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(BQ) Part 2 book Preoperative assessment and management presentation of content: Musculoskeletal and autoimmune diseases, miscellaneous issues, the pregnant patient for nonobstetric surgery, the pediatric patient, anesthetic specific issues, perioperative management issues, organizational infrastructure of a preoperative evaluation center,... and other contents.
P1: KUF/OVY P2: PCX/OVY GRBT273-11 Sweitzer-3499G QC: OVY GRBT273-Sweitzer-v2.cls Printer: RRD December 3, 2007 18:24 11 Musculoskeletal and Autoimmune Diseases Parwane S Parsa This chapter reviews the preoperative evaluation of patients with musculoskeletal and autoimmune diseases The autoimmune diseases discussed in this section include rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, and scleroderma Other musculoskeletal diseases included in this chapter are osteoarthritis and kyphoscoliosis Marfan syndrome and other inherited connective tissue diseases are reviewed These entities are distinguished by variable disease severity and frequent multisystem effects requiring careful preoperative investigation This chapter discusses strategies to identify and treat patients with consequent pulmonary and cardiac involvement and also reviews newer therapies used to delay disease progression RHEUMATOID ARTHRITIS Rheumatoid arthritis (RA), a common and debilitating autoimmune disease, affects up to 1% of the population, typically ranging in age from 40 to 70 years Incidence of the disease is greater in females than in males (ratio of 2.5:1) (1) In addition to the characteristic joint inflammation, multiple organ systems are impacted by the disease, requiring careful evaluation General Patients with RA may report fatigue, malaise, weight loss, and fever Arthropathy The disease involves multijoint inflammation and morning stiffness of both small and large joints of the extremities The temporomandibular joint, cervical spine, and cricoarytenoid cartilages are frequently affected Patients may experience limited neck and jaw mobility or hoarseness The arthropathy is progressive and disabling Neurologic Sensory peripheral neuropathy associated with vasculitis and nerve entrapment occurs with RA Cardiac Pericardial effusion, aortic insufficiency, and conduction abnormalities are common The incidence of myocardial ischemia (and cardiovascular mortality) is higher in RA patients compared with non-RA patients with common risk factors (2) 259 P1: KUF/OVY P2: PCX/OVY GRBT273-11 Sweitzer-3499G 260 QC: OVY GRBT273-Sweitzer-v2.cls Printer: RRD December 3, 2007 Handbook of Preoperative Assessment and Management Pulmonary Decreased thoracic mobility can produce a restrictive defect; other associated pulmonary disorders include pleural effusions and interstitial fibrosis also resulting in predominantly restrictive lung disease Renal Patients with RA can have renal vasculitis Hematologic Anemia, leucocytosis, thrombocytosis, and splenomegaly with thrombocytopenia can be present Dermatologic Rheumatoid nodules, dry eyes, vasculitis, and salivary inflammation are typical History The evaluation of patients with RA assesses the onset and course of the disease, the location and severity of joint involvement, factors that exacerbate symptoms, and the best level of activity the patient can achieve A history of neck stiffness, crepitation with neck movement, hoarseness, stridor, and any neurologic deficits is elicited The evaluator asks about dyspnea with exertion, orthopnea, anemia, and chest pain or pressure Extra-articular effects of RA and any recent hospital admissions are discussed Current medications are listed along with any history of adverse drug effects Physical Examination General Observe the patient for signs of anemia (such as pallor or tachycardia) or malnutrition Examine the extremities for degree of joint involvement so that intraoperative positioning of the patient can be anticipated Airway Examination Several aspects of the airway examination are important in patients with RA Limited neck flexion or extension from cervical spine involvement may make positioning and laryngoscopy difficult Similarly, a limited oral aperture may hamper intubation Atlanto-occipital subluxation caused by ligament laxity can be found in any patient with RA; the incidence is up to 46% The direction of the subluxation is anterior in the majority of cases (3) Patients, therefore, are at risk for spinal cord compression and permanent neurologic injury with excessive movement during airway management (4) or positioning Neurologic signs with neck movement are documented, although neurologic signs not identify all patients at risk of this complication Patients who report significant hoarseness may need preoperative referral to the otolaryngology clinic for fiberoptic laryngoscopy to