromboembolic, and collagen vascular disease. Pulmonary hypertension is associated with HIV infection, exposure to anorexics such as fenfluramine, chronic liver disease, especially if portal hypertension is present, and collagen vascular diseases, including scleroderma, SLE, and rheumatoid arthritis. Pulmonary hypertension is defined as a persistent elevation in mean pulmonary artery pressure greater than 25mmHg with a pulmonary artery occlusion pressure of less than 15mmHg. Occult pulmonary hypertension is more problematic than fully recognized disease because symptoms may be attributed to other diseases and perioperative decompensation may occur unexpectedly. The manifestation of pulmonary hypertension is usually nonspecific, insidious, and associated with delayed diagnosis. Dyspnea is the initial symptom in 60% of patients but is present in 98% by the time of diagnosis. Dyspnea is nonspecific and associated with a multitude of conditions (see the section

Physical examination may reveal a split S2 with a loud second component, right ventricular heave, a murmur of tricuspid regurgitation, ascites, hepatomegaly, jugular venous distention, and peripheral edema. An echocardiogram is the screening test of choice and can used to estimate pulmonary artery pressure, assess right ventricular function, and identify left heart failure and valvular or congenital heart disease.59 Patients with significant findings may require right and left heart catheterization, although the need for catheterization preoperatively depends on the surgical procedure. An ECG, chest radiograph, and echocardiogram are useful in patients with more than mild disease. Findings on the ECG include right axis deviation, RBBB, right ventricular hypertrophy, and tall R waves in leads V1 and V2. Right atrial hypertrophy and P pulmonale may be present in severe pulmonary hypertension, with peaked P waves most apparent in leads II, III, aVF, and V1. Enlargement of the main pulmonary artery and a globular heart shape with loss of the retrosternal air space as a result of right ventricular dilation can be seen on the chest radiograph. Evaluators should inquire about a history of OSA, which can also be the cause of pulmonary hypertension.60 A CBC with platelets, electrolytes, BUN, creatinine, and liver function tests (LFTs; may be elevated as a result of congestion or the use of bosentan) are needed. Preoperatively, patients may be treated with diuretics, anticoagulants, calcium channel blockers, supplemental oxygen, sildenafil (a phosphodiesterase inhibitor), endothelin receptor antagonists (bosentan), and prostanoids (iloprost, epoprostenol). Some of these agents are given by continuous intravenous infusion, and even momentary interruption of therapy can be catastrophic. All drugs need to be continued preoperatively. Management of these patients in conjunction with a pulmonary hypertension specialist is advised. Smokers and Those Exposed to Second-Hand Smoke Exposure to tobacco, directly or through second-hand smoke, increases the risk for many perioperative complications. Smokers are more likely to experience wound infections, respiratory or airway complications (including oxygen desaturation), and severe coughing.61 Smoking decreases macrophage function, negatively affects coronary flow reserve, and causes vascular endothelial dysfunction, hypertension, and ischemia. Smokers require longer hospital stays than nonsmokers do and often need postoperative intensive care admission.

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The greatest benefit of smoking abstinence is probably realized only after several months of cessation. In studies reporting greater perioperative risk in recent quitters than in smokers, selection bias may have contributed to the results. Patients who were motivated to stop or advised to quit smoking may have been at greater risk because of health status. Soon after a patient quits smoking, carbon monoxide levels decrease, which improves oxygen delivery and utilization. Cyanide levels decrease, which benefits mitochondrial oxidative metabolism. Lower nicotine levels improve vasodilation, and many toxic substances that impair wound healing decrease. Patients without a history of ischemic heart disease who smoked shortly before surgery had significantly more episodes of rate-pressure productrelated STsegment depression than did nonsmokers, former smokers, or chronic smokers who did not smoke in the immediate preoperative period.62 A preoperative smoking cessation intervention in patients who underwent knee and hip replacement decreased rates of surgical site infection (SSI) from 23% in the conventional group to 4% in those who stopped smoking. The U.S. Public Health Service recommends that all physicians should strongly advise every patient who smokes to quit because evidence shows that physician advice to quit smoking increases abstinence rates.63 Nearly 70% of smokers want to quit. Effective interventions include medical advice and pharmacotherapy, such as nicotine replacement therapy, which is safe in the perioperative period (see Chapter 35). Nicotine patches, gum, and lozenges are available without a prescription; nasal spray and buproprion (Wellbutrin) require prescriptions. Clonidine is also effective. Buproprion or clonidine should be started 1 to 2 weeks before an attempt at quitting; nicotine replacement therapy is effective immediately.64 Individual and group counseling may increase rates of long-term abstinence. Many hospitals, insurance companies, and communities offer smoking cessation programs. Excellent resources are available on the Internet and from the U.S. government. Advice and guidelines are available at http://www.surgeongeneral.gov/tobacco/default.htm. Tobacco intervention training during medical school and residency can significantly improve the quality of physician counseling and rates of abstinence.

Endocrine Disorders (See also Chapter 35)


Diabetes Mellitus Type 1 diabetes is an autoimmune disease that results in destruction of pancreatic insulin-producing (beta) cells; patients have an absolute deficiency of insulin but normal sensitivity to insulin, are at risk for ketoacidosis, and generally have an onset of disease at a younger age. Because of the often-difficult nature of control and the long duration of disease, by the time that these individuals reach adulthood, they are at increased risk for premature vascular disease, especially myocardial ischemia, even in the second decade of life. Type 2 diabetes is initially a result of insulin resistance, which with time can result in pancreatic burnout, and is usually found in older, overweight adults. Using terms such as insulin dependent, noninsulin dependent, or adult onset is confusing and not recommended. In the United States, approximately 20 million persons have diabetes, with 1 million new cases diagnosed each year. In as many as a third of patients, the disease is diagnosed only after

significant diabetes-related complications develop. Unfortunately, the symptoms of diabetes are nonspecific, so the history, other than a family history of the disease, is not reliable in screening for the disease. However, patients who are overweight, have excessive abdominal fat (even if their BMI is normal), take steroids, or have polycystic ovarian syndrome are at increased risk. Certain ethnic groups (Native American, non-Hispanic black, Hispanic, and Asian American) have a higher incidence. Diabetes develops in females twice as commonly as in males. Diabetics are at risk for multiorgan dysfunction, with renal insufficiency, stroke, peripheral neuropathy, autonomic dysfunction, and cardiovascular disease being most prevalent. Delayed gastric emptying, retinopathy, and reduced joint mobility occur in these patients. Diabetes is considered a CAD equivalent and an intermediate risk factor for perioperative cardiac complications, on a par with angina or a previous MI.7 Diabetic patients without known coronary stenosis or angina have the same risk of myocardial ischemia or cardiac death as a nondiabetic with a previous MI.65 Autonomic neuropathy is the best predictor of silent ischemia. Erectile dysfunction has been shown to be a strong predictor as well. Poorly controlled blood glucose and longer duration of disease also correlate with cardiac risk. See the section Ischemic Heart Disease and Figure 34-2 for further guidance on this topic. Heart failure is twice as common in men and five times as common in women with diabetes as in those without diabetes. Poor glycemic control is associated with an increased risk for heart failure, and both systolic and diastolic dysfunction may be present. Diabetics are at increased risk for renal failure perioperatively and for postoperative infections. Recent studies suggest that tighter perioperative control may be warranted. Patients with poor preoperative management of glucose are likely to be more out of control intraoperatively and postoperatively. Aggressive management of hyperglycemia decreases postoperative complications. Chronic kidney disease is usually asymptomatic until quite advanced. Diabetes is responsible for almost half of the patients requiring dialysis in the United States. The combination of hypertension, diabetes, and age older than 55 years accounts for more than 90% of patients with renal insufficiency. Screening for kidney disease is accepted practice in patients with diabetes. Patients with poorly controlled diabetes are at risk for the development of stiff joint syndrome with reduced cervical mobility, which may influence airway management. The preoperative evaluation should focus on assessing organ damage and control of blood sugar. Cardiovascular, renal, and neurologic systems need close evaluation. Ischemic heart disease is often asymptomatic in diabetics. Inquiring about early satiety, erectile dysfunction, numbness in the hands and feet, and postprandial vomiting is important. Documenting pulses, skin breakdown, a sensory examination, and orthostatic vital signs (BP and HR both lying and standing) are important in most diabetics, especially those with long-standing disease or poor control. Patients with autonomic dysfunction or hypovolemia will have greater than a 20mmHg drop in systolic or greater than a 10mmHg decrease in diastolic BP pressure when assuming an upright position from recumbency. A preoperative ECG plus determination of electrolytes, BUN, creatinine, and blood glucose is recommended for all diabetic patients. Frequently, patients are not fasting when evaluated in a preoperative clinic, and relying on reported glucose values is

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problematic. If patients bring a diary of multiple glucose values at varying times of the day (preprandial and postprandial), one can estimate the adequacy of therapy. However, patients often will only randomly check am fasting blood glucose, which is likely to be lower because of an overnight fast than glucose values obtained later in the day. The glycosolated hemoglobin (HbA1c) level is not influenced by fasting and, if available, can identify those with poor control. The American Diabetes Association recommends a target HbA1c of less than 7%. Suggestions for hypoglycemic medication management on the day of surgery are discussed in Chapter 35. The goals of perioperative diabetic management include avoidance of hypoglycemia and marked hyperglycemia. The American College of Endocrinologists position statement recommends a target fasting glucose level of less than 110mg/dL in noncritically ill hospitalized patients.66 Thyroid Disease Thyroid hormones are important for metabolism and its regulation. Mild to moderate dysfunction probably has minimal impact perioperatively. Significant hyperthyroidism or hypothyroidism appears to increase perioperative risk. Hyperthyroid patients may have tachycardia, arrhythmias, palpitations, tremors, weight loss, and diarrhea. Hypothyroid patients may be hypotensive, bradycardic, and lethargic and exhibit weight gain, depressed cardiac function, pericardial effusions, and an impaired ventilatory response to hypoxia and hypercapnia. Symptoms and findings of both hypothyroidism and hyperthyroidism can be subtle and nonspecific, especially in the elderly. Patients may have goiters with related symptoms such as dysphagia, dyspnea, wheezing, and orthopnea. Graves ophthalmopathy or proptosis is more common in smokers. Patients taking amiodarone are at risk for hypothyroidism and require evaluation of thyroid function before surgery. Determination of medical therapy is important. Patients with a history of chronic thyroid disease need thyroid function tests before surgery. If symptomatology and therapy have not changed, tests within the 6 month before surgery are generally adequate. Thyroid-stimulating hormone (TSH) assays are best to evaluate for hypothyroidism. Measuring both free triiodothyronine (T3) and thyroxine (T4) and TSH is useful in hyperthyroid patients and avoids the confusion of protein-binding effects seen with total hormone levels. Elective surgery should be postponed until patients are euthyroid. Surgery, stress, or illness can precipitate myxedema or thyroid storm in patients with untreated or severe thyroid dysfunction. Preoperative consultation with an endocrinologist should be considered if surgery is urgent in patients with clinical thyroid dysfunction. Hyperthryoid patients should be treated with -blockers, antithyroid medications, and steroids if surgery is urgent. Chest radiography or computed tomography is useful to evaluate tracheal or mediastinal involvement by a goiter. Continuation of medications (thyroid replacement and antithyroid drugs such as propylthiouracil) on the day of surgery is important. Parathyroid Disease Parathyroid hormone regulates calcium, and most cases of hyperparathyroidism are discovered when an elevated calcium level is found incidentally during diagnostic testing. Primary hyperparathyroidism is caused by a primary disorder of the parathyroid glands (adenomas or hyperplasia). Secondary hyperparathyroidism is hyperplasia of the parathyroid gland caused by hyper-

phosphatemia and hypocalcemia from chronic renal failure. Tertiary hyperparathyroidism occurs when the parathyroid hyperplasia in secondary hyperparathyroidism functions autonomously and results in hypercalcemia. Hypercalcemia from parathyroid disease is associated with osteoporosis and bone loss. Rarely, the parathyroid glands can become so enlarged that they compromise the airway. Hypoparathyroidism is rare but can result from total parathyroidectomy. Hypercalcemia and hypo calcemia are discussed in the section on calcium disorders. Hypothalamic-Pituitary-Adrenal Disorders Corticotropin-releasing hormone is released by the hypothalamus and regulates adrenocorticotropic hormone (ACTH) from the anterior pituitary gland, which in turn regulates cortisol from the adrenal cortex. A key component is the negative-feedback suppression by endogenous or exogenous glucocorticoids. Cortisol secretion varies with the circadian rhythm, being highest in the morning and with stress, fever, hypoglycemia, and surgery. Surgery is one of the most potent activators of the hypothalamicpituitary-adrenal (HPA) axis. ACTH concentrations increase with incision and during surgery, but the greatest secretion of ACTH occurs during reversal of anesthesia, during extubation, and in the immediate postoperative period. Excess adrenal hormone results from glucocorticoid treatment of disorders such as asthma or inflammatory diseases or from pituitary or adrenal tumors. Cushings disease denotes the constellation of findings associated with a pituitary tumor; Cushings syndrome refers to the same findings resulting from either an adrenal tumor or hyperplasia, ectopic ACTH from neoplasms, or exogenous steroids. Preoperative findings on evaluation include significant hypertension, weight gain, myopathy, diabetes, moon facies, and a buffalo hump, which can influence airway management. Striae, virilization in females, and easy bruising are common. Exogenous steroids will suppress the adrenals, and the normal hypersecretion expected from stress or surgery will be blunted. Therefore, patients at risk will need steroid coverage, which is discussed in Chapter 35. An ECG and electrolyte and glucose levels should be obtained preoperatively for most surgical procedures. Despite bruising easily, patients have normal coagulation profiles. Adrenal insufficiency results from destruction of the pituitary or adrenal glands or from long-term administration of exogenous glucocorticoid. Tuberculosis and HIV infection can cause primary hypoadrenalism. Prednisone or its equivalent in doses of greater 20mg/day for longer than 3 weeks suppresses the HPA axis. The HPA axis is not suppressed with doses of less than 5mg/day of prednisone or its equivalent. Intermediate doses of steroids taken for longer than 3 weeks have equivocal effects on the HPA axis. The risk remains for up to 1 year after cessation of steroids. Patients with adrenal insufficiency exhibit weakness, weight loss, hypotension, orthostasis, hypovolemia, hyperpigmentation, and electrolyte abnormalities. Electrolytes and orthostatic vital signs should be evaluated. Serum cortisol and plasma ACTH can establish the diagnosis and cause of adrenal insufficiency in most cases. If the serum cortisol concentration is inappropriately low and a simultaneous plasma ACTH concentration is very high, primary adrenal insufficiency (primary adrenal disease) is the cause. Secondary (pituitary disease) or tertiary (hypothalamic disease) insufficiency is the diagnosis if both the serum cortisol and plasma ACTH concentrations are inappropriately low. However,

Section IV Anesthesia Management

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in more urgent situations one may not be able to wait for the ACTH results, so an ACTH stimulation test can be performed unless the diagnosis has been ruled out by a basal serum cortisol value in the upper end of the reference range or higher.67 Cosyntropin is synthetic ACTH and can be administered in either a high-dose or a low-dose test. The time of day is not important because in patients with adrenal insufficiency, the response to cosyntropin is the same in the morning and afternoon. A normal response to the high-dose (250 g as an intravenous bolus) ACTH stimulation test is a rise in serum cortisol concentration, measured after 30 to 60 minutes, to a peak of 18 to 20 g/dL or greater. Low-dose (1-g intravenous bolus) ACTH causes a rise in cortisol of 17 to 22.5 g/dL or greater after 20 to 30 minutes. For both tests, a subnormal response confirms the diagnosis of adrenal insufficiency, but further studies are necessary to establish the type and cause. Preoperative electrolytes should be evaluated and an ECG obtained if appropriate. Patients continue steroids on the day of surgery and may need supplementation with additional doses (see the section on medication). Aldosterone, which is produced by the adrenal cortex, regulates volume and electrolytes (absorption of sodium and chloride, secretion of potassium and hydrogen ions) and is controlled by renin-angiotensin, not the HPA axis. Multiple Endocrine Neoplasia Syndromes The multiple endocrine neoplasia (MEN) syndromes are rare, but recognition is important both for treatment and for evaluation of family members.68 MEN type II (MEN II) is subclassified into three distinct syndromes: MEN IIA, MEN IIB, and familial medullary thyroid cancer. Inheritance of MEN I and II is autosomal dominant. Hyperparathyroidism is the most common manifestation of MEN I, with almost 100% penetrance by 40 to 50 years of age. Hypersecretion of gastrin in MEN I in association with ZollingerEllison syndrome is often manifested as multiple peptic ulcers. The MEN1 gene has been identified, and therefore testing for MEN1 mutations is possible. There is little evidence that early, presymptomatic detection reduces morbidity or mortality in MEN I. Screening of asymptomatic family members can also be done by measurement of serum calcium because of the high penetrance of hyperparathyroidism in MEN I. An undiagnosed pheochromocytoma can cause substantial morbidity or even death during surgery. It is important to consider this preoperative diagnosis as a component of possible MEN II and, if present, remove the tumor before eliminating other endocrine tumors. Extra-adrenal pheochromocytoma is rare in MEN II, but bilateral adrenal disease is common. It is unusual for pheochromocytoma to precede the development of medullary thyroid carcinoma or be the initial manifestation of MEN II. Hyperparathyroidism in MEN IIA is often clinically occult. DNA testing is the optimal test in MEN II syndromes. In contrast to MEN I, in which the long-term benefit of early diagnosis by genetic screening is not well established, early diagnosis by screening of at-risk family members in MEN II kindreds is essential because medullary thyroid carcinoma is a life-threatening disease that can be cured or prevented by early thyroidectomy. Please refer to the appropriate sections in this chapter for discussion of the preoperative evaluation of patients with thyroid, hyperparathyroid, and pituitary diseases and pheochromocytomas.

Pheochromocytoma Tumors that arise from chromaffin cells of the adrenal medulla and sympathetic ganglia and secrete catecholamines are referred to as pheochromocytomas and extra-adrenal catecholaminesecreting paragangliomas (extra-adrenal pheochromocytomas), respectively.69 The term pheochromocytoma is often used for both types of tumors because of similar clinical findings and therapies. Pheochromocytomas are discovered when patients have symptoms, a family history, or discovery of an incidental adrenal mass. Approximately 3% to 10% of adrenal incidentalomas prove to be pheochromocytomas. The classic triad of symptoms is episodic headache, sweating, and tachycardia. Paroxysmal hypertension occurs in half of the patients. Many of the rest have what appears to be essential hypertension. Approximately 5% to 15% of patients have normal BP. Preoperative evaluation may demonstrate paroxysmal hypertension, which is a classic sign of pheochromocytoma; however, patients with this finding rarely have the disorder. Headache, which is variable in severity and duration, occurs in up to 90% of symptomatic patients. Sweating occurs in up to 60% to 70% of patients. Other symptoms include palpitations, dyspnea, weakness, and panic attacks (particularly with pheochromocytomas that produce an increase in epinephrine). Pallor, orthostatic hypotension, blurred vision, weight loss, polyuria, polydipsia, hyperglycemia, psychiatric disorders, cardiopulmonary dysfunction (especially with the initiation of -adrenergic blockers), and dilated cardiomyopathy are due to excess catecholamines. Marked hypertension has also been reported. Pheochromocytoma should be suspected in patients who have one or more of the following: Hyperadrenergic spells (nonexertional palpitations, diaphoresis, headache, tremor, pallor) Difficult-to-control hypertension A familial syndrome that includes catecholamine-secreting tumors (MEN II, neurofibromatosis 1, von Hippel-Lindau disease), often with bilateral disease A family history of pheochromocytoma An incidentally discovered adrenal mass Unusual BP response during anesthesia, surgery, or angiography Hypertension at a young age (e.g., <20 years old) Idiopathic dilated cardiomyopathy A history of gastric stromal tumor or pulmonary chondromas (Carneys triad) Preoperative measurements of urinary and plasma fractionated metanephrines and catecholamines generally establishes the diagnosis. The history and physical examination focus on the cardiovascular system and evaluation of vital signs, orthostatic BP, and findings of heart failure. An ECG and determination of electrolytes, BUN, creatinine, and glucose should be performed in all patients. Computed tomography, echocardiography, and cardiac consultation may be useful. A complete discussion of the anesthetic implications can be found in Chapter 35.

Renal Disease
The type and degree of impairment are important. Patients with renal dysfunction have many associated comorbid conditions that

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are generally related to the accompanying vasculopathy (see Chapters 18 and 45). Hypertension, cardiovascular disease, and electrolyte disturbances are most common. Chronic kidney disease (CKD) is defined as a decreased glomular filtration rate (GFR <60mL/min/1.73m2) for at least 3 months or significant proteinuria. Chronic renal failure is defined as a GFR of less than 15mL/min/1.73m2; acute renal failure (ARF) is a sudden decrease in renal function with a urine output of less than 0.5mL/kg/hr. End-stage renal disease (ESRD) is loss of renal function for 3 or more months. Diabetes accounts for almost half of all cases of ESRD, hypertension for more than a quarter, and the combination of these plus age older than 55 years predicts more than 90% of cases. Polycystic kidney disease (autosomal dominant 90% of the time) is the causative factor in 10% of cases of ESRD and can be associated with intracranial aneurysms and mitral valve prolapse. ARF may be reversible if precipitating factors are identified and corrected. Dividing ARF into prerenal, renal, and postrenal categories allows a systematic approach. Prerenal causes can often be differentiated by calculating the BUN-creatinine ratio. A ratio of 20 or greater suggests a prerenal cause, with hypovolemia or hypotension being most common. Fractional excretion of sodium (FENa) of less than 1% also suggests prerenal azotemia and can be calculated by the following formula: FE Na = PCr U Cr PNa U Na

Obstruction will result in dilated ureters and enlarged kidneys and is always in the differential diagnosis of ARF. Prompt identification with ultrasound leads to attempts to decompress the outflow tract. Rhabdomyolysis can cause ARF and is treatable. GFR decreases with age, and the renal reserve of a normal 80-year-old is less than half that of a 40-year-old. The creatinine level is often not an accurate indicator of renal function, especially in elderly individuals. A doubling of serum creatinine from 0.8 to 1.6mg/dL represents a halving of the GFR. The GFR can be reduced 50% or more without a rise in creatinine. Creatinine does not exceed the normal limits until the GFR has fallen below 50mL/min. The Cockcroft-Gault formula can be used to estimate GFR:

(140 Age) Weight ( kg )


Creatinine clearance = 72 Serum creatinine (mg dL ) (0.85 if female )

Online calculators to estimate renal function are available at www.nephron.com. Calculation of an eGFR can be done in elderly patients, those with an elevated serum creatinine, or individuals with other risk factors for CKD. Chronic renal disease is a significant risk factor for cardiovascular morbidity and mortality and is an ACC/AHA intermediate cardiac risk factor considered to be equal to angina, MI, or a history of known CAD. The annual incidence of death from CAD in patients with both diabetes and ESRD who require hemodialysis is 8.2%. A creatinine concentration of 2.0mg/dL or higher should trigger an assessment of cardiac risk under the ACC/AHA guidelines, simplified in Figure 34-2.7 See the section Ischemic Heart Disease for a more detailed discussion of these guidelines. Pericarditis, pericardial effusions, and diastolic and systolic dys-

function can be present. Valvular heart disease is common in patients undergoing maintenance dialysis. Abnormalities include valvular and annular thickening and, most significantly, calcification of the heart valves resulting in regurgitation or stenosis (or both).70 Mitral and aortic valve calcifications (40% and 55% of patients, respectively) and stenosis (11% to 13%) occur. Valvular calcifications progress to stenosis at an accelerated rate in dialysis patients.71 Systemic hypertension is almost ubiquitous but is generally easier to manage with initiation of dialysis. Pulmonary hypertension and increased cardiac output occur in many patients with an arteriovenous fistula. Renal failure results in anemia from lack of erythropoietin production by the kidneys, but in the present era of aggressive erythropoietin replacement, many of these patients have normal or high hematocrits, which actually increases morbidity and vascular events.30 Patients with CKD can have platelet dysfunction and increased bleeding despite a normal platelet count, prothrombin time (PT), and aPTT. Once on dialysis, patients are more prone to hypercoagulable states. Chronic metabolic acidosis is common but usually mild and compensated for by chronic hyperventilation. Patients may exhibit electrolyte and calcium abnormalities, pulmonary and peripheral edema, anemia, hypercholesterolemia, and hypoalbuminemia. Hyperkalemia is the most serious electrolyte disturbance. Hypocalcemia is common with dialysis, and eventually secondary and tertiary hyper parathyroidism develops. Chronically elevated troponin and creatine kinase levels are common in patients maintained on dialysis. Worsening renal function should be suspected in diabetics who have improved glycemic control or unexpected hypoglycemia because insulin is metabolized by the kidneys and has a prolonged duration of action with progressive renal dysfunction. Autonomic and peripheral (sensory and motor) neuropathies can occur. Patients at risk for perioperative renal failure include those with preexisting renal insufficiency (the single strongest predictor) or diabetes, especially in combination, and those undergoing procedures with the administration of contrast medium. If all three conditions are present, the risk of renal failure may be as high as 12% to 50%. Preoperative identification of at-risk patients alters management, such as hydration, administration of sodium bicarbonate, a change in the type of contrast medium, and avoidance of hypovolemia (see Chapter 65). This may require admission preoperatively. Nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase (COX-2) inhibitors interfere with autoregulation of renal perfusion and should be avoided or discontinued in patients with or at risk for renal insufficiency. Cyclosporine and aminoglycoside antibiotics can cause renal insufficiency. ACEIs and ARBs prevent deterioration in patients with diabetes or renal insufficiency but may worsen function during hypoperfusion states. Many drugs are metabolized or cleared by the kidneys. Drugs with particular implications for anesthesia and surgery are the LMWHs because there is no easy method of monitoring their anticoagulation effects. All the LMWHs available in the United States are cleared by the kidneys and are not removed during dialysis. Therefore, LMWH has a prolonged duration of action in patients with CKD. The risk of significant bleeding or hematomas with centroneuraxial anesthesia may be increased. Preoperative evaluation of patients with renal insufficiency or failure should focus on the cardiovascular and cerebrovascular systems, fluid volume, and electrolyte status. The early stages of

Section IV Anesthesia Management

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CKD typically cause no symptoms. Inquiring about the cardiovascular systems (chest pain, orthopnea, paroxysmal nocturnal dyspnea), urine output, associated comorbid conditions, medications, and dialysis schedules is vital. Understanding changes in patient weight is one method of assessing volume status. In patients with or at risk for renal disease (especially those with two of the following: diabetes, poorly controlled hypertension, advanced age), an ECG and determination of electrolytes, calcium, glucose, albumin, BUN, and creatinine should be performed if the results will have an impact on management. LVH (from hypertension), peaked T waves (hypokalemia), flattened T waves, and prolonged PR and QT intervals (hypokalemia) prompt further evaluation. A chest radiograph (infection or volume overload), echocardiogram (for murmurs or heart failure), and stress testing (see ACC/AHA guidelines) may be indicated in certain patients. Many of these patients will benefit from cardiology evaluation based on these tests as discussed earlier. Venous access or blood draws from the brachial, cephalic (antecubital), and central veins in the nondominant upper extremity should be avoided in patients who may need fistulas for dialysis in the future. Preoperative renal replacement therapy (dialysis) schedules should be determined, with scheduling of surgery ideally within 24 hours after dialysis. In elective cases, dialysis is best performed within 24 hours of surgery but not immediately before because of acute volume depletion and electrolyte alterations. Dialysis is associated with fluid and electrolyte (sodium, potassium, magnesium, phosphate) imbalance and shifting of electrolytes between the intracellular and extracellular compartments. Dialysis should be performed to correct volume overload, hyperkalemia, and acidosis. Coordinating the scheduling of dialysis and elective surgery is an important aspect of preoperative care. Contrast-Induced Nephropathy Contrast-induced nephropathy is defined as a 25% rise in creatinine above baseline after the administration of a radiocontrast agent (see Chapter 79). Patients with diabetes and CKD are at greatest risk, although radiocontrast media causes a transient decrease in the GFR in most individuals. Renal failure requiring dialysis after contrast-induced nephropathy is associated with less than a 20% 2-year survival rate, and a third of patients die during the initial hospitalization.

and E), or autoimmune diseases. All of these conditions have acute and chronic phases that can progress to cirrhosis, which is irreversible fibrosis of the liver. Risk factors for hepatitis are alcohol use, sexual activity (multiple partners, sex industry workers, sex with sex industry workers, or men who have sex with men), intravenous drug use, blood transfusions before 1992, travel to underdeveloped countries, obesity, tattoos, and body piercing. Hepatitis A is caused by contaminated food or water or contact with an infected person and rarely progresses beyond the acute illness. A remote history of hepatitis A has no significance perioperatively. Hepatitis B is transmitted by sexual activity or contact with blood (rarely from transfusions since screening was implemented in 1986). It varies in severity but is much less common since the widespread use of vaccination against this virus. Hepatitis C is caused primarily by blood exposure (blood has been screened since 1992), most often in intravenous drug users. Many patients are unaware of infection because the acute phase is frequently asymptomatic but can advance to cirrhosis. Hepatitis D occurs only with hepatitis B, and hepatitis E is rare in developed countries. Alcoholic hepatitis generally occurs after at least 10 years of daily moderate to heavy alcohol intake (>3 drinks/day for women; >5/day for men) and may progress to cirrhosis. Autoimmune hepatitis primarily affects young women and has no known cause. Virtually any drug, as well as herbals and over-thecounter preparations, can cause hepatitis, including statins, isoniazid, and acetaminophen. Obstructive Jaundice Extrahepatic bile duct obstruction is caused by gallstones, tumors (pancreatic, gallbladder, bile duct, ampulla of Vater), or scarring. Patients may have jaundice, pruritus, and abdominal pain. Predictors of surgical mortality are a preoperative hemocrit of less than 30%, bilirubin concentration greater than 11mg/dL, and malignancy, and death may occur in as many as 60% if all three are present.72 Renal failure develops in up to 8% of these patients postoperatively, which may be lessened with administration of bile salts or lactulose.73 Miscellaneous Liver Diseases Wilsons disease, hemochromatosis, and 1-antitrypsin deficiency are less common than hepatitis, are hereditary, and commonly occur in members of the same family. Obesity can result in nonalcoholic steatohepatitis, also known as fatty liver, which causes abnormal LFT results and can progress to fibrosis. Primary biliary cirrhosis is an autoimmune disorder that results in intrahepatic biliary obstruction; it occurs most frequently in middle-aged women and is associated with antimitochondrial antibodies. Primary sclerosing cholangitis destroys bile ducts, is most frequent in young males, is associated with inflammatory bowel disease but can be idiopathic, and may progress to cirrhosis. Acute illnesses such as sepsis, surgery, and anesthesia can cause hepatic dysfunction. Gilberts syndrome is a benign familial disorder with mildly elevated bilirubin and has no perioperative significance. Remote History of Hepatitis Patients may recount a history of having hepatitis many years before but little other information is known. One must take a careful preoperative history to determine circumstances surrounding the onset (e.g., transfusions, travel, exposure to risky situations) and whether any sequelae of chronic liver disease are present. It is important to clarify whether the episode occurred

Hepatic Disorders
Liver disease can affect hepatocytes, the biliary system, or both (see Chapters 17 and 66). Liver disease affects protein synthesis, including coagulation factors and albumin, drug and toxin metabolism, and bile regulation. Hepatocellular diseases, including viral, alcoholic, and autoimmune hepatitis or hepatocellular carcinoma, affect hepatocytes and synthetic function of the liver. Obstructive disorders, including choledocholithiasis and bile duct tumors (extrahepatic), primary biliary cirrhosis (intrahepatic), or primary sclerosing cholangitis (extrahepatic and intrahepatic), cause bile stasis. Most drug-induced liver disease and some forms of viral hepatitis affect both hepatocytes and the biliary system. Hepatitis Hepatitis is a term used to describe inflammation of hepatocytes and can be caused by drugs, alcohol, viruses (hepatitis A, B, C, D,

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during or soon after surgery. Although halothane is rarely used in adults in the United States today, those who previously had halothane hepatitis may be at risk for cross-sensitivity to other fluorinated volatile agents with trifluoroacetyl metabolites (enflurane, isoflurane, desflurane). Cirrhosis Cirrhosis is the end result of most hepatotoxic conditions. Portal hypertension with splenomegaly, varices, ascites, and pleural effusions occur. The liver fails to synthesize proteins and clotting factors or clear toxins and drugs. Patients may have encephalopathy, bleeding, thrombocytopenia, and a prolonged PT and are at risk for renal insufficiency or failure. Pulmonary shunting may cause hypoxemia and pulmonary hypertension. Hepatorenal syndrome is the occurance of renal insufficiency in patients with hepatic disease in the absence of primary renal disease and may be related to hypoperfusion. Jaundiced patients are at particular risk for hepatorenal syndrome. Spontaneous bacterial peritonitis may develop in patients with ascites and increases perioperative mortality. The Child-Turcotte-Pugh classification (Table 34-5) can predict perioperative morbidity and mortality. The Model for End-Stage Liver Disease (MELD) formula, which factors bilirubin, the international normalized ratio (INR), creatinine, and the cause of the liver disease, is used to select patients for transplantation, may be useful to predict risk for other surgery, and may do so better than the Child class.74 Online calculators to determine MELD can be found at www.unos.org. Higher scores indicate more severe disease. One study showed that a MELD score lower than 14 predicted 77% of patients with poor outcomes.74 Anemia increases postoperative mortality in patients with obstructive jaundice. One study did show that a serum albumin concentration of less than 2.1mg/dL was a strong predictor of mortality in veterans undergoing major noncardiac surgery.75 Unexpected Increased Liver Function Test Values Elevated alanine aminotransferase (ALT) and aspartate aminotransferase (AST) reflect damage to hepatocytes, bilirubin measures the livers ability to conjugate or excrete bile (or both), alkaline phosphatase rises with degradation of hepatic excretion (also from bone turnover and thus nonspecific for liver disease), and albumin and PT measure synthetic function of the liver. Only 1 in 700 preoperative patients is unexpectedly found to have liver disease, and the vast majority are not severe disorders. However, if abnormal LFT values are unexpectedly found, further testing or referral may be warranted. In patients with elevations in ALT
Table 34-5 Child-Turcotte-Pugh Classification Points (For Each with a Maximum of 15) Parameter Ascites Bilirubin (mg/dL) Albumin (g/dL) Prothrombin time (seconds over control) Encephalopathy 1 Absent <2 >3.5 <4 None 2 Slight 2-3 2.8-3.5 4-6 Grade 1-2 3 Moderate >3 <2.8 >6 Grade 3-4

or AST, screening for hepatitis with hepatitis A IgM antibody, hepatitis B surface and core antigens, hepatitis B surface antibody, and hepatitis C antibody can help in establishing a diagnosis. Elevated alkaline phosphatase or bilirubin with normal or mildly to moderately increased transaminases suggests obstruction of the biliary system, and abdominal ultrasound, computed tomography, and endoscopic retrograde cholangiopancreatography can establish a diagnosis. All Forms of Liver Disease The preoperative history often uncovers the cause of the liver disease, therapies, and associated complications. Important issues to explore include the cause and degree of hepatic dysfunction. Patients with liver disease may be asymptomatic or complain of fatigue, weight loss, dark urine, pale stools, pruritus, right upper quadrant pain, bloating, and jaundice. Weight and vital signs, including oxygen saturation, are needed. Physical examination may reveal jaundice, bruising, ascites, pleural effusions, peripheral edema, or hypoxia. The presence of encephalopathy, coagulopathy, ascites, volume overload, and infectivity needs to be determined and explored preoperatively. The bilirubin level is generally higher than 2.5mg/dL before icterus can be seen in mucous membranes and sclerae. Examination may reveal hepatomegaly, splenomegaly, and altered mental status. New-onset or worsening encephalopathy prompts an evaluation for precipitating factors such as worsening liver disease, infection, drug effects, bleeding, or electrolyte disturbances. In selected patients, preoperative evaluation may warrant further testing consisting of an ECG, CBC with platelet count, electrolytes, BUN, creatinine, LFTs, albumin, and PT. An ammonia level may be helpful in patients with encephalopathy. A chest radiograph may identify effusions. Coagulopathy can be a result of vitamin K deficiency caused by an inability to secrete bile (cholestatic disorders), deficiency of coagulation factors because of loss of synthetic function as a result of cirrhosis, or thrombocytopenia secondary to splenomegaly and portal hypertension. Therapy to correct coagulopathy is directed at the cause. Vitamin K, fresh frozen plasma, or platelets are used to correct deficiencies. Vitamin K, 1 to 5mg orally or subcutaneously daily for 1 to 3 days, may correct a prolonged PT and carries minimal risk. However, the coagulopathy in patients with synthetic failure will probably not correct with such measures, and performing a type and screen will prepare the patient for platelet and fresh frozen plasma transfusions with the goal of achieving a platelet count higher than 50,000/mm3 and an INR less than 1.5, respectively. Correction of anemia is controversial but may limit renal dysfunction. Lactulose (30mL orally every 6 hours for 3 days before surgery with the last dose given within 12 hours of surgery) or oral bile salts with intravenous hydration beginning the night before surgery may reduce perioperative progression of renal disease in patients at risk.76 Reduction of ascites preoperatively may decrease the risk of wound dehiscence and improve pulmonary function. Sodium restriction (in diet and intravenous solutions), diuretics (especially spironolactone, which inhibits aldosterone), and even paracentesis are useful. If fluid is aspirated, it is important to analyze it for infection. Encephalopathy is frequently caused by an acute insult such as infection, gastrointestinal bleeding, hypovolemia, or sedatives. It is important to determine reversible factors and treat accordingly. Lactulose, 30mL every 6 hours orally, is first-line therapy. Addressing nutritional deficiencies with enteral or parenteral supplementation

Section IV Anesthesia Management

Class A: <7 points; Class B: 7-9 points; Class C: >9 points.

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may have benefit, especially in alcoholic patients. Patients who abuse alcohol are at risk for neurologic deterioration if thiamine, folate, and vitamin B12 supplements are not provided, particularly when nutrition or glucose is given. These patients are also at risk for alcohol withdrawal syndromes (see the appropriate section). Delaying elective surgery until after an acute episode of hepatitis or an exacerbation of chronic disease has resolved or until a diagnosis is established if hepatic dysfunction is newly detected is appropriate.74 Elective surgery is contraindicated in patients with acute or fulminant liver disease, including alcoholic (mortality >55%), viral (mortality >10%), or undefined hepatitis. Perioperative risk in patients with chronic hepatitis or cirrhosis is predicted by its histologic severity (bridging or multilobular necrosis on biopsy), impairment of the synthetic and excretory functions of the liver, and portal hypertension (ascites, varices, bleeding). Patients with severe liver disease have increased perioperative morbidity and mortality.77 Perioperative management is discussed in Chapter 66. The most common adverse events are bleeding, infection, liver failure, and hepatorenal syndrome (renal failure in patients with portal hypertension but otherwise normal kidneys).

ation should be done by a primary care physician or hematologist, but initial studies include a peripheral smear, determination of mean corpuscular volume (MCV), a reticulocyte count, and further testing such as iron studies, vitamin B12, or folate levels, depending on the findings on the smear and the MCV. MCV, iron, and ferritin are low and total iron-binding capacity (TIBC) is high in iron deficiency anemia. MCV and TIBC are low or normal and iron and ferritin are normal or high in anemia associated with chronic disease. MCV is high and vitamin B12 or folate levels are low in macrocytic anemia associated with these deficiencies. Type and screening and preoperative transfusion may be necessary, depending on the level of anemia and anticipated surgical blood loss. In special circumstances, such as a patients refusal of perioperative blood transfusion or elective procedures with expected significant blood loss in anemic patients, postponement of surgery to treat with recombinant human erythropoietin and iron may be warranted. Sickle Cell Disease Sickle cell disease, a hereditary hemoglobinopathy with vasoocclusion, is responsible for most of the associated complications. Patients homozygous for hemoglobin S (HbS) have disease and are at risk for major morbidity and a shortened life expectancy. Patients with SC disease have both HbS and HbC and a much less severe clinical course with moderate anemia. Heterozygous patients (HbS and HbA) have sickle cell trait and rarely have any consequences related to this condition. Preoperative assessment should focus on identification of organ dysfunction and acute exacerbations.80 Patients may have renal insufficiency, spleno megaly, pulmonary hypertension and infarction, cerebrovascular accidents, and heart failure. They are at increased risk for infection because of splenic infarction. Frequent hospitalizations or a recent increase in hospitalizations, advanced age, preexisting infections, and pulmonary disease are predictive of perioperative vaso-occlusive complications.79 The preoperative history and physical examination should focus on the frequency, severity, and pattern of vaso-occlusive crises and the degree of pulmonary, cardiac, renal, and central nervous system damage. Pulse oximetry, hematocrit, measurement of BUN and creatinine, an ECG, and a chest radiograph should be considered. Additional testing (e.g., echocardiogram, arterial blood gases) may be needed in rare instances. Prophylactic transfusion may be beneficial, especially before intermediateto high-risk cases. Preoperative prophylactic transfusion is controversial, and the decision to transfuse should be made in concert with a hematologist familiar with the disease. The Cooperative Study of Sickle Cell Disease concluded that preoperative transfusion was beneficial, although patients undergoing low-risk surgery had few complications even without transfusion.80 Another study showed that a conservative transfusion regimen (decreasing HbS to <60% and hemoglobin to 10g/dL) was as effective as a more traditional approach (transfusing to decrease HbS to <30% and hemoglobin to 10g/dL). Additional benefits included fewer transfusion-related complications.81 Glucose-6-Phosphate Dehydrogenase Deficiency Glucose-6-phosphate dehydrogenase deficiency is an X-linked hereditary Coombs-positive hemolytic anemia. Hemolysis occurs with exposure to drugs (antipyretics, nitrates, sulfonamides), infections, hypoxia, hypothermia, blood products, or stress. The

Hematologic Disorders
Anemia Anemia may be a known problem or a suspected possibility based on a patients history of underlying medical conditions or the reason for surgery. It is useful to determine the etiology, duration, and stability of the anemia, related symptoms, and therapy (especially transfusions), although the evaluation needs to consider the extent and type of surgery, the anticipated blood loss, and the patients comorbid conditions that may influence oxygenation or be affected by hypoxia, such as pulmonary, cerebrovascular, or cardiovascular disease. Inquiring about a personal or family history of anemia is important. The World Health Organization defines anemia as a hemoglobin level lower than 13g/dL in adult men and less than 12g/dL in adult women. The consequences of moderate levels of anemia and hemoglobin levels of 6.0g/dL or higher in patients without CAD are minimal. The ASA Task Force on Blood Component Therapy concluded that red blood cells should not be transfused solely because of a hemoglobin level but rather because of risk for complications from inadequate oxygenation (see Chapter 55).78 A recent Veterans Affairs study suggests that even mild preoperative anemia increases postoperative mortality and cardiac morbidity, but only in men.31 This study found that individuals with hematocrits between 39% and 51% had the lowest risk for adverse outcomes. Preoperative patients at risk for anemia include those with a history of colon cancer, gastrointestinal or genitourinary bleeding, metrorrhagia, chronic infections, inflammatory diseases, nutritional deficiencies (including gastric bypass recipients), and a host of other conditions. Anemia is the most common preoperative hematologic disorder. An important component of the history and physical examination includes asking about palpitations, fatigue, chest pain, black or bloody stools, weight loss, pallor, murmurs, hepatospenomegaly, or lymphadenopathy. Preoperative evaluation of patients with anemia or suspected anemia will benefit from a CBC. Generally, further evalu-

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severity of the hemolysis varies among patients and the offending agent or condition. Steroids are usually effective. The preoperative history focuses on previous episodes of hemolysis, identification of predisposing factors, and determination of the current hematocrit. Coagulopathies Hypocoagulable states are either inherited disorders such as the hemophilias and thrombocytopenia or are acquired disorders secondary to liver disease, malnutrition, or drug exposure. To determine the diagnosis and risk of bleeding, one inquires about known diagnoses, tests, treatments, previous bleeding episodes, and family history. Asking about excessive bruising, prolonged bleeding after cuts, heavy menstrual cycles, and bleeding gums is sensitive but not specific. A change in one of these factors is more meaningful than a chronic history becauses what one individual considers excessive may actually be normal. The preoperative evaluation inquires into excessive bleeding after previous procedures or childbirth, especially if transfusions were unexpectedly required; such bleeding is more definitive but not diagnostic. Petechiae, multiple bruises, hematomas, jaundice, and frank bleeding are important findings. Diagnostic testing may include a platelet count, CBC, PT, and aPTT. Routine screening for coagulopathies with a PT, aPTT, or a bleeding time without an indication is not indicated. If specific causes of bleeding are suspected or known, such as liver disease or malnutrition, targeted testing with liver enzyme, protein, and albumin levels and a PT is needed. In the case of a prolonged PT without a history of warfarin use, the most common cause is laboratory error, liver disease, or malnutrition. One should first repeat the test. If the test is abnormal again, referral to a hematologist or the primary care physician or evaluation of liver enzymes and a hepatitis panel may be warranted, depending on the surgery. A trial of vitamin K (1 to 5mg orally once a day for 3 days) can be initiated. A prolonged aPTT can result from both hypocoagulable and hypercoagulable conditions. The first step is to repeat the test and ascertain exposure to heparin. Even small amounts of heparin present in indwelling catheters, especially if the blood is drawn from that site, can prolong the aPTT. The most common cause of a prolonged aPTT other than heparin exposure is von Willebrands disease (vWD), but other hemophilias discussed later can prolong the aPTT. Factor V Leiden, anticardiolipin antibody, and lupus anticoagulants, which result in increased clotting, cause prolongation of the aPTT. Further testing for a prolonged aPTT includes a repeat aPTT; an aPTT mixing study; lupus anticoagulant; evaluation of coagulation factors VII, IX, XI, and XII; and checking von Willebrand factor (vWF) antigen and ristocetin cofactor levels. A mixing study, in which normal blood is mixed with the subjects blood, will detect factor deficiencies (the aPTT will correct with this test) or inhibitors (the aPTT will not correct). Hemophilias Hemophilia A (factor VIII deficiency) and hemophilia B (or Christmas disease) are X-linked recessively inherited disorders that occur almost exclusively in males. Hemophiliacs have a prolonged aPTT and normal PT. The severity of bleeding varies among individuals but tends to be similar in relatives and is directly related to the degree of factor deficiency. Even mild trauma can result in significant hemorrhage. Orthopedic procedures account for 50% of operations in hemophiliacs because

recurrent bleeding destroys joints. Hemophilia A accounts for 85% of all cases of hemophilia. A hematologist should be involved in the perioperative care of these patients. A detailed plan to monitor and replace deficient factors is paramount. Typically, factors VIII and IX are maintained at 75% to 100% in the immediate perioperative period and then at 50% until any risk of bleeding is past. Each unit of recombinant or purified factor concentrate raises the factor level by 2% per kilogram. Intramuscular injections are to be avoided. Von Willebrands Disease vWD is an inherited disorder of factor VIII and vWF that affects both genders. It is the most common congenital coagulopathy and is estimated to occur in 1% of individuals.82 Several types (1, 2A, 2B, 2M, and 2N) are autosomal dominant, and type 3 is recessive. Factor VIII and vWF circulate as a complex, and vWD results from both quantitative and qualitative deficiencies. Most patients have a prolonged aPTT, but those with mild disease may have a normal aPTT. The most common cause of a prolonged aPTT in patients not taking heparin is vWD. vWD is diagnosed by measuring ristocetin cofactor (a functional assay for vWF that causes platelet aggregation in the presence of ristocetin), vWF antigen, and factor VIII. vWF is an acute-phase reactant that increases with certain conditions such as stress or surgery, which sometimes makes the diagnosis difficult. Most patients with vWD will have a history of bleeding, but in some the diagnosis will not be made until a second challenge to coagulation occurs, including major surgery or exposure to drugs such as aspirin or NSAIDs. Involvement of a hematologist in the care of these patients is beneficial. Desmospressin (1-desamino-8-d-arginine vasopressin [DDAVP]) increases release of factor VIII, vWF, and plasminogen activator from endothelial cells. An intravenous dose of 0.3 g/kg (given over a period of 15 to 30 minutes to avoid hypotension, flushing, and tachycardia) typically raises vWF threefold to fourfold. However, there is considerable variation among individuals, so vWF and factor VIII levels must be monitored. Desmopressin is available as a nasal spray and should not be given more frequently than every 48 hours to avoid depletion of endothelial stores. To avoid release of plasminogen activator by desmopressin, -aminocaproic acid or tranexamic acid is given. Desmopressin is contraindicated in patients with type 2B because it increases abnormal vWF and may result in thrombocytopenia. Cryoprecipitate or factor VIII concentrates containing vWF will replace abnormal vWF. Thrombocytopenia Thrombocytopenia is a platelet count lower than 150,000/mm3 and results from decreased production, increased destruction, or sequestration. Malignancies, drugs, autoimmune disorders, preeclampsia, hereditary disease, and disseminated intravascular coagulation can cause thrombocytopenia. In patients found to have low platelet counts unexpectedly, first repeat the test, examine the peripheral smear, and collect blood for a platelet count in a tube without ethylenediaminetetraacetic acid (EDTA). EDTA is a chelating agent added to tubes commonly used for determination of the CBC because it prevents clotting. However, in some patients it causes clumping of platelets resulting in pseudothrombocytopenia. Recent exposure to heparin raises the issue of heparininduced thrombocytopenia (HIT), which generally occurs within

Section IV Anesthesia Management

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5 to 10 days after exposure to heparin.83 HIT is an immune-mediated disorder with antibodies directed against platelets and can result in arterial or venous thrombosis, stroke, amputations, and death in up to 30% of patients. Immediate discontinuation of heparin and testing for heparin-induced platelet antibodies are indicated. LMWH is less likely than unfractionated heparin to cause HIT but is contraindicated in patients with HIT. Alternative anticoagulants are danaparoid sodium, lepirudin, and argatroban. Idiopathic thrombocytopenic purpura is a chronic autoimmune disorder with autoantibodies against platelets that results in increased destruction. Patients are treated with corticosteroids and splenectomy (to eliminate the major site of platelet removal). Patients often have minimal bleeding at even very low platelet levels, probably because of increased turnover and a predominance of young platelets. Surgery can be performed safely in patients with platelet counts higher than 50,000/mm3. The risk of bleeding is inversely related to platelet counts lower than 50,000/mm3. Anemia, fever, infections, and drugs that affect platelet function increase bleeding at any platelet level. Centroneuraxial anesthesia is safe with platelet counts higher than 100,000/mm3.84 Patients with newly discovered thrombocytopenia may benefit from hematology consultation before elective surgery. One unit of platelets transfused typically raises the count by 10,000/mm3. Thrombocytosis Thrombocytosis is a platelet count greater than 500,000/mm3 and may be physiologic (exercise, pregnancy), primary (myeloproliferative disorder), or secondary (iron deficiency, neoplasm, surgery, chronic inflammation). Platelet counts greater than 1,000,000/ mm3 place patients at risk for thrombotic events such as stroke, MI, pulmonary and mesenteric emboli, and peripheral arterial and venous clots. Patients with primary thrombocytosis (essential thrombocythemia) have a bleeding tendency that is worsened by exposure to drugs such as aspirin. Older patients and those with a previous history of bleeding or thrombosis may be at increased risk. Hydroxyurea, anagrelide (these drugs decrease production, so 7 to 10 days is needed), or plasmapheresis (removes platelets, so the effect is immediate) may be used to lower the platelet count. Treatment of the underlying disorder of secondary causes of thrombocytosis usually results in normalization of the platelet count. Polycythemia Polycythemia is a hematocrit greater than 54% and can be primary (polycythemia vera) or secondary to chronic hypoxia (COPD, high altitude, congenital heart disease). A steep increase in blood viscosity, which is thrombogenic, occurs with hematocrits higher than 50%. High hematocrits are associated with increased atherosclerosis (carotid stenosis, stroke) and cardiovascular disease (heart failure, MI). There are contradictory reports on whether polycythemia increases perioperative risk. A recent study showed an increase in postoperative mortality in men but not women with hematocrits higher than 51%.31 However, an earlier report found no increased perioperative complications in patients with secondary polycythemia. The preoperative evaluation (history and physical examination) focuses on the pulmonary and cardiovascular systems. Examination for cyanosis, clubbing, wheezing, and murmurs is necessary. Oxygen saturation, an ECG, and possibly arterial blood gas analysis and a chest radiograph are needed in patients with

polycythemia. An unexpected preoperative finding of polycythemia should prompt an investigation to find the cause and, if not readily apparent, the possibility of polycythemia vera. Risk of Thromboembolism or Pulmonary Emboli Fatal pulmonary embolism occurs in 0.1% to 0.8% of patients undergoing elective general surgery, 2% to 3% of patients having elective hip replacement, and 4% to 7% of patients undergoing repair of a fractured hip who do not receive prophylaxis. The risk for venous thrombosis is increased in patients with previous venous thromboembolism, obesity, varicose veins, diabetes, cancer, heart failure, pregnancy, paralysis, the presence of an inhibitor deficiency state, or age younger than 50 years.85 Factor V Leiden is the most common cause of inherited thrombophilia (40% to 50% of cases). The prothrombin gene mutation and deficiencies in protein S, protein C, and antithrombin account for most of the remaining cases. The risk of perioperative venous thromboembolism depends on the surgical procedure (e.g., degree of invasiveness, trauma, and immobilization) and patientrelated variables (e.g., inflammatory bowel disease, acute illness, smoking, malignancy, obesity, increasing age, previous thromboembolism, estrogen use, hypercoagulable state).86 Primary thromboembolic prophylaxis is beyond the scope of this chapter, but it is important to risk-stratify patients preoperatively so that appropriate measures can be implemented on the day of surgery. Because of the high risk of thromboembolism in patients undergoing elective lower extremity joint replacement, these patients are often given a dose of warfarin the night before surgery. American Society of Regional Anesthesiologists guidelines specifically state that if a single dose of warfarin has been administered within the previous 24 hours, it is safe to perform neuraxial anesthesia.87 Recent arterial or deep venous thromboembolism (DVT) requires perioperative interventions or postponement of nonlifesaving procedures. Without anticoagulation, the risk for recurrent DVT within 3 months of a proximal DVT is approximately 50%. A month of warfarin treatment reduces the risk to 10%, and 3 months reduces it to 5%. Patients with a hereditary hypercoagulable state (e.g., antithrombin III or protein C or S deficiency, prothrombin gene mutation, Factor V Leiden), cancer, or multiple episodes of DVT are at higher risk indefinitely. Patients with nonvalvular atrial fibrillation who have had a previous cerebral embolism are also at higher risk. Patients with mechanical heart valves, especially multiple valves, are at risk for embolism. Risk is greater with mitral than with aortic valves. Surgery increases the risk for DVT, but there is no such evidence that surgery increases the risk for arterial embolism in patients with atrial fibrillation or mechanical valves.84 Preoperative evaluation determines whether bridging with either unfractionated heparin intravenously or LMWH subcutaneously as an outpatient (or not to bridge) is warranted for patients with mechanical heart valves or previous episodes of thromboembolism secondary to atrial fibrillation. The decision needs to be made in concert with the treating physician or a cardiologist. The authors believe that elective surgery should be postponed in the first month after an episode of venous or arterial thromboembolism. If postponement is not possible, the patient should receive preoperative heparin while the INR is below 2.0.84 Ideally, 3 months of anticoagulation is recommended before elective surgery. Typically, withholding warfarin for 5 days will allow

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the PT/INR to fall to normal if the INR is chronically maintained between 2.0 and 3.0, the usual therapeutic targets. It may be necessary to withhold more doses if the INR is more prolonged or fewer doses if subtherapeutic. Therefore, it is necessary to check the INR during the preoperative visit to guide cessation of therapy. During the time without warfarin, patients may be at risk for recurrent thromboembolism, but the risk is relatively small in all but the highest-risk patients. It is controversial whether patients require bridging or heparin during this period. Previously, the only option was hospital admission for intravenous heparin therapy, which is costly. However, with the availability of LMWH, patients can receive subcutaneous (usually self-administered) LMWH at home without the need for monitoring.