diagnose poor mobility of the vocal cords from cricoarytenoid arthritis (5) 18:24 P1: KUF/OVY P2: PCX/OVY GRBT273-11 Sweitzer-3499G QC: OVY GRBT273-Sweitzer-v2.cls Printer: RRD December 3, 2007 11 Musculoskeletal and Autoimmune Diseases 18:24 261 Cardiopulmonary Observe the patient for cyanosis, abnormal respiratory rate or effort, and chronic cough Auscultation of the chest may reveal evidence of a pleural effusion or pneumonia, or rales consistent with pulmonary fibrosis Document murmurs or rubs from valvular insufficiency or pericarditis Diagnostic Testing Laboratory Tests Because anemia is a common feature of RA, a complete blood count (CBC) with platelets is ordered for patients who will have surgery with any expected blood loss For individuals with renal or cardiac disease, blood urea nitrogen (BUN), creatinine, and electrolytes are measured Radiology Because of the high incidence of atlantoaxial subluxation in patients with RA, preoperative cervical spine (C-spine) radiographs are performed in patients who are symptomatic or who will undergo anesthetic techniques involving potential airway manipulation The x-ray examination includes the anteroposterior (AP) view of the C-spine, an AP odontoid view, and lateral flexion and extension films Criteria for atlantoaxial subluxation are an anterior atlas—dens interval of >3 mm or a posterior atlas—dens interval of ≤14 mm (3) Patients with abnormal C-spine radiographs and/or neuralgia or myelopathy need neurology consultation and possible intervention (halo traction or surgical correction) (6) Pulmonary Evaluation The resting oxygen saturation is measured Findings on history and physical examination (H&P) that suggest pneumonia, restrictive lung disease, or pleural effusion are further evaluated with a chest radiograph For patients who have limited exercise tolerance and/or possible restrictive lung disease, an electrocardiogram (ECG) and pulmonary function tests (PFTs) are indicated Chapter contains a detailed discussion of restrictive lung disease Cardiac Evaluation Basic cardiac evaluation, such as resting ECG, is warranted in RA patients The ECG yields information about pericardial effusion, conduction abnormalities, or ischemic heart disease Twodimensional (2-D) echocardiography is indicated in patients with suspected pericardial effusion (e.g., muffled heart sounds, friction rub, displaced point of maximal impulse [PMI], low voltage on ECG, enlarged cardiac silhouette on chest radiograph) or valvular disease Ischemic heart disease is an important consideration in any patient with RA undergoing major surgery Some patients may not be able to exercise sufficiently to develop signs or symptoms of myocardial ischemia because of joint pain and limited mobility Evidence supports a more rapid progression of coronary artery disease (CAD) in patients with RA, although the reasons for accelerated atherosclerosis are not entirely clear (2) The preoperative P1: KUF/OVY P2: PCX/OVY GRBT273-11 Sweitzer-3499G 262 QC: OVY Printer: RRD GRBT273-Sweitzer-v2.cls December 3, 2007 Handbook of Preoperative Assessment and Management Table 11.1 Common medications, adverse effects, and preoperative management for patients with rheumatoid arthritis Agent Adverse Effects Nonsteroidal Bleeding anti-inflammatory complications, drugs gastrointestinal irritation, renal dysfunction Methotrexate Pancytopenia, gastrointestinal irritation, abnormal LFTs Glucocorticoids Leflunomide Impaired wound healing, glucose intolerance, increased risk of infection, adrenal suppression Hepatotoxicity, hypertension, pancytopenia Anti–tumor necrosis factor agents: Etanercept Infliximab Adalimumab Increased risk of opportunistic infection and malignancy Interleukin-1 receptor antagonist: Anakinra Skin irritation, increased risk of infection Preoperative Management Stop days before surgery Monitor CBC with platelets and LFTs; if tests are abnormal, discontinue medication to allow normalization before surgery Continue on day of surgery; provide perioperative “stress doses” (see Chapter 17) Monitor CBC with platelets and LFTs; if laboratory tests are abnormal, discontinue drug to allow normalization before surgery Preoperative management based on severity of patient’s disease, duration of action of the drug, and risk of infection with the planned surgery Preoperative management based on severity of patient’s disease and risk of infection with the planned surgery CBC, complete blood count; LFTs, liver function tests 18:24 P1: KUF/OVY P2: PCX/OVY GRBT273-11 Sweitzer-3499G QC: OVY GRBT273-Sweitzer-v2.cls Printer: RRD December 3, 2007 11 Musculoskeletal and Autoimmune Diseases 18:24 263 evaluator can utilize stress-thallium examination or dobutamine stress echocardiography to evaluate the patient for inducible ischemia Patients with positive stress tests may require