Neurologic Disease
In patients with neurologic disease, a detailed history is required with a focus on recent events, exacerbations, or evidence of poor control of the medical condition. Information about previous investigations or therapy is important. A basic preoperative neurologic examination documenting deficits in mental status, speech, cranial nerves, gait, and motor and sensory function is important. This baseline determination allows comparison of new deficits postoperatively. Cerebrovascular Disease If a stroke or transient neurologic deficit has not been fully evaluated or has occurred recently, elective surgery should be considered pending complete evaluation because a history of stroke or symptoms of cerebrovascular insufficiency are strong predictors of perioperative stroke.88 High-quality data are lacking on how soon after an event anesthesia and surgery are safe. The etiology and treatment guide further perioperative management. An embolic stroke from a patent foramen ovale (PFO) may require correction of the PFO or strict attention to avoidance of air emboli. A left atrial or ventricular thrombus or an embolic stroke secondary to atrial fibrillation or mechanical heart valves requires a minimum of 1 month and preferably 3 months of anticoagulation and possible bridging with short-acting anticoagulants for elective surgery.84 Atrial fibrillation (either chronic or new onset) is a common cause of perioperative stroke, especially those occurring postoperatively, the most common time for stroke.89 Asymptomatic Bruit A newly discovered carotid bruit requires a careful searching for symptoms of cerebral ischemia or transient ischemic attack, especially if the procedure is likely to involve manipulation of the neck or the patient has a potentially difficult airway. Frequently, patients will not have volunteered pertinent symptoms until specifically probed, especially if they were transient. Patients with risk factors for carotid atherosclerosis, including those who have undergone head and neck irradiation, especially at a younger age, need to be questioned specifically about amaurosis fugax, dysphagia, dysarthria, and other symptoms of cerebovascular insufficiency. One of the authors met a college professor in the preoperative clinic who was scheduled for an abdominal procedure and had a history of Hodgkins lymphoma as a teenager. After a carotid bruit was ausculated, the patient confirmed receiving mantle irradiation for her lymphoma, but it took much probing to elicit a history of two transient episodes of slurred speech within the previous month.

The patient was found to have 99% occlusion of her left internal carotid artery. In patients who have truly asymptomatic bruits, significant carotid lesions are present 40% to 60% of the time, the risk of stroke in this group is 1% to 2% per year, and most strokes are preceded by transient symptoms.90 A significant prospective, randomized multicenter trial found that patients with asymptomatic carotid stenosis of 60% or greater benefited from revascularization if they were considered good risk and the surgeon had a 3% or lower perioperative morbidity and mortality rate.91 However, after reviewing the published data, a more recent Symposium on Cerebrovascular Diseases concluded that because progression rates are extremely slow and patients with carotid stenosis are at substantial risk for MI and vascular death, revascularization should be contemplated only in centers with low complication rates for medically stable patients, those expected to live at least 5 years with 80% or greater stenosis.90 There is no evidence that truly asymptomatic bruits increase the risk for perioperative stroke. Carotid Doppler ultrasound studies are simple effective tools to evaluate at-risk patients who might benefit from further evaluation. Significant abnormalities on Doppler studies should prompt referral to a vascular surgeon or neurologist. Seizure Disorder The type and frequency of seizures (e.g., grand mal or absence) and the specifics of symptoms such as staring or focal findings are important to ascertain and document. Absence (previously petit mal) seizures may be particularly difficult to recognize because they lack generalized motor signs. More typical symptoms such as staring and obtundation may be misinterpreted as residual anesthetic effects in the postoperative period. Brain tumors, aneurysms, arteriovenous malformations (AVMs), classic epilepsy, drug toxicity, electrolyte disorders, infections, and vascular disease from arteriosclerosis, stroke, sickle cell disease, or SLE can all cause seizures. Preoperative evaluation and documentation of anticonvulsants and the adequacy of seizure control are necessary. Routinely ordering tests for serum drug levels of anticonvulsant medications is not indicated unless toxicity is a concern or the patient is having breakthrough seizures. Patients with good control of seizures may have levels outside the therapeutic range, and the results may be confounded if the timing of administration of the drugs in relation to when the blood is drawn is not considered. Generally, trough levels are necessary for accurate interpretation. Medications to control seizures have multiple side effects (bone marrow suppression, macrocytic anemia, leukopenia, hyponatremia), and testing should be directed at suspected abnormalities. A CBC with a platelet count and electrolyte levels are most commonly obtained. Poorly controlled or new-onset seizures require consultation with a neurologist before proceeding with anything other than emergency surgery. Continuation of anticonvulsants in the perioperative period is necessary. Multiple Sclerosis Multiple sclerosis is thought to be an inflammatory immune disorder with two general patterns of disability: exacerbating-remitting and chronic progressive.92 Symptomatology can include ataxia, motor weakness, sensory deficits, autonomic dysfunction, emotional lability, bladder or bowel dysfunction, and visual disturbances. Exacerbations can be triggered by stress, infections, the peripartum, and elevated temperatures. Varieties of treatments

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have been evaluated, including steroids, immunosuppressants, monoclonal antibodies, plasmapheresis, benzodiazepines, and baclofen. Preoperatively, it is important to document the history and pattern of disease, including symptoms and physical deficits, with special emphasis on respiratory compromise. Medications and previous triggers are important. There has been no documented association with the type of anesthetic or particular anesthetic agents and exacerbation of disease. Regional anesthesia may offer advantages for patients with respiratory compromise or cognitive dysfunction. Detailed documentation of preexisting neurologic deficits is important. Determination of oxygen saturation is needed. Testing is directed toward possible medication effects (e.g., azathioprine can suppress bone marrow and affect liver function, cyclophosphamide may cause electrolyte abnormalities, and steroids can cause hyperglycemia) and associated disturbances (e.g., chest radiography and white blood cell count if pulmonary infection is suspected). Patients with minor, stable disease require no special testing. Medications are continued on the day of surgery. Aneurysms and Arteriovenous Malformations Cerebral and spinal vascular lesions consist of aneurysms and AVMs, which may be intact or ruptured, symptomatic, or an incidental finding (see Chapter 63). Patients with polycystic kidney disease, fibromuscular dysplasia, type IV Ehlers-Danlos syndrome, or a family history of aneurysms are at increased risk for aneurysms. An AVM may be large enough to cause a mass effect. Pregnancy increases the risk for aneurysmal and possibly AVM bleeding. Before rupture, most patients will have minimal symptoms other than headache or seizures, but it is important to document complaints in all patients. With rupture, altered mental status, syncope, increased intracranial pressure with the typical signs and symptoms, inappropriate secretion of antidiuretic hormone, and hemodynamic perturbations are common. Bradycardia, tachycardia, ectopic beats, and ST-T wave changes, often mimicking those seen with ischemia, are common. Significant cardiac dysfunction with depressed contractility and wall motion abnormalities can be present on echocardiography. Preoperatively, concomitant CAD or preexisting cardiomyopathy should be considered and it not be assumed that these changes are related only to the bleeding. A preoperative ECG with determination of electrolytes, glucose, BUN, and creatinine is necessary. Chest radiography and echocardiography may also be helpful. Parkinsons Disease Parkinsons disease is a degenerative disorder of the basal ganglia in which failure of dopamine secretion results in diminished inhibition of the extrapyramidal motor system.93 Preoperative patients typically have diminution of spontaneous movements, rigidity (cogwheel rigidity is classic), resting tremor, masked facies, difficulty speaking and walking, and frequently depression and dementia. Autonomic dysfunction with orthostatic hypotension, excessive salivation, and difficulty regulating temperature also occurs. Patients are at risk for pulmonary complications because of difficulty swallowing and altered mental status and have an increased risk of aspiration and dysfunction of ventilatory muscles. Replacement of dopamine with levodopa, often combined with carbidopa, anticholinergic agents, bromocriptine, amantadine, and selegiline, is standard treatment. Levodopa can cause dyskinesias (dystonic and myoclonic involuntary move-

ments). Pergolide, a dopamine receptor agonist, was recalled in early 2007 because of an increased risk for mitral and aortic regurgitation.94 Patients exposed to this drug need a careful examination for murmurs and, if present, require an ECG and may require an echocardiogram. Selegiline is a monoamine oxidase inhibitor that inhibits dopamine degradation. Metoclopramine, phenothiazines, and butyrophenones may exacerbate symptoms by interfering with dopamine. Preoperative evaluation focuses on the pulmonary system and degree of disability, especially dysphagia and dyspnea. Determination of room-air saturation and orthostatic BP and HR is important. Significant pulmonary symptoms, especially symptoms of infection or if worsening, may require a chest radiograph, pulmonary consultation, and delay of the procedure for improvement. Patients who have taken pergolide need auscultation for murmurs and, if present, may benefit from an ECG and echocardiogram. Deep brain stimulators need to be deactivated before procedures in which electrocautery will be used. All parkinsonian medications are continued. Abrupt withdrawal of levodopa may exacerbate symptoms, epecially dysphagia and chest wall rigidity, or result in neuroleptic malignant syndrome (NMS). NMS is characterized by autonomic instability, altered mental status, rigidity, and fever. Neuromuscular Junction Disorders Myasthenia gravis is an autoimmune disorder of skeletal muscle neuromuscular junctions that is due to antibodies against nicotinic acetylcholine receptors.95 It is characterized by muscle weakness that worsens with activity and improves with rest. Preoperative evaluation determines whether the patient has clinical or progressive weakness that can be exacerbated by stress, infections, hypokalemia, medications (aminoglycoside antibiotics, propranolol, ciprofloxacin, clindamycin), and surgery. Cardiac and smooth muscles are unaffected. Thymic hyperplasia and tumors may be present. The thymus is located in the anterior mediastinum and, when enlarged, has implications related to anesthesia (see Mediastinal Masses). Cranial nerve and bulbar involvement is common with pharyngeal and laryngeal muscle weakness, which increases the risk for aspiration. Ocular symptoms (diplopia, ptosis) are usually present and are frequently the initial or only complaints. Ventilatory function can be compromised. Preoperative PFTs are indicated for severely affected individuals and may be useful in predicting who may require postoperative ventilation.96 PFTs may be particularly helpful if patients are being considered for ambulatory surgery, especially in freestanding surgical centers. Other autoimmune diseases such as rheumatoid arthritis, polymyositis, and thyroid disorders are common in myasthenics. See the appropriate sections of this chapter for discussion of these topics. Patients are treated by thymectomy and with anticholinesterase and immunosuppressant medications. Worsening symptoms may be due to deteriorating disease (a myasthenic crisis) or excessive anticholinesterase treatment (a cholinergic crisis). By using a short-acting anticholinesterase (edrophonium), the two can be distinguished; only a myasthenic crisis will improve with more anticholinesterase. Plasmapheresis and intravenous immunoglobulins have been used to treat myasthenic crises or prepare patients for surgery but require several days to weeks for improvement. Preoperative patients taking azathioprine require a CBC and LFTs because of the bone marrow suppression and liver dysfunction associated with this drug. Patients treated with steroids

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need an ECG and glucose determination and may require higher doses in the perioperative period. Even though anticholinesterases may cause bradycardia (necessitating a preoperative ECG) and salivation and alter the effects of neuromuscular blocking and reversal agents, they need to be continued to prevent a myasthenic crisis. Documentation of dosages and schedules and continuation of these medications up until the time of surgery are paramount. Avoidance of drugs that can exacerbate myasthenic symptoms is necessary. Management with a neurologist is important. Lambert-Eaton syndrome is similar to myasthenia gravis and consists of muscle weakness, including oculobulbar involvement, and dysautonomia. It is caused by antibodies against voltage-gated calcium channels, which results in a decrease in acetylcholine. It is not associated with thymic abnormalities but is most common with malignancies; small cell lung cancer is the most frequent cause, but it also occurs with gastrointestinal tumors. The other distinguishing feature is that the muscle weakness classically improves with activity and is worse after inactivity. Therapies similar to that used for myasthenia, along with 3,4diaminopyridine, a selective potassium channel blocker, are used and continued perioperatively. Preoperative evaluation and management are similar to that for myasthenia gravis. Muscular Dystrophies and Myopathies Muscular dystrophies and myopathies are inherited disorders of the neuromuscular junction (see Chapter 14). They share many similarities but have a few differences. Progressive skeletal muscle weakness commonly leading to respiratory failure and no effective therapy are the hallmarks of these disorders. Many have associated cardiomyopathies and possibly an association with MH. Duchennes and Beckers muscular dystrophies are X-linked recessive disorders that occur in males. Patients have elevated creatine phosphokinase levels, often detected before the onset of symptoms. Males with a family history of Duchennes or Beckers muscular dystrophy who have not been tested are considered at risk and require similar precautions as those with diagnosed disease. Cardiomyopathy and respiratory failure are common causes of death. Otherwise, normal female carriers may have dilated cardiomyopathy. Preoperative evaluation for symptoms such as palpitations, dyspnea, chest pain, syncope, orthopnea, edema, aspiration, and pneumonia is important. Physical examination focuses on the cardiopulmonary system. An ECG, PFTs, and echocardiography are important in the preoperative evaluation. Fascioscapulohumeral dystrophy is autosomal dominant, affects both genders, and causes a slowly progressive weakness of muscles of the shoulders and face. Cardiomyopathy is much less frequent than in the other dystrophies, but arrhythmias have been reported. Limb-girdle dystrophies have a variable inheritance and primarily affect the muscles of the shoulders and pelvis. Conduction abnormalities are present in some patients, although frank cardiomyopathies are less frequent. Inquiring about palpitations, syncope, and cardiac symptoms, examining patients as noted earlier for Duchennes muscular dystrophy, and obtaining an ECG preoperatively are important. Myotonic Dystrophies Myotonia is prolonged contraction and delay of relaxation of muscles. It is a common symptom of several dystrophies, including classic myotonic dystrophy, congenital myotonic dystrophy, myotonia congenita, and central core disease. Myotonic dystro-

phy is the most common of these conditions and is an autosomal dominant inherited disorder that affects both genders. Congenital myotonic dystrophy is a severe form of this disease that is noted in infancy, often in the offspring of mothers with myotonic dystrophy. Preoperative classic findings are severe muscle wasting, typically involving the face, hands, diaphragm, and pharyngeal, laryngeal, and pretibial muscles. Cold can trigger myotonia. The severity of disease is variable and it may not be apparent until the second to third decades of life, so a family history is important. Cardiomyopathies, arrhythmias, and conduction abnormalities are common, and some patients have cardiac valvular abnormalities. Cardiac involvement may not correlate with skeletal muscle atrophy or weakness. Patients require pacemakers once any evidence of second- or third-degree AV block develops, even if the patient is asymptomatic, because there may be unpredictably rapid progression of AV conduction disease. As a result of this potential for rapid progression, pacemaker placement is considered in these patients even with a first-degree AV block, regardless of symptoms. Aspiration with pneumonia and respiratory or cardiac failure are common. An increased risk for pulmonary complications postoperatively has been reported.97 Central core disease is a rare disorder consisting of a deficiency of mitochondrial enzymes. The name derives from the pathology of muscle biopsy specimens in which cores of abnormalities are apparent. Patients have proximal muscle weakness and scoliosis and may have cardiomyopathies. They are at risk for respiratory failure and aspiration, much like patients with myo tonic dystrophy. Myotonia congenita is a hereditary disorder involving only skeletal muscles, is less severe, and does not cause cardiac abnormalities. Patients with myotonia may be at increased risk for MH, although this is controversial. They may have similar findings as those with MH as a result of uncontrolled myotonic contraction with elevated metabolism and rhabdomyolysis. Steroids, quinine, and procainamide may relieve myotonic contractions, but there is no cure for these diseases. These medications need to be continued perioperatively. The history and physical examination focus on the cardiopulmonary systems with special emphasis on findings of pulmonary infection, heart failure, palpitations, syncope, and conduction and valvular abnormalities. Preoperative testing includes an ECG and echocardiogram (except for patients with myotonia congenita), as well as a chest radiograph if acute symptoms of pulmonary disease are present. Any conduction abnormality on the ECG may benefit from cardiology consultation. Central Nervous System Tumors Pituitary tumors may be functioning (associated with endocrine abnormalities) or nonfunctioning and benign (adenomas are the most common pituitary lesion) or malignant (see Chapter 63). Preoperative evaluation determines whether symptoms related to a mass effect of the tumor are present (e.g., headaches, visual field defects) or symptoms related to elevations in intra cranial pressure are present (e.g., gait disturbances, vomiting, cranial nerve deficits, or bladder or bowel incontinence). Symptoms may be related to pituitary insufficiency (hypoadrenalism, hypothyroidism, or infertility being most common) or overactivity (Cushings syndrome from tumors secreting ACTH; acro megaly from growth hormone secretion; hyperthyroidism from TSH production; gynecomastia, lactation, and sex hormone

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related changes from secretion of prolactin and gonadotropin [follicle-stimulating and luteinizing hormone]). These hormones are all produced by the anterior lobe of the pituitary and controlled via a feedback loop by the hypothalamus. The posterior pituitary stores and secretes vasopressin and oxytocin, which are synthesized in the hypothalamus. Cushings syndrome results from excess cortisol production by the adrenals (stimulated by ACTH from the pituitary) and is discussed in the metabolic section of this chapter. Acromegaly is caused by excess growth hormone and results in enlargement of connective tissue, bone, and visceral organs. On the preoperative physical examination, patients classically have an enlarged jaw (macrognathia), nose, feet, hands, and pharyngeal and laryngeal tissues, including the epiglottis and tongue (macroglossia). Patients have an increased incidence of both central sleep apnea and OSA, neuropathies from nerve entrapment, hypertension, LVH, diastolic dysfunction, and valvular abnormalities. CAD, heart failure, diabetes, hypothyroidism, and difficulty with mask ventilation, laryngoscopy, and intubation occur. Preoperative solicitation and documentation of symptoms such as chest pain, dyspnea, snoring, numbness, polydipsia, headaches, and visual disturbances are important. Physical examination focuses on BP, airway features, murmurs, neurologic findings, and edema. Planning for difficult airway management plus discussion with the patient of possible awake fiberoptic intubation is necessary. An ECG, echocardiogram, electrolyte and glucose determination, and thyroid function tests are usually obtained. TSH increases production of thyroid hormones (T3 and T4) by the thyroid gland. See the section Thyroid Disease. Posterior pituitary tumors result in failure to secrete vasopressin, also known as antidiuretic hormone, which regulates excretion of water by the kidneys. Deficiency of antidiuretic hormone results in excessive urine output from failure to reabsorb water and causes diabetes insipidus. These patients need estimation of volume status with orthostatic BP and HR measurement and electrolyte, BUN, and creatinine determination. Patients may have hypernatremia and volume depletion unless maintained on DDAVP. Prolactin- and gonadotropin-secreting tumors have little impact on anesthetic management, but associated symptoms may alert clinicians to an undiagnosed pituitary tumor. Patients with tumors or postpartum hemorrhage that cause pituitary insufficiency or those who have undergone resection of a pituitary tumor may require hormonal replacement such as steroids, thyroid medications, or DDAVP. It is important that these medications not be interrupted during the perioperative period. The preoperative history and physical examination should determine whether patients are adequately treated. Determining electrolyte, BUN, and creatinine levels and performing thyroid function tests and an ECG are necessary. Intracranial tumors include gliomas (45% of tumors), such as glioblastoma multiforme, astrocytoma, ependymoma, medulloblastoma, and oligodendrocytoma, which are malignant and highly lethal. Benign meningiomas (15%) arise from the dura or meninges. Metastatic lesions (6%) are associated with virtually all types of malignancies. Schwannomas, craniophyaryngiomas, and dermoid tumors also occur. Most intracranial tumors are detected when symptoms related to a mass effect develop, patients have seizures, or they are found incidentally. Symptoms include head-

aches, stroke-like symptoms, vomiting, visual disturbances, altered cognitive function, and ataxia. If intracranial pressure becomes elevated, hypertension, bradycardia, arrhythmias, ECG abnormalities, and risk of brainstem herniation develop. Careful questioning and documentation of neurologic deficits and symptomatology are important. For patients with metastatic lesions, issues pertaining to the primary malignancy or previous treatment need to be clarified. Continuation of steroids to decrease brain edema and anticonvulsant medications is essential.

Preoperative Evaluation of Patients with Psychiatric Disorders


Key issues in the preoperative assessment of patients with psychiatric disorders include assessing cognitive capacity, obtaining an accurate psychiatric history, evaluating the patients capacity to give informed consent, and assessing the impact of psychotropic medications.98 Cognition is usually unimpaired in patients suffering from illnesses such as depression or schizophrenia and impaired in those suffering from disorders such as delirium, dementia, and autism. Orientation and memory should be assessed by the preoperative clinician to ensure that cognition is sufficient to obtain an accurate history and consent. Basic orientation to person, place, and time can be determined during the preoperative conversation or by looking at the way the patient has answered questions on forms. Mild cognitive impairment is frequently associated with mild dementia in elderly patients, who are at risk for postoperative delirium. More severe cognitive impairment raises issues regarding the reliability of the history and ability to obtain informed consent. Family members can aid by providing the history and countersigning consent forms.

Musculoskeletal and Connective Tissue Diseases


Deformities and chronic inflammation are key components of many of these disorders. The deformities need to be determined because of potential challenges in airway and regional anesthesia management. Chronic inflammation and associated vasculopathy with diseases such as rheumatoid arthritis, SLE, and scleroderma or systemic sclerosis often result in multiorgan dysfunction. The cardiovascular, pulmonary, renal, hematologic, integumentary, gastrointestinal, central, and peripheral nervous systems can all be involved. Rheumatoid Arthritis Rheumatoid arthritis affects up to 1% of the population (females more than males) and is a chronic autoimmune disorder primarily affecting the joints but often multiple systems.99 Both large and small joints become inflamed, and severe deformity is possible, although the disease course varies dramatically. The temporomandibular joints and cricoarytenoid cartilage can be involved and result in limited mouth opening and hoarseness. Atlantodens subluxation and cervical spine instability can occur.

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Subluxation is caused by laxity of the ligaments, not joint disease, and may be present in as many as 46% of patients.100 Cervical spine diseases can occur without symptoms. Vasculitis or entrapment results in peripheral neuropathy. CAD, pericardial effusion, aortic regurgitation, and conduction abnormalities are frequently present.101 The often severely limited functional status in these patients masks ischemic symptoms. Dyspnea, which can be an anginal equivalent, especially in women, may be confused with pulmonary symptomatology. Restrictive lung disease from decreased thoracic mobility, interstitial fibrosis, and pleural effusions may occur. Patients have an increased incidence of renal dysfunction from both vasculitis and chronic use of NSAIDs. Anemia, leukocytosis, and both thrombocytosis (from chronic inflammation) and thrombocytopenia (from splenomegaly) can be found. Rheumatoid nodules occur subcutaneously, usually over extensor joints, or in the lungs. The preoperative history and physical examination are performed to document symptoms related to the many organ systems affected by rheumatoid arthritis (refer to appropriate sections of this chapter). Special detail needs to be given to the airway and to the neurologic, pulmonary, and cardiovascular systems. A careful history may elicit neurologic deficits, neck and upper extremity pain, and a crunching sound with neck movement. Patients who have neurologic deficits or symptoms or long-standing, severely deforming disease or who are scheduled to undergo procedures requiring manipulation of the cervical spine or special positioning, such as turning prone, require anteroposterior and lateral cervical spine radiographs with special flexion, extension, and open-mouth odontoid views.100 Significant abnormalities (anterior atlas-dens interval >9mm or posterior interval <14mm) may benefit from consultation with a neurologist or neurosurgeon. However, the duration, severity, or symptoms of the disease do not correlate with cervical spine subluxation. Preoperative documentation of deformities and neurologic deficits is important to establish a baseline level of function. For patients with significant hoarseness, referral to an otolaryngologist to assess mobility of the vocal cords and the degree of cricoarytenoid arthritis may be of benefit.102 Acute or worsening pulmonary symptoms may trigger a need for pulse oximetry, chest radiographs, PFTs, or a pulmonary consultation (see the section Pulmonary Disorders). An ECG is always indicated, and abnormalities may prompt further testing or referral to a cardiologist, or both. Muffled heart sounds, pericardial rubs, and an enlarged heart detected by examination or on a chest radiograph together with low voltage on an ECG suggest a pericardial effusion, which can be evaluated with an echocardiogram. Many murmurs, especially if new, would benefit from further investigation (see Table 34-4 and Box 34-4). A CBC with a platelet count and determination of BUN and creatinine are indicated, except for the most minor of procedures. Advanced planning for the management of identified or potential difficult airways is important. Discussion of regional anesthetic options and awake fiberoptic intubation is necessary. Continuation of steroids and chronic pain medications is optimal, but drugs with antiplatelet effects are generally discontinued and immunosuppressants may have to be temporarily stopped to allow normalization of blood counts. Patients with complex regimens and severe disease are best managed in concert with their rheumatologist or primary physician.