further testing or additional medications before the surgical procedure See Chapter Preoperative Medication and Instructions Therapy for RA has improved with the introduction of new agents that slow progression of the disease (7) A list of common medications, adverse effects, and suggested preoperative instructions appears in Table 11.1 Preoperative Preparation Preoperative therapy includes treatment for any underlying pulmonary infection (pneumonia, bronchitis) as well as evaluation and treatment of pleural effusions that impair effective ventilation Based on the results of cardiac evaluation, medical therapy (such as beta blockers) can be started in selected patients Anesthetic Implications Airway Management General anesthesia (GA) in patients with RA requires careful planning for airway management Major concerns are the increased incidence of difficult laryngoscopy and the risk of neurologic deficit with atlantoaxial subluxation during laryngoscopy In patients at high risk (airway examination indicating probable difficulty or positive C-spine films), preparations for awake fiberoptic intubation (FOI) are made After successfully securing the airway, the anesthesiologist tests the patient’s ability to move the extremities before induction Using a smaller-diameter endotracheal tube facilitates placement in the presence of cricoarytenoid involvement In the recovery room, the patient is carefully observed for acute airway obstruction caused, in rare cases, by exacerbation of cricoarytenoid arthritis (8,9) Regional Anesthesia Regional techniques for patients with RA have several advantages Patients who need orthopedic surgery on the extremities can have peripheral nerve block supplemented with intravenous sedation Regional techniques can minimize the risk of cardiovascular depression and airway management problems associated with GA A peripheral nerve block also provides excellent postoperative analgesia Pre-existing neuropathy or patient inability to maintain position for a peripheral nerve block may preclude this technique Neuraxial blockade offers similar advantages for patients with RA ANKYLOSING SPONDYLITIS Ankylosing spondylitis is a rheumatic disease characterized by progressive inflammation of large joints, affecting particularly the sacroiliac joints and the spine Movement can be severely restricted by calcification of spinal ligaments Other manifestations of ankylosing spondylitis are peripheral arthritis and uveitis Vascular inflammation may coexist, with aortitis and aortic P1: KUF/OVY P2: PCX/OVY GRBT273-11 Sweitzer-3499G 264 QC: OVY GRBT273-Sweitzer-v2.cls Printer: RRD December 3, 2007 Handbook of Preoperative Assessment and Management insufficiency (AI) Pulmonary fibrosis and poor chest wall compliance from joint fixation and kyphosis are possible The majority of ankylosing spondylitis patients are young males History Inquire about the location and severity of joint involvement Significant cervical spine or thoracic spine disease affects airway management and patient positioning Any history of associated ocular, cardiovascular, and pulmonary disease is also explored To gauge the severity of cardiopulmonary impairment, patients are asked about their best level of exercise tolerance Physical Examination General examination notes the presence of cyanosis, tachypnea, and asymmetric chest expansion The range of motion of the spine is checked (flexion, extension) Airway management may be challenging because of restricted neck flexion or extension and possible thoracic kyphosis Chest examination focuses on the presence of kyphosis and associated cardiopulmonary disease, such as a diastolic murmur associated with AI Diagnostic Testing Ankylosing spondylitis patients who routinely take nonsteroidal anti-inflammatory agents (NSAIDs) for relief of pain require a preoperative BUN and creatinine level Individuals who take leflunomide require CBC with platelets and liver function tests preoperatively Patients with significant kyphosis and limited exercise capacity need a chest radiograph and ECG PFTs (spirometry and arterial blood gas [ABG] analysis) are useful to assess the severity of restrictive lung disease AI and ventricular performance are assessed with echocardiography Preoperative Medication and Instructions The first-line therapy for ankylosing spondylitis is an NSAID, which decreases pain and stiffness These medications are discontinued days prior to surgery to avoid bleeding complications Leflunomide is employed for the treatment of arthritis in the extremities Tumor necrosis factor (TNF)-α antagonists, such as etanercept and infliximab (see Table 11.1), have been successful treatments, improving mobility in patients and establishing partial remission in some cases (10) Preoperative Preparation In patients with significant spine disease, the severity