Ankylosing Spondylitis Ankylosing spondylitis is a progressive inflammatory arthropathy that affects mainly the spine and sacroiliac joints.103 It occurs primarily in males and can be accompanied by uveitis, peripheral arthritis, and vasculitis causing aortitis and aortic insufficiency. Restrictive lung disease can result from pulmonary fibrosis or poor chest wall movement secondary to joint fixation and kyphosis. Kyphosis can be so extreme that patients cannot face forward and are extremely difficult to intubate or even mask ventilate. Preoperative evaluation by history and physical examination focuses on the skeletal and cardiopulmonary systems. A murmur warrants an ECG and may benefit from an echocardiogram. If ventilatory compromise is suspected or present, room-air pulse oximetry and a chest radiograph are necessary, as well as PFTs when appropriate. Acute processes must be managed preoperatively. Patients taking NSAIDs require determination of BUN and creatinine levels, and a CBC with a platelet count and LFTs are indicated for those treated with leflunomide. Planning for airway management and discussion with the patient about the possibility of awake fiberoptic intubation are important. Peripheral nerve blocks are options, but centroneuraxial anesthesia is often unsuccessful because of severe spinal involvement. Systemic Lupus Erythematosus SLE is a systemic autoimmune disease predominately caused by vasculitis; it has a variable course, often with remissions punctuated by flares.104 SLE affects mainly females and is typically more severe in African Americans than in other groups. Preoperative evaluation determines whether the patient has chronic fatigue, weakness, respiratory compromise, fevers, and migratory arthritis affecting primarily the small joints of the hands and feet, which is common. Fevers may be a result of the disease itself or the frequent infections that develop because of the immune dysfunction and immunosuppressants used to treat the disease. Many patients have dermatologic conditions, including alopecia, the typical butterfly rash across the cheeks and nose, and photosensitivity. Vasospasm of the digits, dubbed Raynauds phenomenon or disease, often with atrophy of the nails and fingernails, makes it difficult to obtain pulse oximetry readings. Preoperative evaluation for interstitial lung disease, pleural effusions, frequent infections, and pulmonary hypertension is important and presents a significant concern. Pulmonary hypertension can result from interstitial lung disease, recurrent pulmonary emboli, or cardiomyopathy and carries a high risk of perioperative complications (see Pulmonary Hypertension). Cardiac involvement includes premature coronary artery arterosclerosis, pericarditis, myocarditis, aseptic endocarditis, and pleural effusions. Coronary vasculitis and cardiomyopathy may occur. Hypertension, frequently difficult to control, is almost ubiquitous. Neuropsychiatric manifestations consisting of cerebral vasculitis, stroke, cognitive dysfunction, seizures, peripheral neuropathy, headache, affective disorders, and carotid artery disease are common. Lupus nephritis is a common morbidity with a poor prognosis that frequently results in renal failure. Patients with SLE often have anemia and may have leukopenia and thrombocytopenia.

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Antiphospholipid antibodies occur frequently and can result in a coagulopathy with recurrent episodes of venous and arterial thrombosis, including pulmonary emboli and stroke. Typically, the aPTT is prolonged in these patients. Antinuclear antibodies are present in most cases and can help establish a diagnosis, especially with atypical manifestations. The preoperative history and physical examination must evaluate all major organ systems and identify medications. Patients with severe disease, exacerbations, or infections are best managed along with the physicians primarily responsible for their care or a rheumatologist. Detailed questioning regarding neurologic symptoms, coughing, dyspnea, chest pain, orthopnea, fever, the course of disease, and medications is paramount. Any history of thromboembolic events is important, but recent events regarding precipitating factors, type and duration of treatment, and severity of the event (e.g., pulmonary embolus or DVT) must be detailed so that one can plan discontinuation of anticoagulants and need for bridging. Because of the significant incidence of both cerebrovascular and coronary artery lesions in these patients, careful questioning about exercise capacity, atypical symptoms of ischemia, and any previous diagnostic studies such as computed tomography, magnetic resonance imaging, echocardiography, or stress testing may be revealing. Systemic Sclerosis Systemic sclerosis, previously known as scleroderma, is an autoimmune disease characterized by excessive fibrosis that occurs more commonly in females.105 Raynauds phenomenon is the most common occurrence besides skin thickening. Localized scleroderma involves just the skin without involvement of other organs. Limited cutaneous systemic sclerosis is limited to the skin of the face and upper extremities as the cutaneous manifestation, but with systemic involvement, the gastrointestinal tract (dysphagia, reflux) and lungs (interstitial lung disease, pulmonary hypertension) can be affected. Pulmonary hypertension is associated with a poor prognosis and increases perioperative risk (see Pulmonary Hypertension).106 Diffuse cutaneous systemic sclerosis causes generalized skin thickening and multiple end-organ damage. Myocardial fibrosis, pericarditis, heart failure, and coronary artery fibrosis or spasm can occur. Patients often have severe hypertension, renal failure, dysphagia, fatigue, weight loss, reflux, and right heart failure. The preoperative history and physical examination focus on the organ systems as outlined in the section Systemic Lupus Erythematosus, with special attention paid to signs or symptoms of pulmonary hypertension (see Pulmonary Hypertension). A careful history to elicit symptoms of pulmonary disease (cough, dyspnea) or cardiac disease (dyspnea, orthopnea, chest pain) is vital. A murmur of tricuspid regurgitation and a split second heart sound are suggestive of pulmonary hypertension. Because of the thickened and fibrosed skin, microstomia, limited neck mobility, poor dentition, and oropharyngeal lesions, airway examination and planning for management are essential. Dermal thickening, scarring, edema, and contractures make venous access and regional anesthesia challenging. Discussing central venous access, even arranging for interventional radiology to place intravenous lines, and explaining the possibility for awake fiberoptic intubation will help on the day of surgery. Preoperatively, patients with systemic sclerosis need an ECG and determination of BUN and creatinine levels. A CBC with a platelet count is indicated in those taking immunosuppres-

sants. A chest radiograph and PFTs can be useful when evaluating patients with symptoms (cough, dyspnea) or signs (rales, hypoxemia) of possible interstitial lung disease or pulmonary fibrosis. Echocardiography is useful to screen for pulmonary hypertension in patients suspected of having this significant end-organ complication. Calcium channel blockers to treat Raynauds phenomenon, antihypertensive agents, and immunosuppressants need to be continued preoperatively. Inherited Connective Tissue Disorders Ehlers-Danlos syndrome, a disorder of collagen synthesis, consists of several subtypes that have various manifestations, but almost all are characterized by joint hypermobility. Type IV is one of the most serious because those affected may have vascular and skin fragility and are at risk for vascular and visceral rupture and pneumothorax. Patients with type VI Ehlers-Danlos syndrome have muscle weakness, scoliosis, ocular and skin fragility, and osteopenia. Marfans syndrome is characterized by tall stature, arach nodactyly (long digits), scoliosis, pectus excavatum, ascending aortic dilatation and even dissection, valvular disease (aortic insufficiency, mitral valve prolapse, mitral regurgitation), and arrhythmias. Ocular (ectopia lentis, strabismus, glaucoma) and pulmonary (blebs, spontaneous pneumothorax) complications can occur.107 Patients may have retrognathia and high arched palates. Careful auscultation for the diastolic murmur of aortic insufficiency is important (see Table 34-3). An ECG, echocardiogram, and chest radiograph should be obtained if a murmur is detected and management will be changed. The most distinguishing feature of osteogenesis imperfecta is the propensity of patients for fractures from extremely fragile bones. Patients may have blue sclerae, short stature, scoliosis, joint hypermobility, hearing loss, pulmonary complications, muscle weakness, mitral valve prolapse, aortic insufficiency, and platelet dysfunction. An ECG and echocardiogram are necessary if a murmur is detected. Epidermolysis bullosa is distinguished by blistering, skin fragility, and scarring because of abnormal epidermal-dermal anchoring. Even obtaining a BP reading may cause skin blistering and breakdown. Kyphoscoliosis Kyphoscoliosis is a curvature of the spine both laterally and anteriorly and may involve the thoracic or lumbar regions, or both. It occurs alone as as a manifestation of other diseases, including collagen vascular disorders, Marfans syndrome, neurofibromatosis, muscular dystrophies, and cerebral palsy, among others. Therefore, the preoperative evaluation is aimed at identifying coexisting abnormalities. Pulmonary and cardiac compromise can occur with severe thoracic deformity. Restrictive lung disease, pulmonary hypertension, tracheobronchial and cardiac compression, and heart failure are possible. The preoperative history focuses on functional capacity and cardiopulmonary symptoms. The ability of the patient to lie supine and allow airway access and management needs to be determined. Vital signs and performance of pulse oximetry are important. Auscultation for rales, decreased air entry, murmurs, and additional heart sounds and examination for edema and jugular venous distention are crucial. An ECG and chest radiograph are needed, and if patients are scheduled for spine correction surgery, a CBC and type and screen are required. An

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echocardiogram may be indicated if symptoms or signs of heart failure are present. Reversible lung disease or heart failure needs to be addressed and optimized before surgery. Raynauds Phenomenon Raynauds phenomenon or disease is an exaggerated vascular response to cold or emotional stress (thought to be due to stimulation of the sympathetic nervous system) that results in color changes of the digits.108 It can be primary (idiopathic without a known cause) or secondary (associated with connective tissue diseases, autoimmune disorders, drugs, use of vibrating tools). It is estimated that more than 95% of patients with systemic sclerosis have Raynauds phenomenon; 20% to 30% of patients with Sjgrens syndrome or SLE have it, but less than 5% of patients with rheumatoid arthritis. Raynauds phenomenon most often affects the hands and typically results in a sudden onset of cold digits (fingers more common than toes) with sharply demarcated pallor or cyanosis. Cutaneous vasospasm is common in other sites such as the face and ears and can cause pain and numbness. Criteria for the diagnosis of primary disease include symmetric episodic attacks, no PVD, no tissue injury or gangrene, normal nail fold capillary examination, normal erythrocyte sedimentation rate, and a negative antinuclear antibody test. Primary Raynauds phenomenon requires no special preoperative evaluation. Secondary disease should direct the assessment for associated disease states as outlined elsewhere in this chapter. It is important to distinguish Raynauds phenomenon from PVD because of the difference in associated comorbid conditions. Calcium channel blockers are useful in many patients and need to be continued in the perioperative period.

Cancer/Tumors in Preoperative Patients


Cancer Patients Patients with a history of cancer may have complications related to the disease or the treatment. Typically, patients will be aware of the side effects of treatment that they have experienced or are at risk of having. Asking them if any unexpected complications occurred or if chemotherapy or radiotherapy had to be interrupted because of adverse effects is important. A hypercoagulable state is common in patients with cancer, particularly those with advanced disease and primary brain tumors, ovarian adenocarcinoma, and pancreatic, colon, stomach, lung, prostate, and kidney cancer. Patients with cancer have a sixfold increased risk for thromboembolic events, and active cancer accounts for 20% of new episodes of thromboembolism (see Risk of Thromboembolism or Pulmonary Emboli). Preoperative evaluation should focus on evaluation of the heart, lungs, and neurologic and hematologic systems. Previous head and neck irradiation may cause carotid artery disease, hypothyroidism, or difficulty with airway management.109 In these patients, auscultation for bruits, thyroid function tests, and carotid Doppler studies are recommended. Mediastinal, chest wall, or left breast irradiation can cause pericarditis, conduction abnormalities, cardiomyopathy, valvular abnormalities, and premature CAD, even without traditional risk factors.110 Therefore, younger patients who might not otherwise be expected to be at risk for heart disease but who have a history of radiation therapy for cancer should be assessed for symptoms

of cardiac disease as part of the preoperative history and should have a preoperative ECG. Cardiovascular disease is the second most common cause of mortality in survivors of Hodgkins disease. One study found that 88% of patients had echocardiographic abnormalities 5 to 20 years after treatment, most of them asymptomatic. Treatment at a younger age increases the risk. Radiation exposure is not considered in the ACC/AHA guidelines for cardiac evaluation for noncardiac surgery but can be an important predictor of CAD.110 A preoperative ECG, echocardiography, and stress testing may be indicated. Radiation pneumonitis can occur in those who have received irradiation of the lungs, breast, or mediastinum. A chest radiograph and oxygen saturation with pulse oximetry are indicated. PFTs may be needed. Chemotherapy with doxorubicin can cause cardiomyopathy, bleomycin can produce pulmonary toxicity, vincristine and cisplatin may cause peripheral neuropathy, and cyclophosphamide may trigger hemorrhagic cystitis. Many agents cause renal and hepatic toxicity or suppress bone marrow, which may result in pancytopenia. Anemia is most common. A chest radiograph, CBC with platelets, determination of electrolytes, BUN, and creatinine, and LFTs may be indicated based on the type of chemotherapy. Patients with hepatocellular cancer have a high incidence of chronic liver disease (see the appropriate section). One study found that almost 25% of patients with Childs class C disease (see Table 34-5) undergoing liver resection died in the hospital and almost 20% more died within the first month after discharge.111 A CBC with platelets, electrolyte, BUN, creatinine, and albumin levels, LFTs, and PT are needed. Intracranial neoplasms can be primary or metastatic and can be complicated by seizures, increased intracranial pressure with mental status changes, nausea, vomiting, gait disturbances, and hemodynamic alterations or neurologic deficits. Previous therapies, including radiation, steroids, and anticonvulsants, need to be determined. If the tumor is metastatic, the primary tumor site, the course of the illness, and complications of therapy are important. Cancers that typically metastasize to the brain include breast, colorectal, and lung cancer. Preoperative neuroimaging, an ECG, and electrolytes and glucose levels are reviewed or obtained. Steroids and anticonvulsants are continued. Breast, colorectal, lung, head, and neck tumors commonly metastasize to bone and the liver. Bone lesions can result in hypercalcemia or pancytopenia. Pancytopenia, with anemia being most common, occurs with many cancers or with treatment of these cancers. Head and neck tumors or therapy for them (surgery, radiation) may cause difficulty with airway management and thyroid dysfunction. Lung cancer can compromise pulmonary function and cause airway problems or mediastinal masses (discussed later). Computed tomography scans of the head, neck, or chest may be indicated. Paraneoplastic syndromes can complicate almost any malignancy but are commonly associated with lung cancer. Hypercalcemia, inappropriate secretion of antidiuretic hormone, Lambert-Eaton or Cushings syndrome (discussed in this chapter), and neuropathies may occur. Preoperative patients who are chronically receiving opioids for cancer pain are likely to require greater than usual doses of medication for postoperative pain control. They should take their usual pain therapies the day of surgery with the exception of antiplatelet agents. Patients at risk for adrenal insufficiency should

Section IV Anesthesia Management

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1038 Anesthesia Management

be assessed with a corticotropin (ACTH) stimulation test (see Hypothalamic-Pituitary-Adrenal Disorders) or should be considered for additional perioperative steroids. A preoperative ECG is indicated for patients who have received mediastinal, breast, or lung irradiation or doxorubicin. All patients with cancer require a preoperative CBC with platelets and determination of electrolytes, BUN, creatinine, and calcium. Patients who are significantly malnourished benefit from 7 to 10 days of enteral or parenteral nutrition before major surgery. Surgery is delayed to allow neutropenia and thrombocytopenia to resolve if possible. Type and screening and planning blood component replacement can avoid delays on the day of surgery. Mediastinal Masses Lymphomas, thymomas, teratomas, metastatic disease, and goiters can occur in the anterior mediastinal space. Anterior mediastinal masses can cause obstruction of the great vessels, including the aorta, pulmonary arteries and veins, and superior vena cava, as well as the heart, trachea, and bronchi. Evaluation of patients with a mediastinal mass can be found in Chapter 59. Von Hippel-Lindau Disease von Hippel-Lindau disease is an inherited, autosomal dominant syndrome manifested by a variety of benign and malignant tumors. The spectrum of associated tumors includes hemangio blastoma, retinal angioma, clear cell renal cell carcinoma, pheochromocytoma, and neuroendocrine tumors of the pancreas. Preoperative evaluation of these patients focuses on evaluation of renal function and determination of symptoms or diagnoses compatible with pheochromocytomas or neuroendocrine tumors (see the section Pheochromocytoma). A careful history and physical examination with vital signs, an ECG, and determination of electrolytes, BUN, creatinine, and glucose is necessary in all patients. Further testing is guided by the history and laboratory findings. Carcinoid Tumors Carcinoid tumors are rare neuroendocrine tumors that release mediators and typically occur in the gastrointestinal tract; they are the most common neoplasm of the appendix but are also found in the pancreas and bronchi. Preoperatively, patients with carcinoid syndrome complain of flushing, tachycardia, arrhythmias, diarrhea, malnutrition, bronchospasm, and carcinoid heart disease caused by vasoactive amines (serotonin, norepinephrine, histamine, dopamine), polypeptides (bradykinin, somatostatin, vasoactive intestinal peptide, glucagon), and prostaglandins released by the tumors. The majority of patients are asymptomatic. The liver inactivates the bioactive products of carcinoid tumors, which is why patients with gastrointestinal tumors have manifestations of carcinoid syndrome only if they have hepatic metastases. Heart disease can involve endocardial fibrosis of the pulmonic and tricuspid valves and cause stenosis and regurgitation, respectively. Right heart failure with peripheral edema and hepatomegaly can occur. Carcinoid tumors occur in MEN I. Preoperative diagnostic tests are guided by the history and physical findings such as dyspnea, orthopnea, wheezing, edema, arrhythmias, and murmurs. Patients with diarrhea need determination of orthostatic BP, electrolytes, BUN, and creatinine. Patients with cardiac involvement need an ECG, electrolye assay, and echocardiography. Malnourished patients need orthostatic BP

determination, an ECG, and electrolyte and albumin levels. Elevated urinary 5-hydroxyindoleacetic acid levels and carcinoid heart disease increase perioperative adverse events.112 H1 and H2 histamine receptor blockers, ketanserin (a serotonin receptor antagonist), and octreotide may be useful to block release or the effects of mediators.

Special Issues in Preoperative Evaluation


Patients with Upper Respiratory Infections
Analysis of the literature available on patients with upper respiratory infections and anesthesia provides guidelines to help ensure patient safety while minimizing unnecessary cancellations. Although children with active and recent upper respiratory infections have been shown to be at increased risk for postoperative respiratory complications, these complications are generally manageable and have not been associated with long-term sequelae. Tait and Malviya summarized the literature on patients with upper respiratory infections and have provided a useful practice algorithm.113 According to this algorithm, afebrile patients with symptoms of an uncomplicated upper respiratory infection, including clear secretions, should be able to undergo surgery. The preoperative evaluation distinguishes patients with more severe symptoms, including purulent secretions, productive cough, temperature higher than 38C, or signs of pulmonary involvement, and elective surgery should be postponed for about 4 weeks. This period was suggested because airway hyperreactivity persists for several weeks after an upper respiratory infection and patients recovering from one have been shown to have a rate of complications similar to those who have acute symptoms. Additional risk factors that should be considered include a history of asthma, need for intubation, surgery on the airway, smoking history, and a history of prematurity in pediatric patients. In patients with severe symptoms, especially those with underlying conditions (e.g., significant asthma, heart disease, and immunosuppression) that may further compromise safe anesthesia, elective surgery should be postponed for at least 4 weeks as well.113 Preoperative laboratory testing and chest films may not be helpful in the decision; patients with viral infections may not have elevated white blood cell counts, and chest film findings typically lag behind clinical symptoms in patients with lower respiratory infections. The risk-benefit ratio in each individual case needs to be assessed. Most would agree that surgery in patients with mild uncomplicated upper respiratory infections should not be canceled and surgery in those with more severe symptoms should be postponed for 4 weeks. Management should include awareness and prevention of potential complications.

Preoperative Evaluation of Patients with a Transplanted Organ


The number of patients with transplanted organs requiring nontransplant surgery increases yearly. These patients present special

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issues for preoperative evaluation because of concerns about transplant function, allograft denervation, immunosuppression, and post-transplant physiologic and pharmacologic issues (see Chapter 67). Close interaction with the transplant team is considered one of the most important steps in the perioperative care of these patients, and clinicians performing the preoperative assessment should ensure that the transplant care providers are aware of the upcoming procedure and be given an opportunity to make recommendations. During the preoperative evaluation, the dosage regimen of all agents should be noted and patients should be instructed to continue taking all of these medications. However, these drugs can modify the pharmacology of many agents administered during the perioperative period. Impact on agents administered during anesthesia is discussed elsewhere and has been summarized in the literature.114,115 There are some general preoperative considerations in all transplant patients, as well as concerns specific to the type of organ transplanted.116 In all transplant patients, the level of function of the transplanted organ and the presence of rejection should be evaluated. Immunosuppressant therapy results in hyperglycemia and adrenal suppression (steroids); risk of infection, hypertension, and renal insufficiency (steroids, cyclosporine, tacrolimus); and myelosuppresion with anemia, thrombocytopenia, and leukopenia (azathioprine, sirolimus). Because these patients are chronically immunosuppressed, the potential for infection should be considered in any preoperative evaluation. Although these patients are at higher risk for the development of infectious complications, there is no evidence suggesting that heightened antibiotic prophylaxis has any added benefit, and the usual preoperative recommendations should be followed. The need for stress dose supplementation in patients taking lowdose corticosteroids is controversial, although because of the low risks involved with this therapy, it is used frequently. Careful cardiac evaluation is important in all transplant patients because the incidence of cardiovascular disease is increased. This is due to a variety of factors, including the association of organ failure with a number of cardiovascular risk factors, as well as the role of drug regimens, transplantation, and rejection episodes in creating new and worsened cardiovascular risk factors. Patients with heart transplants periodically undergo evaluation for CAD (stress testing or catheterization) and function (echocardiogram or multiple gated acquisition [MUGA]). Renal function should be assessed preoperatively because chronic renal insufficiency is becoming a significant problem in recipients of other solid organs secondary to long-term use of immunosuppressive regimens. Although the effects of transplantation and immunosuppressive regimens on intravascular coagulation are controversial, DVT prophylaxis should be considered in all transplant patients. Kidney transplant recipients present some specific issues. Despite the presence of a normal creatinine level, the average GFR is generally decreased. This predisposes patients to electrolyte abnormalities and altered drug metabolism, as reviewed in the articles referenced earlier. The risk for cardiovascular disease in renal transplant recipients is approximately twice that in the general population, and careful presurgical cardiac evaluation is essential. Nephrotoxic drugs, NSAIDs, and COX-2 inhibitors should be avoided in renal transplant recipients. Liver transplant patients require careful evaluation of pulmonary function. Hepatopulmonary syndrome, which consists of

intrapulmonary shunting caused by intrapulmonary vascular dilatation, can result in hypoxemia. These patients can also have ventilation-perfusion mismatching as a result of effusion, ascites, and diaphragmatic dysfunction. Diffusion abnormalities can result from interstitial pneumonitis and impaired hypoxic pulmonary vasoconstriction. In some cases, pretransplant pulmonary disturbances do not completely resolve after transplantation. Lung transplant patients may require months to achieve peak pulmonary functional capacity. Because of exposure to the external environment, the transplanted lung is susceptible to infection and rejection. Lung transplant patients have a high rate of pulmonary infection, and the airway anastomosis is subject to risk of injury with intubation. Loss of the cough reflex and airway hyperresponsiveness may be present. These patients are also at increased risk for pulmonary edema. Preoperative pulmonary function testing can be extremely helpful. Most of the issues relating to heart transplant patients evolve from the absence of autonomic innervation; specific drug effects are described in detail in the items referenced. The preoperative ECG may show two P waves, one from the native atria, which is not conducted, as well as one from the donor atria. The heart transplant lacks innervation, and thus ischemia is silent and autonomic reflexes are absent (lack of chronotropic response to exercise, anemia, or hypovolemia). Conduction abnormalities are common. Permanent pacemakers are required in a significant number of patients, and their function should be confirmed during preoperative assessment.