of pulmonary restrictive physiology is clarified based on history, physical examination, and results of PFTs Any active pulmonary infection needs treatment before surgery, and any coexisting bronchospasm should be well controlled (see Chapter 5) Anesthetic Implications Airway management in patients with potentially limited cervical spine mobility and thoracic kyphosis requires planning Awake or asleep FOI should be discussed with patients For procedures on 18:24 P1: KUF/OVY P2: PCX/OVY GRBT273-11 Sweitzer-3499G QC: OVY GRBT273-Sweitzer-v2.cls Printer: RRD December 3, 2007 11 Musculoskeletal and Autoimmune Diseases 18:24 265 the extremities, regional anesthesia can be employed Neuraxial blockade, difficult or impossible in patients with severe spinal involvement, may be an option in patients with less severe disease Careful positioning in the operating room (OR) is important in these patients with limited range of motion to avoid iatrogenic injury (11) SYSTEMIC LUPUS ERYTHEMATOSUS Systemic lupus erythematosus (SLE) is an autoimmune disease in which antinuclear antibodies (ANAs) are present in almost all cases A significant majority of patients with SLE are younger females, with an overall population incidence of SLE of 40 cases per 100,000 persons (12) The clinical course of the disease is variable, characterized by active periods and remission General Chronic fatigue and fever are features of the disease Arthritis Arthritis with SLE is very common, and migratory, often involving multiple small joints in the hands and wrists Muscle can be inflamed Skin Dermatologic involvement includes photosensitive rash, “butterfly rash” on the face, subacute cutaneous lupus rash, and alopecia Oral ulcers may also be present Vascular Disease Raynaud phenomenon, characterized by episodic vasospasm in the digits, is found in patients with SLE along with atrophic changes at the fingertips Vascular headache is also common Renal Lupus nephritis with associated hypertension is a marker for poor prognosis, and declining renal function may lead to renal failure Pulmonary Pulmonary disease includes pleural effusions, atelectasis, interstitial pneumonitis, and pulmonary hypertension Cardiac Related cardiac disease includes pericarditis (most frequent), myocarditis, and endocarditis of the mitral or aortic valves Patients with SLE have earlier onset of coronary atherosclerotic disease compared with the general population, even after accounting for other common CAD risk factors (13) Corticosteroid treatment of SLE may be a contributing factor Other causes of cardiac morbidity in SLE include coronary vasculitis and possibly hypercoagulability In rare cases, patients can have cardiomyopathy, which may improve with immunosuppressive therapy Neurologic Neuropsychiatric disease manifests as cognitive dysfunction, affective disorders, neuropathy (including phrenic pathology), P1: KUF/OVY P2: PCX/OVY GRBT273-11 Sweitzer-3499G 266 QC: OVY GRBT273-Sweitzer-v2.cls Printer: RRD December 3, 2007 Handbook of Preoperative Assessment and Management propensity for cerebrovascular accident (CVA), and seizures SLE patients have carotid artery disease more frequently than agematched members of the general population (2) Hematologic SLE is often associated with hematologic abnormalities including anemia, leukopenia, and thrombocytopenia Antiphospholipid antibody syndrome in a subset of patients with SLE is associated with thromboembolic complications such as deep vein thrombosis (DVT), CVA, and pulmonary embolism (PE) Anticoagulation therapy for such patients can reduce the incidence of thrombotic events The antiphospholipid antibody syndrome may result in a prolonged activated partial thromboplastin time (aPTT) Infection Immune system dysfunction or the immunosuppressive effects of medications used to treat the disease put patients at risk for serious infection Several drugs can induce a disease similar to SLE; however, drug-induced lupus is relatively mild and time limited (12, 25) Medications associated with this disorder are listed in Table 11.2 History The history includes a discussion of the patient’s general condition: presence of constitutional symptoms, course of the disease, recent exacerbations, medications and side effects, and specific end-organ disease The evaluator also inquires about chronic cough, dyspnea at rest and with exertion, and a history of recent pulmonary infections Recent thromboembolic events or other hematologic problems are discussed The patient is asked about the best level of exercise tolerance and symptoms consistent with ischemic heart disease A history of neurologic events is also elicited Physical Examination The preoperative physical examination documents vital signs, the general appearance of the patient, associated dermatologic signs, and airway examination The remainder of the physical examination focuses on cardiovascular and pulmonary systems, Table 11.2 Drugs capable of causing drug-induced lupus erythematosus ACE inhibitors Beta blockers Carbamazepine Chlorpromazine Hydralazine Hydrochlorothiazide Interferons Isoniazid Lithium Lovastatin Macrodantin Phenytoin Procainamide Propylthiouracil Simvastatin Sulfasalazine Anti-TNF agents ACE, angiotensin-converting enzyme; TNF, tumor necrosis factor 18:24 P1: KUF/OVY P2: PCX/OVY GRBT273-11 Sweitzer-3499G QC: OVY GRBT273-Sweitzer-v2.cls Printer: RRD December 3, 2007 11 Musculoskeletal and Autoimmune Diseases 18:24 267 documenting displaced PMI, muffled heart sounds, murmurs, pericardial rub, carotid bruits, and evidence of pulmonary edema, pleural effusion, or lung consolidation The clinician also examines the patient for lower extremity edema, jugular venous distension (JVD), and hepatomegaly Neurologic examination documents sensory and motor deficits from neuropathy or CVA Diagnostic Testing Laboratory Testing Patients with SLE require certain preoperative tests to identify common abnormalities A CBC with platelets and aPTT is obtained If hematologic abnormalities are present, the patient is referred for further testing to his or her rheumatologist or to a hematologist The risk of renal involvement in SLE mandates a preoperative BUN and creatinine level Patients with heart failure or renal insufficiency should have electrolyte levels measured Cardiovascular Testing An ECG is performed because patients with SLE are at significantly higher risk for ischemic heart disease, pulmonary hypertension, and other cardiac abnormalities The ECG may show right axis deviation (RAD), right bundle branch block (RBBB), low voltage associated with pericardial effusion, Q waves, or ST-T–wave abnormalities With the early onset of atherosclerotic disease in this patient population, the preoperative evaluator should have a low threshold for cardiology referral and exercise or pharmacologic stress testing If pericardial effusion, pulmonary hypertension, heart failure, or a valvular abnormality is suspected, 2-D transthoracic or transesophageal echocardiography (TEE) confirms the diagnosis Pulmonary Testing Patients with worsening pulmonary status who will undergo major surgery should have a chest radiograph PFTs can determine the presence and degree of restrictive lung disease Echocardiography may be indicated for patients with suspected or known pulmonary hypertension See the Scleroderma section in this chapter Preoperative Medications and Instructions A wide variety of medications are used to treat SLE See Table 11.3 for common agents, adverse effects, and perioperative recommendations Preoperative Preparation The patient’s pulmonary status should be optimized with treatment of effusion or infection before surgery Patients with hypertension should have controlled blood pressure (140/90 or lower) before surgery, and diagnosis and management of ischemic heart disease are needed before major procedures (see Chapter 3) P1: KUF/OVY P2: PCX/OVY GRBT273-11 Sweitzer-3499G 268 QC: OVY Printer: RRD GRBT273-Sweitzer-v2.cls December 3, 2007 Handbook of Preoperative Assessment and Management Table 11.3 Common medications, adverse effects, and preoperative management for patients with systemic lupus erythematosus Agent Adverse Effects Aspirin Bleeding complications, gastrointestinal irritation, renal dysfunction Nonsteroidal antiBleeding inflammatory complications, drugs gastrointestinal irritation, renal dysfunction Hydroxychloroquine, Thrombocytopenia, chloroquine, myopathy, quinacrine neuropathy Glucocorticoids Cytotoxic agents: Cyclophosphamide, azathioprine, mycophenolate mofetil Impaired wound healing, glucose intolerance, increased risk of infection, adrenal suppression Immunosuppression, pancytopenia, gastrointestinal effects Preoperative Management Stop days before surgery Stop days before surgery Monitor CBC with platelets; if thrombocytopenic, discontinue drug to allow normalization before surgery Continue on day of surgery; provide perioperative “stress doses” (see Chapter 17) Monitor CBC with platelets; if anemic or thrombocytopenic, discontinue drug to allow normalization before surgery CBC, complete blood count Patients on chronic steroids may require stress doses perioperatively (see Chapter 17) Anesthetic Implications Patients with severely compromised respiratory or cardiovascular function may benefit from peripheral nerve block if the procedure allows In patients with SLE and pre-existing neurologic deficits from CVAs or neuropathy, nerve block or neuraxial blockade can be performed after documenting the neurologic examination and discussing the risks and benefits of the procedure The management of GA is guided by the patient’s coexisting end-organ effects Keeping the patient with Raynaud