Section IV Anesthesia Management

Preoperative Evaluation of Patients with Allergies


The patients history of allergies and adverse drug reactions should be carefully documented in the preoperative record. True anaphylactic reactions should be distinguished from adverse side effects. The patients definition of allergy may be very different from the true clinical definition, and patients may incorrectly think that previous perioperative difficulties are due to allergies to anesthetic or pain medications. The incidence of true anaphylactic and anaphylactoid reactions during anesthesia is in the range of 1 in 6000; muscle relaxants account for 69% of these reactions, followed by latex (12%) and antibiotics (8%).117 A careful history will allow avoidance of precipitating agents; premedication with histamine blockers and steroids is not generally recommended. Anaphylactic reactions to amide local anesthetics are extremely rare. Allergies to preservatives such as para-aminobenzoic acid used with esters are more common. Patients may perceive, especially with dental procedures, adverse side effects from epinephrine in local anesthetic solutions as allergies, and this needs to be carefully distinguished. Similarly, true allergies to opioids are rare, and opioid side effects, such as nausea and emesis, may be misinterpreted as allergies. Skin testing can be used to determine the presence of a true allergy. Allergies to muscle relaxants are more common; there are no reports of anaphylaxis to volatile anesthetics. Penicillin is the most common cause of anaphylaxis; however, of all who report an allergy, only about 10% to 20% actually have a true allergy. There is a small risk of cross reactivity with cephalosporins, but most of these reported reactions involve

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rashes and not anaphylaxis. Anaphylactic reactions to solutions such as bacitracin or providone-iodine have only rarely been reported; contact dermatitis in association with these agents is a more common reaction. The rate of latex sensitization continues to increase; however, as better ways of identifying at-risk patients are developed, the incidence of latex-induced anaphylaxis is decreasing.118 Diagnosis of a latex allergy during preoperative evaluation is based on a careful history. Patients at risk for latex allergy include those with a history of multiple surgical procedures, health care workers, and those with atopic histories. When latex allergy is identified during the preoperative visit, the operative team should be notified in advance to ensure that all appropriate equipment is available. The ASA task force outlines in detail intraoperative considerations for these patients.119 The scientific status of multiple chemical sensitivity disorder is controversial. Patients with this disorder report chronic, diffuse, nonspecific symptoms with low levels of multiple chemical substances. Symptoms involve multiple organ systems and include fatigue, headache, memory loss, palpitations, and gastrointestinal symptomatology. The symptoms are not generally accompanied by biologic test abnormalities or changes on physical examination. This disorder is frequently associated with chronic fatigue syndrome and fibromyalgia.120 Performing a preoperative evaluation on these patients can be extremely difficult because patients have significant concerns about the multiple exposures involved during the perioperative period and the impact on their symptomatology. Cultural, historical, and behavioral issues, possibly in combination with some as yet undetermined physiologic abnormalities, may be responsible for the genesis of this disorder. There are no specific treatments and no current recommendations regarding perioperative care of these patients.

tinct from OSA. OHS is associated with awake, chronic hypoxemia (Pao2 <65mmHg) without a diagnosis of COPD or primary lung disease. These patients have impaired central ventilatory drive. Drugs or methods of weight reduction (purging, diuretics, laxatives, gastric bypass procedures) may result in electrolyte abnormalities, vitamin deficiencies, malnutrition, anemia, and cardiopulmonary disorders. Fenfluramine and dexfenfluramine, unavailable since 1997, caused mainly regurgitant valvular lesions and pulmonary hypertension. It is recommended that anyone ever exposed to these drugs undergo a cardiovascular evaluation. An ECG and echocardiogram (frequently done in the past) are recommended for those suspected of having dysfunction. The preoperative history and physical examination focus on the airway, a history of snoring or daytime sleepiness, the cardiopulmonary system, and vital signs, including pulse oximetry. The BP cuff needs to have a width of approximately two thirds that of the arm and a length to adequately encircle the extremity. Neck circumference predicts difficulty with intubation. Depending on the history and physical findings, additional testing may be indicated. These patients also have an increased incidence of OSA, which can be associated with pulmonary and systemic hypertension, left and right ventricular hypertrophy, and an increased incidence of arrhythmias, MI, and stroke.122

Preoperative Evaluation of Patients with Obstructive Sleep Apnea


Sleep-disordered breathing affects up to 9% of middle-aged women and 24% of middle-aged men; less than 15% of these cases have been diagnosed. Asking patients whether they snore, about the intensity of their snoring and whether it bothers others, about observed awakenings or choking, about daytime sleepiness and whether it interferes with activities, and about falling asleep while driving can identify those with probable sleep apnea. OSA, the most common serious manifestation of sleep-disordered breathing, is caused by intermittent airway obstruction. OSA is characterized by total collapse of the airway with complete obstruction for more than 10 seconds. Obstructive hypopnea is partial collapse (30% to 99%) associated with at least 4% arterial oxygen desaturation. The severity of OSA is measured with the apneahypoxia index, or the number of apneic and hypopneic episodes per hour of sleep. Patients with severe OSA have more than 30 episodes per hour. Cardiovascular disease is common in patients with OSA. These patients have an increased incidence of hypertension, atrial fibrillation, bradyarrhythmias, ventricular ectopy, endothelial damage, stroke, heart failure, pulmonary hypertension, dilated cardiomyopathy, and atherosclerotic CAD.60 Mask ventilation, direct laryngoscopy, endotracheal intubation, and even fiberoptic visualization of the airway are more difficult in patients with OSA than in healthy patients (see Chapters 50 and 64). Patients with OSA are more sensitive to the respiratory depressant effects of opioids than individuals without OSA are. Preoperative evaluation should focus on identifying patients at risk for OSA and improving associated comorbid conditions in those with OSA. Echocardiography may be indicated if heart failure or pulmonary hypertension is suspected. Many of these patients are obese, and even if not, many of the same issues

Preoperative Evaluation of Morbidly Obese Patients


A morbidly obese patient presents a special set of preoperative risks (see Chapter 64). Obesity is associated with an increased incidence of risk factors, including diabetes and cardiovascular disease. These patients have a higher incidence of difficult tracheal intubation, decreased arterial oxygenation, increased gastric volume, decreased gastric pH, postoperative wound infection, pulmonary embolism, and sudden death.121 Obesity is an independent risk factor for heart disease. Hypertension, stroke, hyperlipidemia, osteoarthritis, diabetes mellitus, cancer, and obstructive sleep apnea (OSA) are more common in obese people. Obese individuals have increased oxygen consumption and work of breathing but decreased lung volume and capacity. They have LVH and often decreased functional capacity. They frequently complain of dyspnea, which may be related to cardiac or pulmonary insufficiency or deconditioning. They are at risk for nonalcoholic steatohepatitis, also known as fatty liver, which results in elevated LFT values and can progress to fibrosis. Preoperative evaluation should be directed toward coexisting diseases. Patients with extreme obesity are at risk for heart failure and pulmonary hypertension. Obesity-hypoventilation syndrome (OHS), also known as pickwickian syndrome, is dis-

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that apply to obese patients affect those with OSA. Patients should be instructed to bring their continuous positive airway pressure devices to the hospital on the day of surgery. Postoperative pain management and monitoring are critical.

Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome


The HIV pandemic has spread to every country in the world. Acute infection with the virus causes a mononucleosis-like illness that progresses to chronic lymphadenopathy (lasting 3 to 5 years) and culminates in a cell-mediated immune deficiency characterized by opportunistic infections, malignancies such as Kaposis sarcoma and non-Hodgkins lymphoma, and death, usually secondary to infections, wasting, or cancer. Risk factors for HIV infection include sexual contact with an infected individual, blood-borne contamination, men who have sex with men, sexual workers, and those having contact with sexual workers. Most infection transmitted by blood exposure occurs in intravenous drug users, and infection via transfusion in the United States is rare (1 per 1.5 to 2 million blood transfusions). Mothers can transmit the disease to their infants, usually during breastfeeding or delivery.123 Minority populations are at increased risk for HIV infection. Many patients infected with HIV are unaware of their status. HIV can affect all organs and cause multiple complications. Myocarditis, dilated cardiomyopathy, valvular disease, pulmonary hypertension, pericardial effusions, and tamponade are possible. Antiretroviral-induced lipodystrophy causes CAD. Pulmonary infections with Pneumocystis jiroveci, Mycobacterium avium or tuberculosis, cytomegalovirus, and Cryptococcus are common and often drug resistant. Central nervous system tumors, infections, aseptic meningitis, and acquired immunodeficiency syndrome (AIDS)-related dementia occur, as well as lymphomas, Kaposis sarcoma, cervical cancer, and lymphoid interstitial pneumonitis. Supraglottic or intraoral Kaposis sarcoma may interfere with ventilation and intubation; non-Hodgkins lymphoma can cause mediastinal masses. Dysphagia, diarrhea, esophagitis, and renal dysfunction can lead to malnutrition, dehydration, and electrolyte imbalance (hyponatremia and hyperkalemia are the two major electrolyte disorders). Acute tubular necrosis, glomerulonephritis, renovascular disease, and HIV-associated nephropathy with nephritic syndrome can be present. The nucleoside reverse transcriptase inhibitors (i.e., zidovudine, didanosine, stavudine, lamivudine, abacavir, emtricitabine) may cause lactic acidosis, electrolyte abnormalities, neuropathy, autonomic dysfunction, gastrointestinal upset, renal or hepatic dysfunction, and pancreatitis. Zidovudine can cause pancytopenia. The preoperative evaluation may illicit a history of thrush, fever of unknown origin, chronic diarrhea, lymphadenopathy, or herpes zoster in more than one dermatome. In a relatively young, otherwise healthy individual, this should raise concern of HIV infection. The enzyme-linked immunosorbent assay (ELISA) is the primary screening test and is greater than 99% sensitive but has a high number of false-positive results. The Western blot technique is used to confirm ELISA results. Patients with known HIV infection will frequently require further evaluation, including an ECG, CBC with platelets, determination of electrolytes, BUN, and creatinine, LFTs, and a chest radiograph, depending on

the surgical procedure. If malnourished or evidence of nephritic syndrome is present, measurement of albumin, total protein, and magnesium levels may be beneficial. Determining the CD4+ lymphocyte cell count and viral load, which reflects the patients immunologic status during the previous 3 months, can have prognostic value. A 13% mortality rate within 6 months of surgery has been reported when the CD4+ count is less than 50/mm3 and a 0.8% mortality rate with CD4+ counts greater than 200/mm3.109 Antiretroviral therapy is continued perioperatively.

Section IV Anesthesia Management

Evaluation of Patients with a History of Substance Abuse


A patient with a history of current or previous alcohol or drug addiction presents special challenges for the perioperative team (see Chapter 101). Although the prevalence of these addictions is significant (14% and 7%, respectively), there is limited information based on prospective clinical trials to guide perioperative management.124 The preoperative evaluation allows an opportunity to obtain a detailed history of addiction and recovery. Addictive disease is considered permanent, even in patients who have had long periods of abstinence. If a patient is in recovery, knowledge of the dosages and effects of medications used for maintenance of recovery is essential. Verification of all medication doses is vital. In a recovering patient, anxiety may be heightened as a result of concern about the possibility of both relapse into addiction and inadequate pain treatment because of the history of addiction. The patient should be assured during the preoperative interview that anxiety and pain will be adequately treated. Clinicians may have prejudicial attitudes and may lack the educational background to formulate appropriate plans for pain management. Pain medication may be inadequate and restricted because of concern about provoking a relapse. Identifying these at-risk patients during the preoperative evaluation and involving the acute pain service to assist in management may be helpful. Patients who are actively abusing cocaine and amphetamines are at significant risk during anesthesia because of intraoperative hemodynamic instability. Urine testing (especially on the day of surgery) is appropriate to ensure the absence of abused substances in patients about to undergo procedures. Patients who are currently substance abusers have a variety of clinical manifestations, depending on the drug abused. Jage and Heid suggest classifying the substances into three categories: central nervous system depressors (e.g., heroin, alcohol, sedatives, hypnotics), stimulants (e.g., cocaine, amphetamines), and other psychotropic substances (e.g., cannabis).125 The preoperative period should be used to plan for appropriate management. Heroin addicts may require substitution with methadone, and those addicted to alcohol, sedatives, or hypnotics may require stabilization with benzodiazepines. Discussion of regional techniques, avoidance of inadequate analgesia, and optimization of analgesia with non opioids is essential. Inadequate analgesia can potentially activate addiction. All information and potential management plans should be clearly transmitted to members of the operative team. Many addicts are polysubstance abusers, and psychiatric disorders are common comorbid conditions. Addicts may be at risk for a myriad of perioperative complications, including withdrawal, acute intoxication, altered tolerance of anesthetic and

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opioid medications, infections, and end-organ damage.126 Intravenous drug use should prompt an evaluation for cardiovascular, pulmonary, neurologic, and infectious complications such as endocarditis, abscesses, osteomyelitis, hepatitis, and HIV infection or AIDS. Alcohol abusers are specifically at risk for potentially life-threatening withdrawal with autonomic instability and hyperpyrexia. Cocaine and amphetamine addicts can have cerebrovascular accidents, cardiomyopathy, and arrhythmias. Additionally, cocaine and amphetamine inhibit the uptake of sympathomimetic neurotransmitters, increase BP, raise HR, and can cause paranoia, anxiety, seizures, angina, and MI (even in patients without CAD).127 Long-term use causes ventricular hypertrophy, myocardial necrosis, and nasal septal perforation. Solvents can cause cardiac dysrhythmias, pulmonary and cerebral edema, diffuse cortical atrophy, and hepatic failure. Hallucinogens, including lysergic acid diethylamide (LSD), can cause autonomic dysregulation and paranoia. 3,4-Methylenedioxymethamphetamine (MDMA), commonly known as ecstasy, can cause excessive thirst, resulting in hyponatremia and pulmonary or cerebral edema. Alcoholics are at risk for alcoholic hepatitis, cirrhosis, portal hypertension, cardiomyopathy, arrhythmias, seizures, neuropathies, dementia, Wernicke-Korsakoff syndrome (ataxia, cognitive dysfunction), and macrocytic anemia from vitamin deficiencies, delirium tremens, pneumonia, gastrointestinal bleeding, and coagulopathies secondary to either hepatic dysfunction or vitamin K deficiency. Marijuana can affect the cardiovascular and autonomic nervous systems and result in tachycardia, dysrhythmias, ECG abnormalities (T-wave and ST-segment changes), and increased cardiac output. Patients who smoke marijuana are at the same risk as patients who smoke tobacco. Opioid (including heroin) users will have a tolerance to narcotics. It is important to document dosages of opioids taken, as well as any drugs to treat addiction such as methadone, clonidine, or buprenorphine (Suboxone or Subutex; with and without naloxone, respectively), a partial -agonist. Patients who are receiving opioid substitution therapy will experience normal pain responses to nociceptive stimuli and will require additional analgesia for control of postprocedure pain.128 Patients who use alcohol or prescription opioids to excess or illicit drugs may not give a reliable history. Vital signs, including temperature, are needed. Cocaine and amphetamines may raise BP and HR. Acute opioid use can slow the respiratory rate and cause lethargy and pinpoint pupils. Alcohol can often be detected by smell. Examination of venous access sites for signs of abscesses and skin and soft tissue infections is important. Auscultation for murmurs in intravenous drug users is essential. Symptoms and signs of heart failure or arrhythmias may be present in cocaine or alcohol abusers. Long-term use of alcohol causes liver dysfunction (see the appropriate section). Preoperative testing depends on symptoms and findings from the history and physical examination. An ECG may be warranted in patients taking methadone because this drug can cause prolongation of the QT interval. It is important to ascertain whether and for how long patients can stop consuming alcohol or addictive drugs. In addition, more importantly, what happens when they do interrupt use? Does delirium tremens develop; do they have seizures or other signs of withdrawal? Ideally, patients with drug or alcohol dependence should be drug free well before elective surgery. Acute preoperative abstinence in alcoholics, however, has been associated with a poorer outcome postopera-

tively than if drinking is continued.129 Preanesthesia clinic staff should be prepared to refer patients to addiction specialists or programs or prescribe medications to prevent withdrawal in the preoperative period if patients agree to abstinence. Benzodiazepines are useful in preventing or treating alcohol withdrawal symptoms. Patients with a history of alcohol abuse who are taking disulfiram may have an altered response to sympathomimetic drugs; Hernandez and coworkers suggest that this agent be discontinued 10 days before surgery. If disulfram is continued, users can be sensitive to small amounts of alcohol (even from skin preparations or medications) and can experience flushing, nausea, and tachycardia. These authors also suggest that patients taking naltrexone for a history of alcohol or opioid abuse discontinue the drug 3 days before surgery. Patients taking SSRIs or methadone should continue maintenance doses. Marijuana users should be advised to avoid use at least 7 days before surgery because of its long half-life.124 Patients on methadone maintenance regimens continue the drug through the day of surgery. Because it may be difficult to overcome the analgesic agonist effect of Suboxone, it should be stopped 3 days before surgery. Patients may require substitution to avoid relapse of addiction during this period. Preoperative consultation with pain or addiction specialists (or both) may be useful for opioid abusers or patients taking methadone to combat addiction if the planned procedure will result in significant postoperative pain.

Preoperative Nutritional Evaluation


Patients who need surgery may be malnourished, either because of a chronic disease process (e.g., cancer or difficulty swallowing after a stroke) or because of a medical condition such as intermittent bowel obstruction (see Chapter 95). Malnutrition is associated with postoperative complications ranging from a prolonged hospital stay for patients undergoing total hip replacement to more major morbidity, such as wound breakdown, abscesses, infections, anastomotic breakdown, respiratory failure, and death.130,131 There is clear evidence that preoperative nutrition therapy in appropriate patients can reduce postoperative complications. TJC emphasizes the importance of preoperative nutritional evaluation and planning by requiring that nutritional screening be performed within 24 hours of admission, with full nutritional assessment in at-risk patients. Organizations must establish guidelines for nutrition screening and assessment that will identify patient characteristics known to be associated with nutrition problems and appropriately refer for planning. Reasonable agreement exists about predictive indicators of poor nutritional status: weight loss greater than 10% in the 6 months before surgery, change in dietary intake relative to normal, gastrointestinal symptoms that persist for longer than 2 weeks, decreased functional capacity (from lethargic to bedridden), and other physical factors such as loss of subcutaneous fat, muscle wasting, ankle edema, sacral edema, and ascites. Detsky and colleagues have incorporated these factors into the Subjective Global Assessment Scale.132 The physical factors are rated as normal (0), mild (1+), moderate (2+), or severe (3+). Because of the high incidence of elective procedures that occur without previous admission, screening and assessment by TJC guidelines can be done either during the preoperative visit or during the first 24 hours of admission. This

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makes it extremely difficult to implement preoperative nutrition support in patients who may benefit. Kudsk reported that in a group of patients undergoing gastrointestinal procedures, TJCrequired assessments were performed in the vast majority of cases between 12 and 25 hours after surgery.133 As a result, although the TJC mandate was met, the clinical team did not have the opportunity to provide preoperative nutrition support if indicated. Proper identification of at-risk patients would best be accomplished at the time of preoperative assessment and in an outpatient setting to allow time for implementation of preoperative nutrition plans. The best places to look for loss of subcutaneous fat are the triceps region of the arms, the midaxillary line at the costal margin, the interosseous and palmar areas of the hand, and the deltoid region of the shoulder. Muscle wasting is best assessed in the quadriceps femoris and deltoid region. The nutritional status of patients can be classified A (well nourished), B (moderately malnourished; weight loss of 5% to 10% without stabilization or weight gain, poor dietary intake, and mild loss of subcutaneous tissue), or C (severely malnourished; ongoing weight loss of >10%, severe subcutaneous tissue loss, muscle wasting, and edema). A serum albumin level of less than 3.5g/dL in the general surgical population or less than 3.9g/dL in patients who need total hip replacement is an accurate predictor of malnutrition.130,131 Serum albumin less than 2.1mg/dL was a strong predictor of mortality in veterans undergoing major noncardiac surgery.75 The combination of history plus physical examination and serum albumin level provides slightly improved accuracy in predicting malnutrition than either indicator alone does. When possible, nutritional status should be improved preoperatively in severely malnourished patients. Enteral nutrition is the preferred means, but if the gut cannot be used, total parenteral nutrition (TPN), though not without its own risks, is acceptable. In a Veterans Affairs study, severely malnourished patients who received TPN had fewer noninfectious complications than controls did (5% versus 43%), with no concomitant increase in infectious complications.80

1993 the ASA adopted guidelines for the care of these patients and updated them in 2001 (Box 34-7).134 Frequently, in circumstances with DNR orders, care providers are focused on a procedure-directed approach (i.e., do not intubate, no resuscitative drugs), which is problematic in the perioperative period when much of anesthesia care involves this approach. It has been suggested that a better tactic would be to discuss DNR status in the context of anesthesia in a goal-directed approach (i.e., from the perspective of the patients values and objectives, such as qualityof-life concerns).135 The ideal time to discuss this emotional, complex issue is during the preoperative evaluation. It has been shown that short discussions in a preoperative clinic can foster dialogue among patients, their proxies, and physicians regarding advance directives concerning end-of-life care. A durable power of attorney was completed by 27% of intervention patients versus 10% of controls, and 87% of the intervention group discussed end-of-life care with the appropriate individuals versus 66% of the control group.136
Box 34-7 Do-Not-Resuscitate Orders in the Perioperative Period Policies automatically suspending DNR orders or other directives that limit treatment before procedures involving anesthetic care may not sufficiently address a patients rights to self-determination in a responsible and ethical manner. Such policies, if they exist, should be reviewed and revised, as necessary, to reflect the content of these guidelines. 1. Full Attempt at Resuscitation: The patient or designated surrogate may request full suspension of existing directives during anesthesia and the immediate postoperative period, thereby consenting to the use of any resuscitation procedures that may be appropriate to treat clinical events that occur during this time. 2. Limited Attempt at Resuscitation Defined with Regard to Specific Procedures: The patient or designated surrogate may elect to continue to refuse certain specific resuscitation procedures (e.g., chest compressions, defibrillation, or tracheal intubation). The anesthesiologist should inform the patient or designated surrogate about which procedures are (1) essential to the success of anesthesia and the proposed procedure and (2) which procedures are not essential and may be refused. 3. Limited Attempt at Resuscitation Defined with Regard to the Patients Goals and Values: The patient or designated surrogate may allow the anesthesiologist and surgical team to use clinical judgment in determining which resuscitation procedures are appropriate in the context of the situation and the patients stated goals and values. For example, some patients may want full resuscitation procedures to be used to manage adverse clinical events that are believed to be quickly and easily reversible but to refrain from treatment of conditions that are likely to result in permanent sequelae, such as neurologic impairment or unwanted dependence on life-sustaining technology.
From Committee on Ethics, American Society of Anesthesiologists: Ethical guidelines for the anesthesia care of patients with do not resuscitate orders, 2001. Available at http://www.asahq.org/ publicationsAndServices/standards/09.html.

Section IV Anesthesia Management

Breastfeeding Patients
There is little science to guide recommendations for the safety of anesthetics and medications in the babies of mothers who breastfeed and receive these agents. For elective cases, women need to be advised to pump and store milk preoperatively, which can be used in the first 24 hours after administration of an anesthetic or for the duration of breast milk exposure to potentially harmful agents. The mother should discard milk produced within the first 24 hours after anesthesia and generally resume breastfeeding after this period. Very young or premature babies, especially those at risk for apnea, may have complications if the mother continues to take opioid or sedating drugs. Mothers should be advised to discuss with their childs pediatrician the safety of breastfeeding while taking medications.

Patients with Do-Not-Resuscitate Orders


Some patients scheduled for procedures will have advance directives or a do-not-resuscitate (DNR) status (see Chapter 97). In

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Pseudocholinesterase Deficiency
A personal or family history of pseudocholinesterase (specifically, butyrylcholinesterase) deficiency should be identified preoperatively (see Chapter 29). When patients report an allergy to succinylcholine, one should suspect this disorder or MH. Inquiring whether the patient had to remain intubated postoperatively, was gravely ill, or required intensive care may help differentiate these disorders. Pseudocholinesterase activity may be reduced permanently because of abnormal genotypes or transiently altered because of disease, drug effects, parturition, or infancy. Patients should be educated that this enzyme also metabolizes ester-linked local anesthetics. Preoperative records from previous anesthesia may clarify an uncertain history. A dibucaine number and plasma pseudocholinesterase, chloride, and fluoride levels should be obtained. The dibucaine number is a measure of the qualitative activity of pseudocholinesterase and is the percentage of inhibition of the enzyme by the local anesthetic dibucaine. Normal individuals are homozygous for the wild type, and their dibucaine number is 80 because their plasma cholinesterase is 80% inhibited by dibucaine. Those who are homozygous for the atypical genes have a dibucaine number of 20 because of 20% inhibition. Heterozygous individuals have a dibucaine number of 60 because of approximately 60% inhibition. The plasma cholinesterase level is a quantitative measure of this enzyme. Plasma cholinesterase should not be confused with cholinesterase activity, which is an assessment of erythrocyte or red blood cell cholinesterase. The combination of dibucaine number and plasma cholinesterase can differentiate genetic from nongenetic causes of prolonged apnea after the administration of succinylcholine. A transient decrease in pseudocholinesterase activity as a result of drug interactions or other identified reasons has been observed soon after episodes of suspected pseudocholinesterase deficiency, so diagnostic testing should be delayed at least 24 hours. Patients with known or suspected pseudocholinesterase deficiency should be urged to obtain proper identification (Web search for medical alert identification).

Malignant Hyperthermia
A history of MH or a suggestion of it (hyperthermia or rigidity during anesthesia) in either a patient or family member should be clearly documented so that special arrangements can made before the day of surgery (see Chapter 37). Individuals are genetically predisposed to MH and are asymptomatic until exposed to triggering agents. Certain neuromuscular diseases are associated with a risk for MH, including Duchennes, Beckers, and myotonic muscular dystrophies, King-Denborough syndrome, central core disease, periodic paralysis, osteogenesis imperfecta, myelomeningocele, and strabismus.

practitioners who can function well in roles both inside and outside the operating room. Optimal preoperative assessment, as well as continued improvement, will rely on properly educating anesthesiologists in the skills of physical diagnosis and patient assessment, personnel and business management, and conducting and understanding outcome-based research in this area. It is unrealistic to expect the next generation of anesthesiologists to successfully manage administrative and clinical roles in perioperative medicine without adequate exposure during residency training. A survey of training programs published in 2001 revealed that although almost all program directors agreed that competency in preoperative evaluation was an important skill, less than half had a formal curriculum in this area, nearly 50% did not teach patient interview skills, and 39% of programs did not expose their residents to a preoperative clinic experience.137 The American College of Graduate Medical Education (ACGME) has recognized the importance of adequate training in this area during anesthesia residency. Requirements have been amended and became effective in July 2008; requirements in preoperative education have been increased and more specifically defined.138 During the 3 clinical anesthesia training years, 1 month must be spent in a preoperative evaluation clinic. This may occur in divided rotations not less than 1 week in length. Successive experiences must reflect increased responsibility and learning opportunities. Program objectives must include adequate training not only in the clinical aspect of preoperative assessment but also in interpersonal skills, effective communication, and business practices. Practice management, operating room management, and systems-based practice issues should be included in the curriculum. Assessment of skills in this area requires a definition of objectives. Instruments for assessing resident performance in this area should be developed. A Preanesthesia Consultation Scoring Checklist has been developed that contains 37 items grouped into the domains of physician-patient relationship, medical history, physical examination, patient education, and preanesthesia records.139 This instrument was shown to have high construct validity, moderate internal consistency, and high probability of inter-rater agreement. Analysis of the scores could reliably assess resident performance at the defined criteria. The development of similar instruments in conjunction with the institution of a specific curriculum in preoperative evaluation will be of great help in assessing resident performance, as well as in meeting ACGME requirements.