phenomenon warm is important to minimize vasospasm 18:24 P1: PCX/OVY GRBT273-Index P2: PCX/OVY QC: PCX/OVY Sweitzer-3499G T1: PCX GRBT273-Sweitzer-v1.cls Printer: RRD December 12, 2007 Index Obliterative bronchiolitis, COPD and, 128 Obstructive jaundice, 225 surgical risk of, 225 Obstructive sleep apnea (OSA) in case study 1, 449 with pituitary gland disorders, 163 preoperative assessment of, 443 OHS See Obesity hypoventilation syndrome OI See Osteogenesis imperfecta Oncologic disease, of pediatric patient, 368 Opioids for chronic pain, 289–290 delirium and, 250 myasthenia gravis with, 243 Orthopnea, 133 Orthostatic hypotension with carcinoid tumors, 165, 165t with diabetes, 148, 150–151, 151t with hypothalmic-pituitaryadrenal disorder, 161–162, 162t, 164 with Parkinson disease, 250–251 with pheochromocytoma, 166–168, 167t with porphyrias, 170t OSA See Obstructive sleep apnea Osteoarthritis, 273 anesthetic implications of, 273 diagnostic testing for, 273 history for, 273 physical examination for, 273 preoperative medication and instructions for, 273 Osteogenesis imperfecta (OI), 276–277 aortic insufficiency with, 97 Outpatient procedures, preoperative evaluation for, 14 Oxytocin, for hyponatremia, 209 Pacemaker in case study 2, 456 classification of, 107, 108t function of, 107–109 495 interference problems of, 109 permanent, 107–109 placement of, 107 preoperative assessment of, 442–443 rate modulation of, 109 for SSS, 107 temporary, for perioperative period, 102 PAD See Peripheral arterial disease Pain management for chronic pain, 288–293 risks with, Pallor anemia and, 175 pheochromocytoma with, 166 Palpitations anemia and, 174 pheochromocytoma with, 166 SSS with, 106 with thyroid disorders, 154, 155t Pancreatitis with alcohol abuse, 294 hypocalcemia with, 157 PAP See Pulmonary artery pressures Paraneoplastic syndromes, with lung cancer, 332 Parathyroid hormone (PTH) calcium regulation by, 157 with renal disease, 207 Paresthesiae hypocalcemia, 157 renal disease and, 205 Parkinson disease, 250–252 with dementia, 249 overview of, 250–251 preanesthetic assessment for, 251–252 treatment modalities for, 251 Pathophysiology of perioperative cardiac morbidity, 51–52 of renal disease, 198–200 Patient comorbidity, assessment of procedural risks and, 5, 6f Patient-controlled analgesia (PCA), for chronic pain, 290 Patient instructions, 31, 32f 9:58 P1: PCX/OVY P2: PCX/OVY GRBT273-Index 496 QC: PCX/OVY Sweitzer-3499G T1: PCX GRBT273-Sweitzer-v1.cls Printer: RRD December 12, 2007 Index Patient management, in preoperative evaluation and testing, 41–45 consultations, 43–44, 43f medicolegal culpability, 44 practice guidelines, 45 PCA See Patient-controlled analgesia Pediatric patient, 355–372 anesthesia risks with, 357, 357t diagnostic testing for, 363–364 DNR orders of, 371–372 fasting guidelines for, 369, 369t history and review of systems for, 357–358, 358t–360t induction choices for, 369–370 Jehovah’s Witnesses, 371 medications and allergies of, 361 parent-present induction, 370 physical examination of, 361–363, 362t preoperative medications for, 369–372 psychological preparation of, 355, 356t special anesthetic considerations for, 371 special circumstances for, 364–368 asthma, 366 cardiac disease, 366 central nervous system disorders, 367 cervical spine instability, 367 cystic fibrosis, 366 diabetes mellitus, 368 hematologic disorders, 367–368 minimally invasive surgery, 368 myelomeningocele, 367 oncologic disease, 368 premature birth, 365–366 seizure disorders, 367 upper respiratory infection, 364–365 Percutaneous transluminal coronary angioplasty (PTCA), after acute MI, 54 Pergolide, Parkinson disease and, 251 Pericardial effusion, with rheumatoid arthritis, 259 Perioperative cardiac morbidity CHF and, 54 pathophysiology of, 51–52 Perioperative interventions, to reduce risk, 64, 65t Perioperative morbidity ASA physical status classification for, 4–5 causes of, Perioperative myocardial infarction (PMI) angina risk with, 53–54 cause of, 52 etiology of, 51 Perioperative period, long-term health consequences of, 14 Perioperative risk index ASA physical status score comprehensive v., 4–5 development of, 3–4, 4t for pulmonary risk assessment, 140 John Hopkins risk classification system, 5, 5t Peripheral arterial disease (PAD), 110–111 See also Peripheral vascular disease etiology of, 110 history, physical examination and testing for, 110–111 recommendations for, 111 Peripheral edema carcinoid tumors with, 165 hypertension, 82 mitral stenosis, 92 pheochromocytoma with, 166, 167t Peripheral neuropathy with diabetes mellitus, 150 mitigating risks of, 413–414 with porphyrias, 168 Peripheral smear, for anemia, 175 Peripheral vascular disease (PVD) See also Peripheral arterial disease BP measurement for, 55 9:58 P1: PCX/OVY GRBT273-Index P2: PCX/OVY QC: PCX/OVY Sweitzer-3499G T1: PCX GRBT273-Sweitzer-v1.cls Printer: RRD December 12, 2007 Index CAD with, 54–55 cardiorespiratory fitness and, 23 diagnostic testing for, 18t DM and, 148, 151 Personnel, for preoperative assessment, 432 PFTs See Pulmonary function tests Pharmacologic interventions anticoagulants, 405–406 antidepressants, 410, 410t antiepileptics, 410 for antiplatelet therapy, 403–407 clopidogrel, 403–404 LMWH, 405 NSAIDs, 406–407, 406t stents, 404 thienopyridine, 403–404 ticlopidine, 403–404 warfarin, 405 antipsychotics, 410 antiretroviral therapies, 410 anxiolytics, 410 aspirin, 403 for atrial fibrillation, 104 benzodiazepine, 410 for chronic pain, 289–292 buprenorphine, 291–292 methadone, 290–291 neuropathic pain medications, 292 NSAIDs and acetaminophen, 289, 292 opioids, 289–290 diuretics, 400 estrogen, 408 for extreme obesity, 321, 324 for heart disease ACEIs, 115, 400 α1 -adrenergic agonists, 114 α2 -adrenergic agonists, 72–73, 114–115 antiarrhythmic drugs, 115 antiplatelet agents, 69–71 ARBs, 400 beta blockers, 67–69, 116, 400–401, 402t calcium channel antagonists, 73 CCBs, 116 digoxin, 116–117, 117f diuretics, 117 nitroglycerin, 72 497 statins, 71–72, 401 vasopressin, 400 for hypertension, 398t–399t, 400 insulin, 407 for ischemic heart disease, 67–73 lorazepam, 410 MAOIs, 410, 410t metformin, 407 neuraxial techniques, 406 for nonischemic heart disease, 114–117 overview, 397–410, 398t–399t for porphyria, 170–171, 171t postmenopausal hormone replacement therapies, 408 for psychiatric disease, 282–288 anticonvulsants, 284t–286t, 287 anxiolytics, 284t–286t, 287–288 atypical antidepressants, 284t–286t, 287 atypical neuroleptics, 284t–286t, 288 MAOIs, 284t–286t, 287 mood stabilizers, 284t–286t, 288 SSRIs, 283, 284t–286t TCAs, 283, 284t–286t typical neuroleptics, 284t–286t, 288 in renal disease, 214–215, 214t dopamine agonists, 216–218 protective strategies, 216–218 steroids, 407–408, 409t for substance abuse, 294–299, 295t–296t alcohol, 294–297, 295t–296t cocaine, 295t–296t, 298 heroin, 295t–296t, 298–299 marijuana, 295t–296t, 297–298 for thrombophilias, 185 for VPBs, 106 Pharmacologic stress testing See Stress testing, pharmacologic Phenothiazines, for Parkinson disease, 252 9:58 P1: PCX/OVY P2: PCX/OVY GRBT273-Index 498 QC: PCX/OVY Sweitzer-3499G T1: PCX GRBT273-Sweitzer-v1.cls Printer: RRD December 12, 2007 Index Phenoxybenzamine, for pheochromocytoma, 167 Phentermine, for extreme obesity, 321, 324 Phenytoin preoperative management of, 410 for seizure disorders, 240, 240t Pheochromocytoma, 166–168 clonidine withdrawal v., 73 diagnostic testing for, 167, 167t implications of, 167–168 interview, history, and physical examination for, 166, 167t overview of, 166 Photosensitivity, with porphyrias, 168 Physical examination for anemia, 174–175 for ankylosing spondylitis, 264 for aortic insufficiency, 97–98 for aortic stenosis, 93–95 for carcinoid tumors, 164–165, 165t for carotid bruit, 112 in case studies, 449–450, 453, 456–457 for CVD, 55–56 for diabetes mellitus, 150–151, 151t for dyspnea, 133–135 for hepatobiliary disease, without known liver disease, 222 for HF and cardiomyopathy, 85, 85t–86t for HPA conditions, 161–162, 162t for hypercalcemia, 160 for hypertension, 81–82, 81t for hypocalcemia, 157, 158t for inherited connective tissue disorders, 277–278 for kyphoscoliosis, 274–275 airway examination, 274 cardiopulmonary examination, 275 for medical history, 26–29, 27t, 28f, 29t for murmur, 90t for osteoarthritis, 273 overview of, 26–29 for PAD, 110–111 of pediatric patient, 361–363, 362t for pheochromocytoma, 166, 167t for pituitary gland disorders, 163–164 for porphyrias, 168–170, 170t for renal disease, 204–209, 205t for rheumatoid arthritis, 260–261 airway examination, 260 cardiopulmonary, 260 screening batteries v., 19 for SLE, 266–267 for systemic sclerosis, 270 for thyroid disorders, 154–155, 155t Physical status (PS), 52 Pituitary gland disorders, 163–164 See also Hypothalamic-pituitaryadrenal diagnostic testing for, 164 interview, history, and physical examination for, 163–164 Pituitary neoplasms, 252–254 overview of, 252 preanesthetic assessment of, 252–253 Plasmapheresis, for Lambert-Eaton syndrome, 244 Platelet count for anemia, 177 for hemophiliac, 179, 180t in preoperative testing, 18t, 34–35 renal disease, 210 for thrombocytopenia, 182–183, 182t, 329 for thrombocytosis, 184 Platypnea, 133 PMI See Perioperative myocardial infarction Polycystic kidney disease, 201–202 Polypharmacy, delirium and, 250 PONV See Postoperative nausea and vomiting 9:58 P1: PCX/OVY GRBT273-Index P2: PCX/OVY QC: PCX/OVY Sweitzer-3499G T1: PCX GRBT273-Sweitzer-v1.cls Printer: RRD December 12, 2007 Index Porphyrias, 168–171 classification of, 168, 169t diagnostic testing for, 170, 170t implications of, 170–171, 171t interview, history, and physical examination for, 168–170, 170t overview