Meeting Regulatory and Reporting Requirements


Appropriate and safe clinical assessment includes elements that are considered standard of care medically, in addition to elements that are requirements mandated by outside agencies. These outside agencies may be those mandating practice for quality accreditation, such as the TJC. Agencies may mandate practice for payment, such as the Center for Medicare and Medicaid Services (CMS) or other agencies that provide payment based on practice or performance. A detailed discussion of the use of technology in the preoperative clinic to meet requirements will follow in a later section. Regulatory requirements may exist internally as well. Institutions generally develop practice guidelines or standards,

Residency Training in Preoperative Evaluation


The evolution of preoperative evaluation, as well as the anesthesiologists role in this area, challenges training programs to educate

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and it is incumbent on all practicing clinicians to abide by the standards of their respective institutions. A number of these standards involve preoperative care issues, and a number of requirements for accreditation by TJC involve preoperative issues. These requirements are described in detail in the TJC manual referenced and are available through the TJC website (www.jointcommission.org). As far as the timing of preoperative assessment is concerned, TJC requires that the history and physical examination be completed within 30 days before the procedure and that a reassessment be done within the 24-hour period immediately preceding the surgery. No other TJC requirements exist regarding the timing of assessments, consents, or laboratory testing. It should be realized, however, that insurance payers might have specific requirements regarding the timing of assessments in relation to the surgical procedure and payment; providers may obtain information from their respective institutional compliance departments about the timing of assessments and payment by carrier. Hospital policies must ensure that patients have the right to refuse care, treatment, and services in accordance with the law. When the patient is not legally responsible, the surrogate decision-maker has the right to refuse care on the patients behalf. To this end, the hospital must have a framework for ensuring that such advance directives are completed. TJC requires that the hospital document and have available to clinicians the patients decision regarding such advance directives. The preoperative visit is an opportunity to supply the patient with information regarding advance directives, as well as to document the patients wishes regarding such directives. TJC also requires that patients with special needs be assessed and these needs addressed. Such patients may be victims of abuse or neglect, alcohol or substance abusers, patients with significant emotional or behavioral disorders, and patients with specific nutritional needs. These assessments can be performed and documented at the time of the preoperative evaluation. Many of these elements are documented as portions of the patients nursing assessment, which TJC mandates be performed on each patient by a registered nurse. The preoperative history and physical examination may be performed by any licensed practitioner who is credentialed to do so. The anesthesia assessment may be performed by a physician or advanced practice nurse (nurse practitioner or certified registered nurse anesthetist) with appropriate training. TJC mandates that pain be assessed in all patients. A comprehensive pain assessment can be performed as part of the preoperative nursing or physician assessments. Establishing a baseline for the pattern of pain existing preoperatively is extremely important in formulating a postoperative care plan. Patients who are taking significant amounts of narcotics and other pain relievers preoperatively can be identified and appropriate postoperative care plans formulated and communicated to the perioperative care team. TJC also supports a number of National Patient Safety Goals (NPSGs).140 How an appropriate preoperative process can advance achievement of the 2007 NPSGs is illustrated in Table 34-6.

Table 34-6 Role of the Preoperative Clinic in Achieving National Patient Safety Goals 2007 National Patient Safety Goal Improve the accuracy of patient identification

Preoperative Clinic Role Use two patient identifiers when doing evaluation or testing; verify that all information on the operating room chart is correctly labeled Communicate patient issues among multidisciplinary perioperative care providers Use a standardized list of abbreviations in the preoperative chart; eliminate the use of acronyms Identify and transfer information to the operating room and postoperative areas regarding patients colonized with antibioticresistant organisms Begin a single accurate list of prescription and nonprescription medications and dosages that can follow the patient throughout the perioperative experience Perform patient and family education related to the upcoming procedure

Section IV Anesthesia Management

Improve the effectiveness of communication among caregivers Reduce the risk of health care associated infection Accurately and completely reconcile medications across the continuum of care Encourage patients active involvement in their own care as a patient safety strategy Identify safety risks inherent in its patient population

Establish and implement a universal protocol to prevent wrong-sided procedures; verify sidedness at the time of preoperative assessment and correct errors

Preoperative Medical-Legal Issues


In a malpractice action involving preoperative professional negligence, the burden is on the plaintiff to show the generally rec-

ognized standard of medical care, deviation from that standard by the defendant, and that the deviation was the proximate cause of the patients alleged injuries (see Chapter 10). Expert testimony is generally used to demonstrate the standard of care, as well as deviation from such standards. The ultimate decision of whether practice deviated from the standard of care should be a matter of fact, not opinion. However, in the preoperative area, many clinical standards are in actuality only guidelines based on general consensus or expert opinion, not on outcome data from large population-based studies. Compliance with the specific institutional guidelines, as well as with guidelines and standards set forth by credible groups such as the TJC and ASA, is heavily considered. The court generally accepts statements from these groups regarding definitions of standard of care. For example, there are a number of cases in which performance of preoperative assessment as defined by the TJC or guidelines for preoperative assessment as defined by the ASA have been placed into evidence as defining standard of care. Understanding the components of proper informed consent and establishing an effective system for obtaining consent are critical elements of the preoperative process. A review of legal decisions in this area by Raab has attempted to define appropriate parameters.141 The absence of appropriate informed consent can result in consideration of the tort of battery. Lack of adequate informed consent has also been found to constitute the main cause of negligence, even when malpractice or substandard care cannot be proved. Courts apply either of two standards for adequate disclosure; one refers to what a reasonable clinician would consider important to the patients decision (reasonable practitioner standard), and the other is whether the clini-

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cian has disclosed what a prudent patient would need to know in order to make an intelligent decision (prudent patient standard). These are different legal concepts that are applied on a state-bystate basis. The law requires that nontrivial risks be disclosed; extremely rare complications need not be disclosed. As far as disclosure regarding risks associated with anesthesia is concerned, Raab believes that the risk of anesthesia-related death or severe injury in a patient whose health is otherwise reasonably good would be in the range of a rare consequence; however, most reasonable patients would still want to be aware of this. The signed consent form is documentation that such discussions have occurred. Raab thinks that the dilemma regarding informing patients of rare probabilities of anesthesia complications remains unsolved. With regard to surgical informed consent, a closed claims analysis has revealed that documentation of discussion in the surgeons office notes was a significant factor in reducing indemnity risk, regardless of whether the actual consent form was signed by the surgeon, resident, or nurse practitioner.142 Clinicians may be concerned about liability in overordering or underordering preoperative testing. In general, clinicians are not held liable for errors in judgment; liability holds only when the testing rendered would be considered to fall below accepted standards of practice.143 It is extremely difficult to decide what is standard of practice for routine preoperative laboratory testing because of numerous articles demonstrating lack of impact of routine preoperative screening tests on management. However, failure to order appropriate laboratory testing that would diagnose an important presurgical comorbidity would imply that the clinician had performed a substandard assessment. This emphasizes the importance of a complete and well-documented preoperative history and physical examination with testing geared toward comorbid diseases revealed by this evaluation. Routine screening batteries in the setting of inadequate evaluation would seem to put the clinician at a much greater risk of missing an important preoperative condition. A review of more than 400 diagnostic malpractice claims in the outpatient setting would support this view.144 These investigators reported that the most common breakdowns in the diagnostic process were failure to obtain an adequate history or perform an adequate physical examination, failure to order a specific diagnostic test, failure to follow up on rest results, and incorrect interpretation of test results. A clinician who has informed discussions with the presurgical patient and documents a proper history, physical examination, and anesthesia and nursing assessment in the chart would minimize medical-legal risk. Additionally, the clinician must provide chart evidence of discussions regarding consent, risks, and alternatives; orders of preoperative testing geared to the results of the patients particular assessment, along with appropriate follow-up of the abnormalities documented; and notes that all the patients questions were answered.

Information Technology and Decision Support Systems in Preoperative Evaluation


Decision support algorithms can suggest appropriate clinical management and preoperative testing based on factors docu-

mented in the patients history and physical examination (see Chapter 4). These algorithms can be generated by clinical leadership and distributed as part of the educational and orientation process for the preoperative clinic providers. Appropriate use of clinical and testing algorithms by clinicians, even in the absence of computer-based prompts, has been demonstrated to decrease laboratory costs as a result of unnecessary or unreimbursed testing and consultations.145 Algorithms can be built into computer-based programs; integration with patient data stored as part of the hospitals electronic medical record would be particularly valuable. Because institutions frequently store data in programs using different platforms, there is often difficulty in attempting to integrate multiple data storage programs within a single institution and even greater difficulty in considering complete integration of patient data with commercially available systems. Despite the potential benefits, there are a number of barriers to implementation of electronic preoperative systems. The lack of uniformity in coding medical conditions presents significant impediments to computer-based preoperative assessment systems. Coding of physician data is extremely complex, in contrast to computer recording of laboratory data. Most of the commercially available systems involve pull-down menus, which may or may not be consistent with the physicians thought processes. Pull-down menus may result in information being recorded where it best fits and therefore may not be completely accurate. The use of free text results in loss of the ability to generate a plan based on decision support and also prevents the use of aggregate data for reporting. Coding needs to be recorded in such a way that the data can be used for individual patient billing, as well as in aggregate for reporting of quality performance measures. It will be difficult to demonstrate an impact of quality reporting programs on clinical outcomes until adequate physician coding through information technology can be achieved. Because of lack of this focus in coding, regulatory quality reporting programs have been shown to influence hospital improvement activities but have not been shown to have a positive impact on outcomes.146 Confidentiality issues in protecting computer-based data from interception are of great concern. Unlike paper-based records, computer-stored data have the potential for security risks as a result of inappropriate access to information on large numbers of patients. Proper policies and education of staff regarding privacy issues are essential. The Health Insurance Portability and Accountability Act (HIPAA) is legislation regarding the privacy of health care information and related transactions. HIPAA requirements from the Department of Health and Human Services are outlined in their website (www.hhs.gov/ocr/hipaa). Business partners of health care institutions, such as billing agencies and insurance companies, must comply with these regulations as well. There is some concern that a change from manual to computer-based data entry during the patient visit would decrease the efficiency of established workflow patterns. The effect on the patient interview needs to be considered as well. Clinicians will need to ensure that the quality of the interview does not suffer as they divide their time between the computer terminal and the patient. The resource savings may not be demonstrated if information is merely being typed instead of written, thus again emphasizing the need for integration among platforms and reduction of requirements for free text entry. There is no evidence-

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based literature demonstrating truly successful implementation, quality outcomes, and resource management with either commercially based or internally developed systems that address all of the necessary elements. Groups such as Leapfrog and the National Surgical Quality Improvement Program have encouraged the development and use of such systems to record and report quality indicators and develop technologies to improve patient safety (www.leapfroggroup.org and www.acsnsqip.org). Because of the difficulties described with development and implementation of technology, adaption has been slow.147 No off-the-shelf products are available, and no standards have been developed between vendors and institutions. Regulatory groups promote the ability of such systems to decrease errors and improve standardization and safety. Physicians are concerned about cost and the impact on workflow. The use of such systems may actually increase physician workload; one study estimated that computerized order entry would require 5% of a residents weekly work hours.148 Again, the ability of integration to allow medications already known in primary care and specialists offices to be automatically entered into preoperative and order entry systems would vastly increase their appeal and efficiency. Appropriate technology can address the TJC mandate regarding medicine reconciliation. According to this mandate, providers must enter an accurate single list of all prescription and nonprescription medications and dosages that starts at the time of entrance into the hospital for services. Development of such preoperative systems and incorporation into automated electronic perioperative information systems will aid in achieving efficient assessment before surgery. Acceptance of such systems and adequate patient and clinician use will require instruction, encouragement, and delineation of potential impact for improvement of the perioperative process.

Box 34-8 Factors Influencing Surgical Site Infection after Clean Surgery Patient Risk Factors Age Nutritional status Diabetes

Section IV Anesthesia Management

Obesity Factors Associated with Preoperative Preparation Preoperative antiseptic showering Preoperative hair removal Preoperative antibiotic prophylaxis Factors Associated with the Procedure Preoperative hand and arm antisepsis Length of the procedure Surgical technique

Preoperative Involvement in Prevention of Surgical Site Infections


The preoperative visit provides an opportunity to intervene in the prevention of surgical site infections (SSIs). The Centers for Disease Control and Prevention (CDC) has used the National Nosocomial Infections Surveillance system to monitor nosocomial infections in acute care hospitals in the United States since 1970. Detailed information on this topic can be found on the CDC website (http://www.cdc.gov). In addition to considerable morbidity and mortality, SSIs significantly increase health care costs.149 The CDC has developed standardized criteria for defining SSIs so that surveillance and comparisons can be done. Many institutions monitor the incidence of SSIs among various surgical services and procedures as a quality indicator. An analysis of ones own institutional performance and comparison with CDC benchmarks can yield extremely useful information. SSIs occurring after what would be defined by the CDC as clean surgery are probably due to certain factors, many of which can be identified during the preoperative visit (Box 34-8). The CDC recommends preoperative antiseptic showering. Preoperative showering with an antiseptic skin wash product is a well-accepted procedure for reducing skin bacteria, and showering on successive days with a

skin antiseptic reduces counts progressively. However, there are no clear studies showing a direct independent relationship between preoperative antiseptic showering and a lower incidence of SSIs. Nevertheless, because of the CDC recommendation, many institutions instruct preoperative patients to perform these showers. At Brigham and Womens Hospital in Boston, patients undergoing nonmucous membrane surgery are given a skin antiseptic at the time of their preoperative clinic visit and instructed to take an antiseptic shower on each of the 2 days before the procedure. The preoperative visit can also provide an opportunity to ensure that appropriate SSI prophylaxis is ordered. If an institution establishes suggested guidelines, these algorithms can be followed and antibiotic orders written and available in the chart when the patient arrives for surgery, which would allow ample time for administration as indicated in the recommendations.

Infective Endocarditis Prophylaxis


The preoperative evaluation can also be used to identify patients in need of antibiotic prophylaxis to prevent subacute bacterial endocarditis. The recommendations by the AHA that were last published in 1997 were updated in 2006 and have included significant changes from the previous version. In this update the committee concludes that administration of antibiotics solely to prevent endocarditis is not recommended for patients undergoing a procedure on the genitourinary or gastrointestinal tract. Prophylaxis for dental procedures is recommended only for patients with underlying cardiac conditions associated with the highest risk of an adverse outcome from infective endocarditis. Infectious endocarditis is thought to be more likely to develop from frequent exposure to bacteremia associated with daily activities than from bacteremia associated with a dental, gastrointestinal, or gastrourinary procedure. The risk of antibiotic-associated adverse events and the cost-effectiveness of prophylactic therapy are such that the benefits are outweighed. Under these revised guidelines, many fewer patients will be candidates for prophylaxis.

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The committee defined cardiac conditions associated with the highest risk for an adverse outcome from endocarditis. Such conditions include patients with prosthetic heart valves, unrepaired cyanotic congenital heart disease, congenital heart disease repaired with prosthetic devices for 6 months after the procedure (at which time endothelialization should have occurred), repaired congenital heart disease with residual defects, and cardiac transplantation with valvuloplasty. These are also the conditions for which prophylaxis during oral/dental procedures involving gingival manipulation or perforation of the oral mucosa are recommended, although the efficacy of such prophylaxis is unknown. Prophylaxis is recommended for the patients listed who are to undergo respiratory procedures that involve incision or biopsy of the mucosa. Prophylaxis for bronchoscopy is not recommended unless the procedure involves incision of the respiratory mucosa. Administration of prophylactic antibiotics solely to prevent endocarditis is not recommended for patients who undergo genitourinary or gastrointestinal procedures. Treatment is recommended if patients have an established infection or urinary tract colonization with enterococci. Antibiotics solely for the prevention of endocarditis are not recommended for patients with other cardiac conditions, including those with previous bypass surgeries or stents. Prophylaxis for patients after total joint replacement was reviewed and an advisory statement issued in 2003. According to this advisory, patients with joint replacement who are under going high-risk procedures may need preventive antibiotics. This includes all patients during the first 2 years after joint replacement, immunocompromised/immunosuppressed patients, patients with inflammatory arthropathies such as rheumatoid arthritis and SLE, and patients with comorbid conditions, including previous prosthetic joint infections, malnourishment, hemophilia, HIV infection, insulin-dependent diabetes, and malignancy. The statements conclude that prophylaxis is not indicated for patients with pins, plates, or screws. The preoperative clinic visit can be an opportunity to identify those with joint replacements requiring prophylaxis and to ensure that appropriate orders are available at the time that the patient arrives for the procedure so that optimal timing of antibiotic administration can occur. Recommended prophylaxis is amoxicillin, 2g orally in adults and 50mg/kg orally in children given 30 to 60 minutes before the procedure. This dose can be administered intravenously or intramuscularly if necessary. In patients allergic to penicillin, clindamycin (600mg orally, intramuscularly, or intravenously in adults or 20mg/kg orally, intramuscularly, or intravenously in children) can be used. Cephalexin (2g orally in adults and 50mg/ kg orally in children) or cefazolin (1g intramuscularly or intravenously in adults and 50mg/kg intramuscularly and intravenously in children) can be used unless the patient has a history of anaphylaxis, angioedema, or urticaria with penicillin.

Preoperative Planning for Postoperative Pain Management


The preoperative evaluation provides an important opportunity to discuss and plan for the management of acute postoperative pain (see Chapter 87). Patients may be extremely concerned about this issue. Patients with chronic pain conditions need to have a plan for the management of acute pain in the setting of the chronic situation. In institutions that have an acute pain service,

patients with particularly difficult management issues, patients taking large doses of analgesics, or patients with histories of analgesic abuse can be referred for consultation and appropriate perioperative managment. Patients can also be evaluated by the acute pain service postoperatively for management recommendations. In the absence of an acute pain service, the surgical service will generally be responsible for postoperative pain management. TJC is particularly concerned that patients with pain issues be appropriately assessed and treated. A baseline pain assessment is an important part of any preoperative evaluation and is generally performed as part of the nursing assessment.150 The preoperative pain standards in this regard state that patients have the right to appropriate assessment and management of pain and that pain must be assessed in all patients preoperatively. Standardization of pain measurement is difficult because of the subjective nature of the variable. Scales used fall into the categories of single-dimension scales, such as visual analog and numerical rating scales, and multidimensional scales, such as the McGill pain questionnaire.151 Figure 34-4 shows one example used for pain assessment in a preoperative evaluation. The location of the pain is noted on the figure; the character, duration, and frequency are documented, and intensity is recorded with a numerical rating scale from 1 to 10, with 1 being no pain and 10 being the worst pain imaginable. If a numerical scale cannot be used, a scale using faces can be substituted. Use of these scales readily allows comparison when reassessments are performed postoperatively. As part of the preoperative pain assessment, any information regarding previous and ongoing pain issues should be documented, including pain control methods that have worked or not worked in the past. Some understanding of patients attitude toward pain medication (e.g., fear of addiction) is helpful. The exact dose of their current analgesic medications is essential. If patients take them as needed, how many are being used on average per day should be recorded. Patients with chronic pain conditions present a special management problem. There is no reason to wean patients from pain medicine before surgery. If the patients analgesic is an NSAID or COX-2 inhibitor, the patient may be told to discontinue use before surgery. If so, the patient may need to be given a different analgesic for pain control before the procedure. Patients should be told to take their usual morning doses of pain medicine. If the patient wears a fentanyl transdermal patch, it can be left on. It is important to inform the patient that care providers will do everything possible to maintain comfort postoperatively, but the expectation of having no pain should not be given. It should be expected that a chronic pain patients requirement for pain medication will be increased postoperatively and should be managed accordingly. There are no useful algorithms for treatment of acute pain in chronic pain patients, and care needs to be individualized. A pain service consultation may be very useful in this situation, especially when the surgical staff is not familiar with complicated chronic pain regimens and alternative options.

Preoperative Use of Alternative and Complementary Therapies


A significant number of patients have been reported to use alternative and complementary therapies in the preoperative period (see Chapter 32). A survey of preoperative clinic patients demon-

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Section IV Anesthesia Management

Do you currently have pain? Yes Character: Duration: Frequency: No sharp If Yes, location: ______________________________________________ throbbing dull burning

______________________________________________________ ______________________________________________________

Intensity scale: ______________________________________________________ Numeric Faces What makes the pain better? ______________________________________________________ What makes the pain worse? ______________________________________________________ What is an acceptable pain level to you? ______________________________________________
Figure 34-4 Pain/status/history form.

strated that 22% reported the use of herbal medications and 51% used vitamins.152 Women and patients in the age range of 40 to 60 years were more likely to use herbal medicine. The most commonly used compounds, from highest to lowest, included echinacea, Ginkgo biloba, St. Johns wort, garlic, and ginseng. The pediatric population has a significant amount of use as well, which varies with ethnic subgroup.153 Use of nonprescribed dietary supplements was significantly higher in Hispanic than in white children (33% versus 9%). Of concern is that unless specifically questioned, patients may not report the use of these nonprescription agents. In a group of patients awaiting cardiac surgery, 56% did not inform the anesthesiologists before surgery regarding the use of these products.154 Because patients may fail to disclose the use of alternative therapies unless specifically questioned, it is difficult to make specific associations between potential drug and herb interactions. In addition, the U.S. Food and Drug Administration (FDA) does not have regulatory oversight of purity and other standards of these nonprescription medications. Many of the herbs sold are ineligible to be approved as a drug, and the FDA can take action only when a substance is determined to be unsafe.

The ASA has published two documents on dietary supplements, one for patients and one for providers.155 Both these pamphlets are available through the ASA website. The ASA recommends discontinuation of all alternative therapies 2 weeks before elective procedures, although there are no definite data supporting this recommendation. The impact of alternative therapies on perioperative outcome is unclear. In a Hong Kong cohort study, 80% of presurgical patients took self-prescribed traditional Chinese herbal medicines (TCHMs).156 Despite the high use of alternative therapies in this group, there was no significant association between any type of TCHM and the occurrence of either intraoperative or postoperative events when adjusted for covariates. Patients who used TCHMs were more likely to have a preoperative event, including a prolonged aPTT and hypokalemia. The most common potential adverse effects of herbal medicines in the perioperative period include impaired coagulation, cardiovascular side effects, electrolyte disturbances, and prolongation of the effects of anesthetic agents.157 There is little information available about the epidemiology of perioperative events related to alternative therapies, and there is no agency currently

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Box 34-9 Potential Adverse Effects of Alternative Therapies Cardiovascular instability, including high blood pressure, tachycardia, angina, and atrial arrhythmias: saw palmetto, ginseng, black cohosh, St. Johns wort Thromboembolic events: saw palmetto, ginseng Enhanced potential for bleeding: black cohosh, ginkgo, garlic, ginseng, ginger, chamomile, vitamin E Prolongation of anesthesia: St. Johns wort Hypothyroidism: soy Hyperthyroidism: triiodoacetic acid Hepatotoxicity: echinacea, kava Decreased effectiveness of HIV protease inhibitors: St. Johns wort Seizures: black cohosh Enhanced effect of opioid analgesics: valerian, kava, chamomile Inhibited effect of opioid analgesics: ginseng

responsible for overseeing manufacturing and safety, regulating sales, and reporting adverse events. Starting in 2005, TJC required that alternative therapies be considered like any other drug when documentation of patient medications is performed. Potential adverse effects of the more commonly used agents are summarized in Box 34-9. However, much of these data is based on anecdotal evidence, theoretical proposals, and case reportsnot from good epidemiologic studies with large databases.158,159 Further in vitro data, animal studies, and clinical epidemiologic studies are needed to assess the significance of these potential interactions. A significant number of patients also report the use of nonherbal alternative therapies. The most common complementary and alternative therapies reported in a survey of preoperative patients were massage therapy (15%), herbal therapy (10%), relaxation (8%) and acupuncture (7%).160

Preoperative Laboratory and Diagnostic Studies


The value and outcome of preoperative diagnostic studies and testing have become a central issue in evaluating cost-effective health care in presurgical patients. It is estimated that up to $4.0 billion is spent annually in the United States on preoperative diagnostic and laboratory evaluation. The value of obtaining preoperative studies as a screening tool to detect disease and evaluate the stability of the patients medical condition for anesthesia and surgery has been extensively published in the academic literature.161 The concept of standardized testing in all presurgical patients regardless of age or medical condition is no longer considered medically appropriate. Unnecessary testing is inefficient and expensive, and it requires additional technical resources. Inappropriate studies may lead to costly evaluation of borderline or false-positive laboratory and diagnostic test abnormalities. This may result in unnecessary operating room delays,

cancellations, and potential patient risk through additional testing and follow-up. Patients require preoperative diagnostic and laboratory evaluation that is consistent with their medical history, the proposed surgical procedures, and the potential for intraoperative blood loss. Preoperative diagnostic and laboratory testing should be obtained for specific clinical indications that may increase perioperative risk and not simply because the patient is to undergo a surgical procedure. Consistent accuracy of diagnostic testing and the problems associated with false positives are reason enough to limit preoperative tests to specific indications. The sensitivity, specificity, reproducibility, and clinical predictive value of preoperative diagnostic studies have been comprehensively reviewed in previous editions of this chapter. It has been well documented in academic studies that routine preoperative screening tests in an asymptomatic healthy patient have no beneficial effect on surgical or anesthesia outcomes. At many hospitals, the tradition has been that all preoperative tests and diagnostic studies be ordered by the surgeon or primary care physician. Frequently, these tests are obtained without a specific diagnostic focus other than a speculation that the anesthesiologist may require them to proceed with surgery and thus avoid delays and cancellations. Other reasons include routine screening for disease states, establishment of a diagnostic baseline, personal habit (using a standard checklist for all patients), physician reassurance, and a perceived medicolegal necessity not to miss anything. This historical method of ordering preoperative laboratory tests as screening devices and to avoid cancellations and delays cannot be justified and is clinically inappropriate. Nonselective laboratory testing and diagnostic studies result in significant cost to the hospital and expense for the patient.162,163 Routine presurgical screening tests are no longer supported or reimbursed by Medicare and most private insurance carriers without specific indications. Implementation of changes is necessary to reduce these costs and enhance patient care. Anesthesiologists are the perioperative medicine experts and are best qualified to establish appropriate and necessary preoperative laboratory and diagnostic tests for intraoperative anesthesia management. Providing specific guidelines and education to physician colleagues and surgical services for recommended preoperative testing reduces costs, expedites patient care, and enhances the anesthesiologists recognition as the perioperative physician specialist. Several academic studies have demonstrated reductions in hospital cost for preoperative diagnostic evaluation when diagnostic testing is coordinated through the anesthesia preoperative evaluation clinic.164,165 Preoperative diagnosis-based guidelines (Table 34-7) provide basic recommendations for perioperative management of patients with medical conditions that increase operative risk. These disease-specific guidelines are not intended as absolute or standard requirements. There are no consistent recommendations or protocols in anesthesia texts or the literature or by medical/anesthesia society consensus of what constitutes recommended laboratory and diagnostic studies in an asymptomatic healthy patient at any age. After 6 years of extensive discussion, The ASA Task Force on Preanesthesia Evaluation published recommendations in 2002 that testing and consultation be done on the basis of a reasonable expectation that the patient may have an abnormal value and that such a value will have an effect on the decision whether and how to provide care during perioperative

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Table 34-7 Diagnosis-Based Preoperative Testing Preoperative Diagnosis Cardiac disease MI history Stable angina CHF HTN Chronic atrial fibrillation PVD Valvular heart disease Pulmonary disease Emphysema Asthma Chronic bronchitis Diabetes Hepatic disease Infectious hepatitis Alcohol/drug induced Tumor infiltration Renal disease Hematologic disorders Coaglopathies CNS disorders Stroke Seizures Tumor Vascular/aneurysms Malignancy Hyperthyroidism Hypothyroidism Cushings disease Addisons disease Hyperparathyroidism Hypoparathyroidism Morbid obesity Malabsorption/poor nutrition Select drug therapies Digoxin (digitalis) Anticoagulants Dilantin Phenobarbital Diuretics Steroids Chemotherapy Aspirin/NSAID (no tests) Theophylline X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X ECG X X X X X X X CXR Hct/Hb CBC Lytes X* X X X Renal Glucose Coag LFTs Drug Levels Ca

34

Section IV Anesthesia Management

X (PFTs only if symptomatic; otherwise no tests required) X X X X X

*Patients taking diuretics. Patients taking digoxin. Patients taking theophylline. X, obtain; , consider. Ca, calcium; CBC, complete blood count; CHF, congestive heart failure; Coag, coagulation; CXR, chest x-ray; ECG, electrocardiogram; Hb, hemoglobin; Hct, hematocrit; HTN, hypertension; LFTs, liver function tests; Lytes, electrolytes; MI, myocardial infarction; NSAID, nonsteroidal anti-inflammatory drug; PFTs, pulmonary function tests; PVD, peripheral vascular disease.

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management.3 Specific preoperative laboratory testing will be reviewed as follows, with an emphasis on diagnosis-based/clinical indications.

Pregnancy Test
Pregnancy testing is often determined by individual group practice protocols and can be based on the history and specific questions. Clinical indications can include the date of the last menstrual period, sexual activity, type or absence of birth control method, and patient or physician intuition.

Complete Blood Count, Hemoglobin, and Hematocrit


The proposed surgical procedure and potential blood loss, together with individualized clinical indications, should determine the requirement for a blood count preoperatively. Primary clinical indications include a history of increased bleeding, hematologic disorders, renal disease, chemotherapy or radiation treatment, steroid or anticoagulant therapy, poor nutrition/malabsorption status, surgical procedures with anticipated high blood loss, and trauma.

The Electrocardiogram
The ECG is used to determine a previous history of MI, conduction/rhythm disturbances, ischemia, chamber hypertrophy, and metabolic/electrolyte disorders. Primary clinical indications preoperatively include a history of CAD or MI, hypertension, diabetes, congestive heart failure, chest pain, palpitations, abnormal valvular murmurs, peripheral edema, syncope, dizziness, dyspnea on exertion, shortness of breath, paroxysmal nocturnal dyspnea, and cerebrovascular disease. The ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation provide additional recommendations for preoperative resting ECGs (see Box 34-3).7

Liver Function Testing


There is no routine preoperative anesthesia requirement for liver function testing. It should be based on a history of hepatic injury and physical examination findings. Primary clinical indications include a history of viral, alcohol, or drug-induced hepatitis, jaundice, cirrhosis, portal hypertension, biliary or gallbladder disease, hepatotoxic drug exposure, infiltration of tumor, certain immunologic disorders, and bleeding disorders.

The Chest Radiograph


There is no routine indication to obtain a chest radiograph in preoperative evaluation. The chest radiograph should be used to assess concerned abnormalities that are present by history or physical examination. Primary clinical indications for a preoperative chest radiograph include auscultation of rales or rhonchi, advanced COPD and blebs, pulmonary edema, suspected pneumonia, pulmonary or mediastinal masses, tracheal deviation, aortic aneurysm, atelectasis, cardiomegaly, pulmonary hypertension, or dextrocardia.

Renal Function Testing


Tests of renal function measure the degree of renal tubular dysfunction and glomerular filtration. Primary clinical indications include patients with diabetes; hypertension; cardiac disease; dehydration; nausea and vomiting; anorexia; bulimia; increase fluid overload, such as in congestive heart failure, peripheral edema, or ascites; renal, hepatic, or cardiac impairment; hematuria; nocturia; polyuria; oliguria; anuria; and a history of renal transplantation.

Preoperative Pulmonary Function Assessment


PFTs are not considered routine for patients with a history of asthma, emphysema, or COPD. Patients with pulmonary diseases have often undergone pulmonary function testing through their primary care physician, obtainable as needed. Clinical examination and a careful history will indicate the patients current respiratory status and the potential for anesthesia/surgical pulmonary compromise. Preoperative PFTs can assess potential respiratory complications in patients undergoing surgical resection of the lung. PFTs determine the patients pulmonary reserve and whether the patient may require postoperative chronic ventilation support. The specifics of preoperative pulmonary function testing in patients undergoing lung resection are reviewed in another section of this chapter.

Coagulation Testing
Clotting studies are not indicated as a routine preoperative evaluation, even in patients undergoing regional procedures, unless there is specific indication of a known or suspected coagulopathy. A careful history that includes drug therapies and physical examination will provide guidance if coagulation testing is indicated. Primary clinical indications include a history of a bleeding disorder or previous excessive intraoperative surgical bleeding, hepatic disease, poor nutritional status, and use of anticoagulants or other drugs that affect coagulation.

Urinalysis
There is no indication during preoperative anesthesia evaluation for routine urinalysis. Primary clinical indications could include a suspected urinary tract infection or unexplained fever or chills.

The Preoperative Evaluation Clinic


Many anesthesia groups and major medical centers have developed preoperative evaluation programs and clinics with the goal

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34

of enhancing operating room efficiency and the quality of patient care.166,167 There are many variations in the staffing, structure, financial support, and daily operations of preoperative programs; however, all have a common goal of avoiding cancellations, delays, and adverse patient outcomes that could have been addressed before the day of surgery. The development and implementation of a preoperative evaluation clinic depend on the daily volume of patients, the predominant medical patient acuity, the availability of facilities, the demographics of distance of the patient from the hospital, and a perioperative staff, hospital administrative, and anesthesia departmental commitment that supports changes. It is essential that the anesthesiologist develop the leadership and management position in the preoperative evaluation program. When internal medicine departments and other medical specialties develop preoperative programs within hospitals, the anesthesiologists role and expertise in perioperative patient management often become secondary. This can result in significant interdepartmental conflict and disagreement concerning a patients evaluation, risk stratification, and optimal stability to proceed with anesthesia. When patients are cleared for surgery by other specialties, this is often considered by the surgeon as evidence that the patient is appropriate and suitable for anesthesia. Unfortunately, this clearance is frequently provided with limited knowledge of current anesthesia practice and intraoperative patient management. The preoperative history, physical examination, and assessment by a medical specialist may not address specific anesthesia concerns of risk assessment168,169 and patient optimization, thus providing the framework for potential surgical delays and cancellations. Additionally, patients may have had medications preoperatively withdrawn, changed, or added to their treatment in preparation for surgery, which further complicates intraoperative anesthesia management. When cases are delayed or canceled by the assigned anesthesiologist on the day of surgery, it often creates significant frustration in the surgeon and patient. The anesthesiologist is the only specialist who can make the final determination of whether the patient is appropriate for anesthesia and whether the patient is stable to proceed. It is advantageous to accentuate this fact to hospital administrators and those who plan the development of a preoperative clinical program but remain uncertain regarding which speciality to support. Clinical studies have demonstrated that the anesthesiologists leadership and direct clinical responsibility in a preoperative program will reduce hospital costs by decreasing operating room delays, cancellations,164,170 and potential adverse intraoperative patient events. Good outcomes depend strongly on awareness and planning. Anesthesia groups with a predominantly healthy outpatient and to-be-admitted population and hospital facilities with limited resources and staffing may be unable to evaluate all patients preoperatively before the day of surgery. This requires a means of screening patients and triaging them from the preoperative program in a manner that ensures a high level of accuracy in determining the patients current health status. Accurate triaging results in time savings and avoidance of costly cancellation and delays on the day of surgery without compromising patient quality of care and outcomes. One process of triaging involves having an anesthesia questionnaire (see Fig. 34-1) available in the surgeons office, which could be filled out by the patient during the initial assessment by

the surgeon. The questionare would be faxed to the groups anesthesia location before the surgical date. Reviewing the patients medical history before the day of surgery, even by paper, reduces unresolved or unexpected medical concerns. A decision could then be made of whether the patient requires a formal preoperative consultation or could be evaluated on the day of surgery. A phone call by an anesthesiologist to a patient with a questionable medical history could clarify issues of concern. Another method of triaging patients to reduce the impact of unnecessary clinic evaluations would be to provide patients at the initial surgical visit with an anesthesia department Internet address where patients could fill out their medical questionnaire online for review. Anesthesia groups with a larger number of medically complex presurgical patients may benefit from a more formal preoperative facility with multiple examination rooms, dedicated staffing, and a full-time operational system. The following sections describe the development and implementation of an anesthesia preoperative evaluation clinic with a focus on the necessary protocols, policies, and requirements for recognition, accomplishment, and success. Not every aspect of what is described becomes necessary. Various modifications and adaptations for individual practices, facility expansion, and financial support are expected. Establishment of a successful anesthesia preoperative evaluation clinic requires interdepartmental commitment, collaboration, and financial support of several hospital disciplines.164,171 The departments of anesthesia, surgery, nursing, and hospital administration must agree that a centralized preoperative clinic has value for the hospital, and each discipline must firmly support the necessary changes and operational goals of a preoperative evaluation clinic (Box 34-10).

Section IV Anesthesia Management

Collaboration, Commitment, and Teamwork


The preoperative evaluation clinic is a visible partnership and collaboration between the departments of anesthesia, surgery, nursing, and hospital administration in achieving common goals as illustrated in Figure 34-5. It conveys the important concept that the development of this new clinical program is an integrated enterprise and requires obligation, sharing of endeavor, and financial responsibility. Initially, surgeons may be reluctant to send patients to a newly developed anesthesia preoperative evaluation clinic. This hesitation stems from an unclear understanding of the supportive process, significance, and enhanced outcomes of a medical evaluation by an anesthesiologist. A surgeons hesitation to send patients to the preoperative evaluation clinic can be reduced by identifying the clinical advantages of the preoperative program. For example, informal assurances should be given to the surgical services that if a patient is evaluated in the preoperative program, the case will proceed to surgery without cancellation or delay by the assigned anesthesiologist, the only exception being illness or an adverse medical event between the time of evaluation and the time of the planned surgery. Cancellations and delays on the day of surgery can be a prominent source of aggravation and even antagonism for surgeons and patients and results in loss of revenue. Additionally, patients are often billed for hospital services although their actual surgical procedure was not performed.

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Box 34-10 Operational Goals for a Preoperative Evaluation Clinic Improve the clients perception of the preoperative evaluation experience by increasing personalized patient care, comfort, and convenience. Provide a centralized site for preoperative evaluation. Institute an anesthesia scheduling system for timely patient access and flow. Ensure the presence of an anesthesiologist on site when patients are present. Appoint a medical director to coordinate all activities. Ensure the availability of medical records and surgical notes at the time of preoperative evaluation. Decrease logistic shuffling of patients to multiple hospital service areas. Integrate and coordinate services through on-site facilities for admission/registration, insurance authorization, laboratory tests, and electrocardiographic studies. Improve the education of patients and families about the elements of their surgical procedure and the proposed anesthesia care, including postoperative pain control options. Educate patients about what to expect regarding postoperative feeding and discharge needs. Ensure and coordinate cost-effective ordering of preoperative laboratory and diagnostic studies. Provide an anesthesia medical consultation service for evaluation of medically complex inpatients and outpatients. Decrease the number of cancellations and delays in operative procedures on the day of surgery. Enlist the skills of a nurse practitioner to assist in preoperative evaluation and patient/family education. Develop protocols, policies, and clinical pathways. Perform quality assurance reviews. Maximize efficiency in operating room function and turnover time by coordinating all preoperative information at one location in the anesthesia preoperative evaluation clinic. Enhance patient and surgeon satisfaction.

It is of paramount importance that anesthesia departmental practitioners discuss and agree on individual practice variations. Differences, such as at what fasting blood glucose level a surgical case would be canceled or what degree of preoperative hypertension is acceptable, require departmental clarification and agreement. If half the anesthesiologists would perform a particular surgical case with increased patient risk and the other half would cancel the case, the inconsistency demonstrated to the surgeon would foster a lack of support and reluctance to have patients evaluated, and essentially the clinic would be unsuccessful. The anesthesia preoperative evaluation clinic can become a valued perioperative and hospital asset by providing consistent quality patient management and cost-effective outcomes that decrease surgical delays and cancellations. If a special medical concern related to anesthesia is identified before surgery, the preoperative program coordinates collecting the medical data, managing any additional workup or consultations, and discussing the case with the surgeon and the assigned anesthesiologist before the date.

Financial Concerns in Developing a Preoperative Clinic


Health care reforms have resulted in closer evaluation of the costbenefit ratio and operational efficiency of many hospital programs.172,173 Economic changes have decreased reimbursement and reduced the patients length of stay in the hospital. At the same time there has been rapid advancement in outpatient services, especially in ambulatory surgery. The percentage of surgical patients entering the hospital as outpatients or admitted on the same day as surgery continues to increase and challenge perioperative personnel, especially the anesthesiologist. Physicians are the primary decision-makers concerning the utilization of health care services. In preparing a patient for surgery, physicians are directly responsible for ordering virtually all of the patients evaluations, including preoperative diagnostic testing and referral to specialists. Although health care continues to be in an active state of reform, it is frequently difficult for an individual physician or group to change the manner or routine of clinical practice patterns. There is increasing demand from hospitals and insurance carriers that providers demonstrate veri-

Department of anesthesia Hospital administration Department of nursing

Department of surgery

Preoperative Evaluation Clinic Decreased cost Efficient services Clinical productivity Timely access to clinic Patient and surgeon satisfaction

Figure 34-5 The anesthesia preoperative evaluation clinic is a constructive partnership toward common goals. Sharing of resources and budgetary costs is apportioned.

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fiable evidence of decreasing costs while maintaining productivity and a high level of quality patient care. Hospital support and financial contribution for a preoperative evaluation clinic will focus on price, quality, and value. Economic analysis of a proposed preoperative evaluation clinic is imperative to align administrative, operational, and financial support. It requires a documented comparison between the current preoperative resource utilization, costs, and outcomes (operating room delays, cancellations) with the projected preoperative evaluation clinic and anticipated operational improvements (decreased operating room delays, cancellations, enhanced operating room efficiency, etc.) This document must be comprehensive and focused on opportunities for improvement. It is presented for hospital financial analysis in a business plan (Box 34-11) linked with academic publications demonstrating cost-effectiveness and outcomes in the preoperative clinic model. A preoperative clinic that offers no improvement and an increase in cost is unsuitable and economically detrimental to the hospital. Financial support for the anesthesia medical director is derived from both the department of anesthesia and hospital administration because the preoperative evaluation clinic is a hospital improvementbased program and can reduce hospital costs.

Quality assurance measurements and clinical benchmark indicators for the preoperative clinic should be entered into a database, which can then be used to determine performance standards and areas in need of improvement.174,175 This information could measure, for example, operating room cancellation and delays, the specific causes, cost, and resource time loss. It provides the basis for operational changes and improvements in hospital service. Figure 34-6 is an example of a quality and service indicator form for a preoperative evaluation clinic.

Section IV Anesthesia Management

Preoperative Standardization and Accuracy of Documentation


Standardization of the preoperative process is essential for both clinical and administrative reasons. Important reasons to encourage standardization in process and documentation are listed in Box 34-13. Standardization maximizes reimbursement by ensuring accurate coding for the diagnosis-related group (DRG) and for preoperative testing. In many institutions, nonclinical personnel are used to review the preoperative history and physical assessment, from which comorbid conditions are coded to define the appropriate reimbursement level based on the surgical diagnosis and procedure. In some cases, a variety of clinicians in outside offices may be submitting preoperative history and physical assessments in nonstandard ways, thus making coding difficult. These assessments may focus on the surgical diagnosis and may not appropriately list all existing comorbid conditions. If an institution does not have a standardized process for preoperative recording of the history and physical examination, appropriate reimbursement for these issues may not be attained. This can be a major source of institutional revenue loss. In addition, a standardized process allows the clinician to accurately code for preoperative laboratory testing by diagnoses that can be reimbursed, as opposed to screening laboratory tests, which are no longer reimbursed by the CMS. Standardization maximizes reimbursement by standardizing coding and data collection regarding pay-for-performance measures. Numerous strategies, including pay-for-performance measures, are being instituted across the country in an attempt to improve quality. Standardizing preoperative processes will allow the development and implementation of protocols so that the measures are met and appropriately documented. This is particularly important if implementation of these protocols is required before the day of the procedure. Presently, this could include implementing some of the national Surgical Care Improvement Project measures (e.g., appropriate perioperative -blocker therapy). Standardization allows the implementation of clinical algorithms based on best practice, which will optimize preoperative medical management and potentially reduce complications and ensure the best possible outcomes. Preoperative risk factors have been shown to be effective predictors of hospital cost.176 Therefore, preoperative intervention to reduce risk could lead to significant cost savings. For example, despite the existing evidence, a significant number of patients who would be candidates for perioperative -blockade are not receiving it at the time of the preoperative visit. There is inconsistent application of these guidelines by surgeons and referring physicians, thus again leading to

Facility Restructuring and Modernization


Focusing all preoperative clinical services into one hospital location establishes a center of visibility, competitiveness, and efficiency. The preoperative clinic should be regarded as a long-term investment for the hospital, physicians, and patients. Facilities that have been developed at Stanford University Hospital are listed in Box 34-12 and are provided as an example of an extensive facility already in need of expansion because of increasing patient volume. However, not all hospital centers have the facilities or funding to construct a formal preoperative evaluation clinic. A compromise of sharing the preoperative clinic space with another medical specialty clinic could be beneficial in terms of staffing and reducing costs. The simplest of preoperative evaluation areas might be a private space in the presurgical holding area or the postanesthesia care unit as patient census decreases later in the day. Cross-trained staff from available resources such as the operating room or recovery room can assist in the preoperative evaluation program during downtime/low patient volume to process preliminary paperwork, obtain medical and outside records, record vital signs, collect laboratory specimens, and perform ECGs, for example. The predominant costs of operating a preoperative evaluation clinic are essentially the number of staff per diem. Facility renovation can be costly or nominal. Material and supplies are usually minimal. A preoperative facility with a comfortable, lowstress patient waiting area is a positive investment in patient relationships. Patients often express their primary complaint with hospital services as waiting for excessive periods. A thoughtfully designed clinic facility enhances the patients anesthesia experience. Hospital administrators, surgeons, and other physicians will monitor performance of the preoperative evaluation clinic in terms of outcome measurements, personal observations, and value analysis. Achievement and success are often linked to renewed or additional financial support.

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Box 34-11 Outline of a Business Plan for an Anesthesia Preoperative Evaluation Clinic (APEC) The business plan provides or describes the following items: I. An Executive Summary One-paragraph summary of the proposed APEC program II. Description of the APEC Objective or mission of the APEC Names of the proposed APEC medical director, department chair Location within the hospital designated for the APEC (define an area, even if currently occupied) Development stage (is there an existing preoperative program?) Services of the APEC (see operational goals, Box 34-10) Anesthesiology specialty information (i.e., anesthesiologists are the experts in operating room medicine and preoperative evaluation) III. Analysis of General Factors Affecting Viability of the APEC Volume and medical condition of preoperative patients (present a graph for past years) Anticipated growth trends Vulnerability to economic factors (e.g., fee-for-service payment is decreasing, managed care is increasing, hospitals need to decrease cost) Technologic factors (e.g., anesthesia and surgical procedures are increasingly becoming more complex) Regulatory issues (the APEC conforms to all local, state, and federal policies) Financial considerations IV. Definition of Target Markets All outpatient and same-day admissions (i.e., increased smooth flow of a healthy patient through the health care system and educational processes, often starting in the surgical office) Medically complex patient undergoing anesthesia and surgery V. Discussion of Factors Relating to Competition Competitive position of the APEC (the anesthesiologist is the operating room and preoperative medicine expert) Barriers to entry (primary care physicians/consultants believe that they have sufficient specialty knowledge to clear patients for anesthesia and surgery) Future competition VI. Description of Effective Marketing Strategies Increased visibility, which increases viability of the APEC Use of hospital/health system news media to explain who anesthesiologists are and what they do Formation of strategic partnerships with the departments of nursing and surgery and with the hospital/health system administration Informal assurance that cases will be facilitated by anesthesia if seen in the APEC Presentations at surgical, medical, gynecologic, pediatric, and administrative grand rounds (as well as others) and conferences VII. Description of Operational Aspects of the APEC Facilities (e.g., examination rooms, phlebotomy/ electrocardiography room) Equipment and supplies Variable labor requirements (e.g., nurse practitioner, anesthesiologist) Daily anticipated operations and flow Quality assurance and utilization review Management information systems VIII. Description of Management and Organization of the APEC Clinical and administrative director Inclusion of the department of nursing and hospital administration Organization management (presented in a flow chart) IX. Description of the Developmental Goals of the APEC Short-term goals (changes in clinical practice) Long-term goals (e.g., renovation of facilities) A time line (demonstrates a developmental plan) The growth strategy (projection of 6-month, 1-year, and 5-year goals) Evaluation of risk X. Discussion of Financial Matters Income statement (consider a facility fee, anesthesia medical consultation charge, projected hospital/health system cost savings, and market share enrichment) Variable expenditures (e.g., APEC personnel and resources, facility housekeeping and supplies) Balance sheet

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Box 34-12 Facilities of the Anesthesia Preoperative Evaluation Clinic at Stanford University Hospital Five combination office and examination rooms A patient and family education room (preoperative teaching) A patient-centered media and video room A phlebotomy and electrocardiography room An on-site office for the medical director A registration and reception area On-site restroom facilities A large, comfortable patient lounge An area for admitting and financial services Approximately 2200 square feet for facilities Conference room and shared chart and computer support room

Information Management and Centralization


For a patients surgery to proceed without delay, all required paperwork and information must be present. At many hospitals, the surgeons history and physical examination, operation consent form, laboratory test results, nursing operating room admission form, and anesthesia preoperative notes must be present in the patients chart before entering the operating room. The preoperative evaluation clinic can coordinate, process, and centralize all patient presurgical information in the medical chart. A simple checklist of required content can reduce delays and increase operating room efficiency by correcting problems before the day of surgery. Because patients from out of the local area may be staying in hotels or with family or friends, it is important that a day before surgery local/cellular phone number be recorded in the presurgical chart so that the patient can be contacted before surgery. The preoperative staff telephones patients on the evening before surgery to ensure compliance with arrival time, to reinforce instructions, and to answer any questions. This contact by telephone avoids day-of-surgery delays and potential cancellations. Accuracy of preoperative records is imperative, with multiple health care professionals, regulatory agencies, and occasionally the legal profession reading and reviewing medical entries. Preoperative issues that result in misinterpretation of intended documentation or physician orders can be a factor in adverse patient outcome and potential legal responsibility. Box 34-15 reviews preoperative evaluation documentation fundamentals and concerns.

Section IV Anesthesia Management

the question of accountability for the preoperative process. An anesthesia preoperative clinic can develop and standardize clinical presurgical evaluation policies and guidelines to coordinate the process of implementing appropriate protocols before the day of surgery. This could result in decreased cost for prolonged hospitalizations caused, for example, by perioperative cardiac complications. Providing algorithms for clinical practice in areas where outcome-based data are unavailable may result in the use of arbitrary parameters based on consensus opinion. An algorithm provided to clinical staff performing preoperative assessment is provided in Box 34-14. A second example in which implementation of a preoperative protocol may reduce postoperative complications is protocols that address reduction of SSIs. A standardized preoperative process provides a means for instruction in this regard; for example, at the time of the preoperative visit, patients can be given antiseptic agents to shower with before surgery. Standardized processes allow more accurate data collection for quality reporting. Hospitals may be contributing data on their operational results to organizations such as TJC, the National Surgical Quality Improvement Program, or the Institution for Health Care Improvement. In addition, state law may mandate reporting requirements. For example, in the state of Massachusetts, information on the preoperative, operative, and postoperative factors and outcomes of cardiac surgical patients must be collected in a standardized fashion and reported to the state. Standardized processes help minimize complications caused by communication errors. Recent work shows that serious communication breakdowns occur throughout the continuum of surgical care.177 In a review of surgical malpractice claims, 81 communication breakdowns occurred in a total of 444 cases. Of these breakdowns, 38% involved problems with communication of preoperative information. Ambiguity about responsibility was a commonly associated factor. Standardization of documentation would improve transfer of care from preoperative clinicians to the operative team. Responsibility for dealing with abnormalities identified during the preoperative assessment could be clearly delineated.

Box 34-13 Importance of Preoperative Process Standardization Standardization maximizes reimbursement by diagnosisrelated group and for preoperative testing by standardization and accuracy of documentation in the preoperative assessment. Standardization maximizes reimbursement by standardizing coding and data collection regarding pay-for-performance measures. Standardization allows the implementation of clinical algorithms based on best practice, which will optimize preoperative medical management and potentially reduce complications and ensure the best possible outcomes. Standardized care protocols and optimization of clinical care with a potential impact on reduction of complications can reduce the cost of admission and length of stay. Standardized processes allow more accurate data collection for quality reporting. Standardized processes help minimize complications caused by communication errors.

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Preop Program Quality & Service Indicator Form Today's date: _____________________ (Addressograph) Anesthesia evaluator: _________________________________________ Scheduled appointment: Arrived 30 minutes of appt. time: Patient triaged out: Patient chart available: Time in preop program<90 minutes: If No, cause of delay in preop program: No chart Outside records/tests did not arrive with patient Time to find old/recent: ECG Chest X-ray ECHO Stress test Lab order problems/changes Wait to clear patients ECG Consult with medical director Medical director not available, find appropriate person Contact outside source for additional information Patient arrived after 5:00 P.M. Patient had surgery recently, chart not available, start all over with information Clinical complication that could postpone or cancel surgery Language barrier w/interpreter Physical disabilities Teaching Nursing assessment forms Solved problems unrelated to anesthesia; explain: _________________________________________ Cardiac surgical team not available Comments: ________________________________________________________________________________ Language barrier w/NO interpreter Call resident MUGA Lab work PFTs Visit time in: Yes Yes Yes Yes Yes No No No No No Ordered Time in: Time out: Pt. Level: Teach: Yes ( Date of surgery: _____________________ Referring clinic: ______________________ Evaluator
(Military Time)

____________ ____________ ____________ ) No ( )

Time first seen in preop clinic: ______________ (military time)

TOTAL ____________

Visit time out: ____________

Complex history, No H&P, start from the beginning for history

Figure 34-6 Preoperative program quality and service indicator form. ECG, electrocardiogram; ECHO, echocardiography.

Structure and Activities of the Preoperative Evaluation Clinic


The daily operations of an anesthesia preoperative clinic will vary according to patient volume, acuity of the patients medical conditions, availability of facilities, and employee resources. However, a generalized operational structure can be suggested by examining several preoperative clinic models currently in practice. Centers with a large volume of patients should have their patients formally scheduled in the clinic before the day of evaluation so that medical records and appropriate outside information would be available. The surgeons office should schedule the

anesthesia clinic appointment at the same time that the operating room case is booked. Flexibility in scheduling appointments is needed in the clinic to accommodate patients with urgent surgical requirements and those residing outside the local hospital area. The anesthesia evaluator interviews and examines the patient, obtains historical medical information and outside records (via facsimile and phone as needed), and determines the appropriate diagnostic, laboratory, ECG, and other evaluation requirements. Phlebotomy, ECG, and hospital admitting/insurance registration are available in the preoperative clinic. Such centralization of multiservices provides a significant convenience to patients, who no longer must search for multiple hospital locations to complete preoperative requirements. It also centralizes all

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Box 34-14 Algorithm for Preoperative Clinical Assessment A. Assess Surgical Risk: High risk (>5%) Aortic surgery Major vascular surgery Peripheral vascular surgery Prolonged procedures with fluid shifts* Moderate risk (1% to 5%) Head and neck surgery Intraperitoneal and intrathoracic surgery Carotid endarterectomy Orthopedic surgery Prostate surgery Low risk (1%) Superficial procedures Cataract surgery Breast surgery B. Assess Functional Status Low functional status: METs less than 4, unable to climb two flights of stairs, or inability to assess functional status Acceptable functional status: METs greater than 4 or able to climb two flights of stairs without symptoms C. Assess Stability 1. Does the patient have shortness of breath that is not due to pulmonary disease? 2. Does the patient have a history of syncope that has not been investigated? 3. Does the patient have a change in the pattern of chest pain or a history of chest pain that has not been investigated? 4. Does the patient have an increase in leg swelling, rales on lung examination, or new leg swelling that has not been investigated? 5. Does the patient have a history of paroxysmal nocturnal dyspnea or orthopnea that has not been investigated or has worsened? D. Decision for Referral Based on A, B, C: With a yes answer to any of the questions in C, consider referral to the PCP or cardiology regardless of functional status or surgical risk If the answer to questions 1 to 5 is no and functional status is low, consider referral to cardiology only if the surgery is very high risk If the answer to questions 1 to 5 is no and functional status is adequate, the patient does not warrant referral based on stability Consider Cardiology Evaluation: Pacemaker not checked within 6 months Automatic implanted cardioverter-defibrillator not checked within 3 months History of positive exercise tolerance test without follow-up (Bruce <6 minutes, >4 segments with perfusion abnormalities) New left bundle branch block Atrial fibrillation (new or old) with a ventricular rate greater than 120 beats/min New T-wave inversions or new ST elevations or depressions greater than 2mm New atrial fibrillation Second-degree atrioventricular block with a wide QRS complex (not investigated) New pathologic Q waves consistent with myocardial infarction Prolonged QT (>520msec) Consider Primary Care Evaluation New anemia (hematocrit less than 30% with unknown cause) Diastolic blood pressure greater than 110mmHg Glycohemoglobin greater than 8.5 Wheezing on physical examination Potassium less than 3.2 Platelet count less than 100,000, cause unknown or not investigated New hyperthyroidism Abnormal urinalysis suggestive of urinary tract infection Unexplained coagulation abnormalities New murmur

Section IV Anesthesia Management

*Mastectomy with reconstruction, major bowel resection with colectomy, major lung resection procedures, hip revision, major back surgery, pelvic debulking. METs, metabolic equivalents of the task; PCP, primary care provider.

hospital data into one chart, which remains in the preoperative evaluation clinic area until the time of surgery. The patients ECG is assessed during the clinic visit, and laboratory test results are evaluated at the end of each clinic day, with follow-up of abnormal findings as needed. In this manner, significant abnormalities can be addressed immediately, and if needed, cancellation of a surgical case would occur before the day of surgery. One of the fundamental goals of the preoperative evaluation clinic is patient perioperative education to increase awareness and comfort by decreasing anxiety and fear. A nurse educator specifically trained in perioperative teaching discusses in detail

the forthcoming surgical/hospital process with each patient and family member.

Enhanced Operating Room Efficiency and Outcomes


Appropriate utilization of perioperative services yields net benefits to the hospital and achieves a cost-benefit framework. Unnecessary surgical delays result in increased cost to the hospital and reduce operating room efficiency. The preoperative evaluation

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Box 34-15 Preoperative Documentation and Concerns Legibility of records. Poor handwriting results in misinterpretation or failure to implement important orders preoperatively. Entries that are not signed or the signature is illegible. Print your last name and beeper/contact number. All preoperative evaluation entries must be dated and timed in the document. Do not black-out, obliterate, or white-out an error. Place one line through the entry, initial, and write error. Document all phone calls, time, and date to consulting physicians with their name and specifically what was discussed. Note HIPAA* guidelines regarding unapproved abbreviations, which can result in patient medication and treatment errors. If the patient has an abnormal diagnostic test result, document it and indicate what follow-up is planned. If you order a laboratory test, chest radiograph, electrocardiogram, or any test, you are responsible for knowing the results, follow-up, or referral if needed. Document it in the chart.
*Health Insurance Portability and Accountability Act.

program focuses on patient management and preparation for a smooth transition to surgery. In one study on start times of the first case of the day, 91% of patients evaluated in the preoperative evaluation clinic entered the operating room by 6:50 am for 7:30 am start times. Delays were considered the exception rather than the customary occurrence. The operating room day ends earlier with decreased cost and overtime staffing when delays and problems are minimized. The preoperative evaluation clinic can establish a standard of efficient clinical services, including a contribution to on-time starts, decreased delays, and increased patient and surgeon satisfaction. Although there are defined costs in developing and maintaining a preoperative evaluation clinic, a comparison with previous outcomes clearly demonstrates the clinics utility, performance, and an improvement in operating room efficiency in terms of energy, time, and money.

are closely linked. In work using an internally generated patient satisfaction questionnaire to assess satisfaction with all elements of the preoperative evaluation, the subscale that involved information and communication had the highest correlation with the overall satisfaction subscale.178 Providing good patient education may facilitate patients involvement in their care, give them a sense of control over the process, and contribute to increased patient satisfaction. Consumerism and transparency in quality measures, with patient satisfaction being one of these quality measures, are becoming ever more important issues in health care. Measuring patient satisfaction with the various elements of the preoperative process is essential to evaluate success and plan process improvement. Although health care leaders realize the importance of feedback systems, they often do not use the information they receive to pinpoint opportunities for change and correction.166,179 Gail Scott provides tools and techniques that would allow feedback on the preoperative process to drive improvement.179 These techniques are summarized in Box 34-16. Most currently available surveys used by hospitals, such as the commonly used Press Ganey survey, reflect the overall perioperative experience. These standard questions are not effective at discerning patient satisfaction with particular elements of the preoperative process. For this reason, studies have developed internal questionnaires to measure this. Studies using this questionnaire (Box 34-17) show successful evaluation of preoperative process improvement. As noted, in this study the subscale that involved information and communication had the highest correlation with the overall satisfaction subscale. The authors conclude that the clinical and functional aspects of the preoperative evaluation visit have a significant impact on patient satisfaction, with information and communication versus the total amount of time

Box 34-16 Using Feedback to Drive Preoperative Process Improvement Raise awareness; make sure that everyone in the organization understands the focus of process improvement. Create measurable targets and goals (e.g., decreasing wait time). Set service expectations and standards of behavior. Allow direct service providers (frontline staff) access to hear feedback and input into problem solving.

Patient Education and Patient Satisfaction


The benefits of an effective preoperative evaluation process on efficiency have been well documented; however, there is limited information on the benefit of these clinics to the patients experience. The use of patient satisfaction has been advocated as a unique clinical end point and as an indicator of the quality of the health care provided. Fung and Cohen believed that this outcome could be more insightful than the use of rare major outcomes such as death or common minor outcomes such as pain and nausea, which can be influenced by many other factors. Patient education and patient satisfaction with the preoperative process

Develop skills. Teach staff members customer service skills such as interviewing, dealing with difficult people, and conflict management. Identify and remove barriers. Policies that do not make sense need to be eliminated. Develop and support teams and relationships. Listen to your customers: surveys, interviews, comments, shadowing. Do not forget internal customers; obtain feedback from other teams and departments in the organization. Share feedback in ways that teach. Eliminate an environment of blame.

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Box 34-17 Sample Preoperative Satisfaction Questionnaire Your feedback is important to us in assessing our services and helping us make changes. Please rate the quality of the services you received during your visit to the Pre-Admitting Test Center. To indicate your answer, just fill in the circle. Please do not check or X circles. What Type of Surgery Are You Having? Orthopedic Neurosurgery Thoracic Cardiac General surgery Plastic 1. 2. 3. 4. 5. 6. Ear, nose, throat/ophthalmology Gynecology Urology Other/Dont know Use these ratings: Poor

Section IV Anesthesia Management

Fair Good Very Good Excellent

Please rate the following about your visit to the Weiner Center for Preoperative Evaluation (CPE): Explanation of the CPE process by your surgeons office _ _________________________________________________________ . Ease of locating the CPE in the hospital _ ________________________________________________________________________. How clearly the CPE receptionist explained what would happen during your visit ______________________________________. Courtesy and efficiency of the CPE receptionist __________________________________________________________________. Length of time you spent waiting to be seen _ ___________________________________________________________________. If you called the CPE, how promptly and efficiently were your questions answered_____________________________________.

Visit with the Anesthesia Care Provider 1. Courtesy and respect you were given by your anesthesia provider __________________________________________________. 2. Explanation of your options and plan for anesthesia ______________________________________________________________. 3. Amount of time spent with the anesthesia provider _ _____________________________________________________________. Visit with a Nurse or Nurse Practitioner 1. Courtesy and respect you were given by your nurse/nurse practitioner_______________________________________________. 2. Explanation of your planned operation _________________________________________________________________________. 3. Amount of time spent with the nurse/nurse practitioner ___________________________________________________________. 4. Explanation of how you should prepare for your surgery __________________________________________________________. Visit with Laboratory/X-Ray Technicians 1. Courtesy and respect you were given by the lab and x-ray technicians _______________________________________________. 2. Skill of the lab and x-ray technicians _ __________________________________________________________________________. Other 1. Overall, how would you rate the care and service you received in the CPE?_ __________________________________________. 2. To what degree were your questions answered clearly and completely? _ ____________________________________________. 3. After your CPE visit, how prepared do you feel for your surgery? _ __________________________________________________. 4. If you submitted information to the CPE over the Internet, such as medical history, how would you rate the service? __________________________________________________________________________________________________________.

spent being the most positive and negative components, respectively. Of note is that after the preoperative visit, the vast majority of patients felt appropriately prepared for their upcoming procedure regarding education and communication of information (Box 34-17). It is the role of the preoperative staff to educate the patient about issues regarding anesthesia, surgery, and the perioperative experience and to address specific patient anxieties about the procedure. A variety of ways to provide this have been evaluated, including direct communication, written information, videos, and websites. When comparing a face-to-face interview with an interview plus a brochure or a video, patients in the group receiving an interview plus a video had the highest scores in patient satisfaction and information gain.167 An Internet tool may be a viable way for patients to receive information about their particular

upcoming procedure, as well as to express concerns and formulate questions without the pressure of a rushed preoperative visit. Past studies have shown that patients may in fact be more likely to provide more information and reveal more problems, especially social and psychiatric issues, at a computer interface instead of to a health care provider.180 By being aware of patient concerns, the visit can be tailored to better meet the needs of the patient. Time that would otherwise be spent trying to extract information from the patient can be used instead to answer patient questions more comprehensively, build rapport, and decrease stress. How best can education be provided and patient concerns addressed? To answer this requires some understanding of what concerns patients have regarding their anesthetic and surgical experience. A number of studies have been reviewed to understand this information. Failure to wake up from an anesthetic has

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consistently been shown to be a major concern. Younger patients and women tend to express more anxiety regarding their anesthesia. Some practitioners believe that informing patients of all possible risks in detail will serve only to increase anxiety. Several studies have shown that more information does not necessarily decrease anxiety. It may be more important to identify subgroups of patients and focus the information toward the patients coping style. A British study showed that although there was no correlation between the level of information provided preoperatively and patient anxiety, there was a strong correlation between patients satisfaction with the amount of information provided and decreased anxiety. Identifying patient subgroups that may benefit from specific educational methodologies and providing this education to these subgroups in a cost-effective manner remain a challenge. In addition, optimal skills in the practitioner providing the patient education must be ensured. Diverse levels of educator experience can result in inconsistent patient information. Skill levels and core competencies in providing patient education must be established. Preoperative patient education has been demonstrated to be a factor in reducing postoperative pain. Egbert found reduced narcotic requirements and reduced length of stay in patients who had intensive preoperative instruction about pain. Reduction in length of stay and postoperative medication was also shown in patients undergoing spinal surgery for back pain who received teaching sessions before surgery. In patients undergoing CABG, the group receiving information plus coping preparations had a lower incidence of postoperative hypertension, although this study did not show a decrease in length of stay or postoperative narcotic requirements. In addition, patients who are taught to use a pain scale during the preoperative visit can more effectively self-report pain postoperatively.181 Preoperative education can also provide an opportunity for intervention to improve patient lifestyle, such as an introduction to smoking cessation programs. Optimal preoperative patient education can influence a number of factors that affect overall operating room efficiency. For example, appropriate preoperative fasting and medication orders can be given, thereby preventing delays and cancellations. An adequate discussion of informed consent during the clinic visit prevents delays in the preoperative holding area to address these issues. The preoperative visit can ensure that the patient receives adequate bowel preparation and stoma care instructions, and patients undergoing day surgery can be educated regarding the requirement for transportation home.

These guidelines recommend that the preoperative evaluation include assessment of factors that may increase the risk for aspiration, including gastrointestinal motility disorders, the potential for difficult airway management, and diabetes mellitus. Separate fasting guidelines are not provided for patients with these and other conditions that may increase the risk of regurgitation and pulmonary aspiration. There is great diversity among institutions in the current practice patterns for preoperative fasting, with many being more conservative than the ASA guidelines would suggest.182 There is agreement among most institutions in this study that ingestion of clear fluids up to 2 to 3 hours before anesthesia is acceptable. There is diversity regarding solids, with many institutions still restricting intake of solids after midnight.

Role of the Medical Consultant in Preoperative Evaluation


The use of medical consultation for preoperative patients will vary by institution, depending on the level of expertise in perioperative medicine of the clinicians performing preoperative assessments. The comfort level of the preoperative staff in interpreting ECGs and in ordering and interpreting stress testing and echocardiograms will have a major influence on the amount of consultation requested, as demonstrated by Tsen and colleagues. Park has summarized the recommendations for preoperative cardiology consultation in a 2003 review.183 This analysis suggests that anesthesiologists need consultation for a significant number of patients with cardiac disease who are undergoing noncardiac surgery.184 However, as Kleinman states in the accompanying editorial, the level of expertise of the cardiology consultant over and beyond that of the requesting anesthesiologist is related to the immediate management of acute coronary syndromes. As a perioperative physician, the anesthesiologist should have adequate expertise to quantify and manage perioperative risk. For example, in the one generally accepted effective intervention of perioperative -blockade, a cardiologist is not needed to provide this therapy. In Kleinmans opinion, the cardiologists major role is in the perioperative management of acute coronary syndromes and in long-term management of chronic medical conditions. There seems to be little agreement among cardiologists, anesthesiologists, and surgeons regarding the purposes and utility of consultation; a review of 55 consecutive cardiology consultations suggests that most give little advice that truly affects management.169 When requesting a cardiology or any specialty consultation, the anesthesiologist should ask specific questions regarding the information desired to increase the value of the consultation and perioperative management. The anesthesiologist is the final physician who questions and determines the patients appropriateness and stability for surgery. There can be considerable frustration and tension in the presurgical holding area when a patients surgery is delayed or canceled just before entering the operating room. Essential diagnostic studies such as a cardiac stress test or specific laboratory tests may not have been obtained. A perioperative risk concern may not have been evaluated by the specialty consultation. To avoid day-of-surgery delays and cancellations by the anesthesiol-

Preoperative Fasting Status


Preoperative fasting recommendations have been made to reduce the occurrence of pulmonary aspiration. The ASA has published practice guidelines for preoperative fasting based on the evidence available.5 The task force supports a fasting period of 2 hours for clear liquids in all patients. The volume of liquid ingested is less important than the type of liquid ingested. A fasting period of 4 hours for neonates and infants receiving breast milk and 6 hours for those receiving formula and solids is recommended. For noninfants, a fasting period of 6 hours after a light meal and 8 hours after a meal that includes fried or fatty foods is recommended.

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ogist, some surgeons have developed a pattern of obtaining more medical specialty consultations than are necessary or appropriate. When the anesthesiologist is involved in the determination of whether a medical consultation is needed, overall numbers of specialty consultations decreasea substantial savings in cost and time.164

Summary
The practice of anesthesiology has changed.185,186 The expanding role of the anesthesiologist outside the operating room has redefined our specialty in the hospital and with our physician colleagues with regard to our clinical expertise, effectiveness, and contribution to quality patient care. Anesthesiologists have noticeably evolved from a specialty practicing only inside the operating rooms to an acknowledged position as perioperative medicine specialists who comprehensively evaluate and manage patients preoperatively, intraoperatively, and through their postoperative pain requirements. Frequently this occurs in formalized hospital service programs or anesthesia preoperative/pain management clinics. The anesthesiologists visibility and leadership position in perioperative patient management has enhanced hospital opportunities, leadership recognition, and the viability of our specialty. Anesthesiologists need to be clinically knowledgeable and skilled in assessing patients in the preoperative period, whether it be in an evaluation clinic setting before the day of surgery or at the bedside immediately before induction of anesthesia. Preparation for anesthesia and surgery can be straightforward or complex and difficult. Medicine is increasingly fragmented and extremely specialized. Patients are getting older and living longer with chronic diseases. Surgical technologies, procedures, and settings where anesthesia is administered, as well as regulatory requirements, are constantly changing and requiring anesthesiologists to accept expanding perioperative responsibilities. Guidelines and evidence-based medicine practices are being developed and updated frequently. Virtually all disease states have an impact on perioperative patients and their care. Anesthesiologists can collaborate with primary care providers, physician extenders, and specialists, but none can truly evaluate the risks associated with anesthesia, discuss these risks with patients, or manage them perioperatively other than a physician trained in anesthesiology. Although health care changes, regulatory issues, consensus guidelines, and medical developments will occur, the primary purpose of preoperative evaluation will never change. The anesthesia preoperative evaluation is the clinical foundation and framework of perioperative patient management and can potentially reduce operative morbidity and enhance patient outcome.

Section IV Anesthesia Management

Role of the Preoperative Clinic in Guiding Intraoperative Management Choices


The role of preoperative evaluation is to provide data and guidance so that the team managing the case on the day of the procedure can make appropriate choices. It is inappropriate for clinic providers or any preoperative consultant to make ultimate decisions regarding a specific type of anesthesia to be provided. Possible options that depend on the type of procedure, patient comorbid conditions, and patient preference should be discussed. Documentation in the final anesthesia assessment should include a statement that the options have been discussed with the patient and any patient preference noted. The patient should be informed that the final decision regarding the anesthetic plan would be made by the team managing the case. The preoperative clinician should provide ample opportunity for the patient to have any questions or concerns regarding anesthetic options addressed. Patients are often concerned that they are not speaking with the anesthesia clinician who will be providing their care. They should be reassured that all information obtained in the clinic is transferred and reviewed by the team and that they will have a chance to speak with their actual care providers on the day of surgery if additional questions arise. Additionally, should a high-risk case warrant the skills of a specialty anesthesiologist, this assessment and request can be facilitated through the preoperative evaluation clinic before the day of surgery. A personal discussion the day before surgery between the preoperative evaluator and anesthesiologist assigned a difficult case or airway enhances the perioperative management plan and avoids operating room delays, cancellations, and potential adverse outcomes.

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Kinney MA, Warner ME, Nagorney DM, et al: Peri anesthetic risks and outcomes of abdominal surgery for metastatic carcinoid tumours. Br J Anaesth 87:447-452, 2001. 113. Tait AR, Malviya S: Anesthesia for the child with an upper respiratory tract infection: Still a dilemma? Anesth Analg 100:59-65, 2005. 114. Kostopanagiotou G, Smyrniotis V, Arkadopoulos N, et al: Anesthetic and perioperative management of adult transplant patients in nontransplant surgery. Anesth Analg 89:613-622, 1999. 115. Kostopanagiotou G, Smyrniotis V, Arkadopoulos N, et al: Anesthetic and perioperative management of paediatric organ recipients in nontransplant surgery. Paediatr Anaesth 13:754-763, 2003. 116. Gohh RY, Warren G: The preoperative evaluation of the transplanted patient for nontransplant surgery. Surg Clin North Am 86:1147-1166, 2006. 117. Hepner DL, Castells MC: Anaphylaxis during the perioperative period. Anesth Analg 97:1381-1395, 2003. 118. Hepner DL, Castells MC: Latex allergy: An update. 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Detsky AS, Smalley PS, Chang J: Is this patient mal nourished? JAMA 271:54-58, 1994.

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IV

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133. Kudsk K: Joint Commission for Accreditation of Health Care Organizations guidelines; too late to intervene for nutritionally at-risk surgical patients. JPEN J Parenter Enteral Nutr 27:288-290, 2003. 134. Committee on Ethics, American Society of Anesthe siologists: Ethical guidelines for the anesthesia care of patients with do not resuscitate orders, 2001. Available at http://www.asahq.org/publicationsAndServices/standards/09.html. 135. Truog RD, Waisel DB, Burns JP: DNR in the OR. A goal-directed approach. Anesthesiology 90:3-6, 1999. 136. Grimaldo DA, Wiener-Kronish JP, Jurson T, et al: A randomized controlled trial of advance care planning discussions during preoperative evaluations. Anesthesiology 95:43-50, 2001. 137. Tsen L, Segal S, Pothier M, Bader A: Survey of resi dency training in preoperative evaluation. Anesthesiology 93:1134-1137, 2000. 138. ACGME website. 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Anesthesiology 105:454-461, 2006. 157. Hodges PJ, Kam PC: The perioperative implications of herbal medicines. Anaesthesia 57:889-899, 2002. 158. Alexander JA: The potential hazards of used and abused perioperative drugs, herbs and dietary supplements. ASA Refresher Courses Anesthesiol 34:119, 2006. 159. Abebe W: Herbal medication: Potential for adverse interactions with analgesic drugs. J Clin Pharm Ther 27:391-401, 2002. 160. Wang SM, Peloquin C, Kain ZN: Attitudes of patients undergoing surgery toward alternative medical treatment. J Altern Complement Med 8:351-356, 2002. 161. Johnson RK, Mortimer AJ: Routine pre-operative blood testing: Is it necessary? Anaesthesia 57:914917, 2002. 162. Imasogie N, Wong DT, Luk K, et al: Elimination of routine testing in patients undergoing cataract surgery allows substantial savings in laboratory costs. A brief report. Can J Anaesth 50:246-248, 2003. 163. Finegan BA, Rashiq S, McAlister FA, OConnor P: Selective ordering of preoperative investigations by anesthesiologists reduces the number and cost of tests. Can J Anaesth 52:575-580, 2005. 164. Fischer SP: Development and effectiveness of an anesthesia preoperative evaluation clinic in a teaching hospital. Anesthesiology 85:196-206, 1996. 165. Starsnic MA, Guarnieri DM, Norris MC: Efficacy and financial benefit of an anesthesiologist-directed university preadmission evaluation center. J Clin Anesth 9:299-305, 1997. 166. Scott G: The voice of the customer: Is anyone listen ing? J Healthc Manage 46:221-223, 2001. 167. Snyder-Ramos SA, Seintsch H, Bottinger BW, et al: Patient satisfaction and information gain after the preanesthetic visit: A comparison of face-to-face interview, brochure, and video. Anesth Analg 100:1753-1758, 2005. 168. Minai FN, Kamal RS: Evaluation of cardiology con sultations sought from the anaesthesia clinic. J Coll Physicians Surg Pak 14:199-201, 2004. 169. Katz RI, Barnhart JM, Ho G, et al: A survey on the intended purposes and perceived utility of preoperative cardiology consultations. Anesth Analg 87:830-836, 1998. 170. Ferschl MB, Tung A, Sweitzer B, et al: Preoperative clinic visits reduce operating room cancellations and delays. Anesthesiology 103:855-859, 2005. 171. Schmiesing CA, Brodsky JB: The preoperative anesthesia evaluation. Thorac Surg Clin 15:305-315, 2005. 172. Macario A: Are your hospital operating rooms efficient? A scoring system with eight performance indicators. Anesthesiology 105:237-240, 2006. 173. Macario A, Vitez TS, Dunn B, et al: Where are the costs in preoperative care? Analysis of hospital costs and charges for inpatient surgical care. Anesthesiology 83:1138-1144, 1995. 174. Archer T, Schmiesing CA, Macario A: What is quality improvement in the preoperative period? Int Anesthesiol Clin 40(2):1-16, 2002. 175. Ausset S, Bouaziz H, Brosseau M, et al: Improve ment of information gained from the preanaesthetic visit through a quality-assurance programme. Br J Anaesth 88:280-283, 2002. 176. Davenport DL, Henderson WG, Khuri SF, et al: Preoperative risk factors and surgical complexity are more predictive of costs than postoperative complications: A case study using the National Surgical Quality Improvement Program (NSQIP) database. Ann Surg 242:463-471, 2005. 177. Greenberg CC, Regenbogen SE, Studdert DM, et al: Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg 204:533-540, 2007. 178. Hepner DL, Bader AM, Hurwitz S, et al: Patient satisfaction with preoperative assessment in a preoperative assessment testing clinic. Anesth Analg 98:1099-1105, 2004. 179. Scott G: Customer satisfaction: Six strategies for continuous improvement. J Healthc Manage 46(2):82-85, 2001. 180. Bachman JW: The patient-computer interview: A neglected tool that can aid the clinician. Mayo Clin Proc 78:67-78, 2003. 181. Bond LM, Flickinger D, Aytes L, et al: Effects of preoperative teaching of the use of a pain scale with patients in the PACU. J Perianesth Nurs 20:333-340, 2005. 182. Ferrari LR, Rooney FM, Rockoff MA: Preoperative fasting practice in pediatrics. Anesthesiology 90:978-980, 1999. 183. Park K: Preoperative cardiology consultation. Anesthesiology 98:754-762, 2003. 184. Kleinman B: Preoperative cardiology consultation: How helpful is it? Anesthesiology 99:1240-1241, 2003. 185. Deutschman CS, Traber K: Evoultion of anesthesi ology. Anesthesiology 85:1-3, 1996. 186. Wiklund RA, Rosenbaum SH: Medical progress: Anesthesiology (first of two parts). N Engl J Med 337:1132-1141, 1997.