of, 168 Portal hypertension, cirrhosis and, 226 Postoperative nausea and vomiting (PONV), 380–381 problem of, 380 risk factors for, 380–381, 380t Postoperative ventilation, for myasthenia gravis, 243, 243t Potassium homeostasis disorders of, 200 hyperkalemia, 200, 208, 211 hypokalemia, 200, 208–209, 211 Practice guidelines, in patient management, 45 Prednisone and HPA, 161 for Lambert-Eaton syndrome, 244 Pregnancy testing for pediatric patient, 364 for porphyrias, 170, 170t for preoperative testing, 18t, 31, 37–38 Pregnant patient, 342–352 in ambulatory setting, 437 in case study 2, 453 concluding remarks on, 352 evaluation of fetus, 347–350 evaluation of mother, 342–346 cardiovascular, 342–343, 343f, 347t endocrine, 346 gastrointestinal, 344–346, 347t hematologic changes, 346, 347t renal, 346, 347t respiratory, 343–344, 344f, 347t incidence of surgical conditions, 342 499 preoperative counseling of, 350–352 preterm labor, 351–352 teratogenicity of anesthetic agents, 350–351 Premature birth, pediatric patient, 365–366 Premature infant, problems in, 357, 359t Preoperative assessment financial justification for, 420–422 interdisciplinary and international interest in, 429 patient satisfaction with, 425–426 procedures for, 432–433, 433f, 434t, 444–445 for specific procedures or locations, 431–445 introduction to, 431 Preoperative clinic facilities for, 431–432 organizational examples of, 424–425 personnel for, 432 Preoperative counseling, of pregnant patient, 350–352 preterm labor, 351–352 teratogenicity of anesthetic agents, 350–351 Preoperative evaluation center assessment process at decision analysis tools for, 428–429 decision support systems and IT in, 426–428, 426t, 428t establishment of, 419–420, 422–424, 423t financial justification for, 420–422 goals of, 424, 424t interdisciplinary and international interest in, 429 patient satisfaction with, 425–426 goals of, 418, 419t organizational examples of, 424–425 organizational infrastructure of, 418–429 9:58 P1: PCX/OVY P2: PCX/OVY GRBT273-Index 500 QC: PCX/OVY Sweitzer-3499G T1: PCX GRBT273-Sweitzer-v1.cls Printer: RRD December 12, 2007 Index Preoperative medication, 397–410 by anesthesiologists, 17 for ankylosing spondylitis, 264 antidepressant, 398t–399t antihypertensive, 398t–399t antiplatelet therapies, 398t–399t, 400–405, 405t antiseizure, 398t–399t ARBs and ACEIs, 400 aspirin, 398t–399t, 403, 404t asthma, 398t–399t beta blockers, 400–401, 402t birth control, 398t–399t cardiac, 398t–399t of coronary stents, 398t–399t, 404–405 cyclooxygenase-2 inhibitors, 398t–399t diuretics, 398t–399t, 400 eye drops, 398t–399t glucocorticoids, 408, 409t HAART, 410 heartburn or reflux, 398t–399t heparin, 405–406 herbals and supplements, 398t–399t, 408 for HF and cardiomyopathy, 88 for hypertension, 82–83, 400 for inherited connective tissue disorders, 278 instructions for, 397, 398t–399t insulin, 152–154, 398t–399t, 407 for kyphoscoliosis, 275 MAOIs, 398t–399t, 408–410, 410t metformin, 407 narcotic pain, 398t–399t NSAIDs, 398t–399t, 406–407, 406t for osteoarthritis, 273 for pediatric patient, 369–372 for rheumatoid arthritis, 262t, 263 for SLE, 267, 268t statins, 398t–399t, 401 steroids, 398t–399t, 407–408 for systemic sclerosis, 271–272 thyroid, 398t–399t warfarin, 398t–399t, 405–406 Preoperative preparation for ankylosing spondylitis, 264 for chronic pain, 289 for HF and cardiomyopathy, 88–89 for hypertension, 82–83 for inherited connective tissue disorders, 278 for kyphoscoliosis, 275–276 for psychiatric disease, 281–282, 283t for rheumatoid arthritis, 263 for SLE, 267 for substance abuse, 294 for systemic sclerosis, 272 Preoperative testing, 31–40 ABG, 38 age-based testing, 39–40 blood typing, 35–36, 176 cataract surgery, 40 chemistries, 36–37 creatinine, 18t, 36 electrolytes, 36, 162, 208–209 glucose, 36–37, 149–150, 162 HbA1c, 37, 149–150 liver tests, 37, 223 chest radiographs, 39, 135 coagulation studies, 35, 177–178 disease detection, 20–30 medical history components for, 21–24 medical history importance for, 20–21 medical history of specific conditions for, 24–30 documentation, 30f, 31 economics of, 40–41 economics of testing, 40–41 electrocardiograms, 31–34, 55, 85–88, 99f–101f future of, 45–46 guidelines for, CAD, 56–61, 57t, 58f, 59t-61t harm of, 19 hematocrit levels, 18t, 34 hematology, 34, 176 hemoglobin levels, 34 for hypertension, 82 overview of, 14–17, 17t–18t, 31 clinics for, 16–17 goals of, 14–15 9:58 P1: PCX/OVY GRBT273-Index P2: PCX/OVY QC: PCX/OVY Sweitzer-3499G T1: PCX GRBT273-Sweitzer-v1.cls Printer: RRD December 12, 2007 Index guidelines for, 16–17, 17t–18t, 19f requirements of, 16, 16t reviews of, 15 for PAD, 110–111 patient management, 41–45 consultations, 43–44, 43f medicolegal culpability, 44 practice guidelines, 45 platelet count, 34–35, 180t pregnancy testing, 37–38 preoperative testing, 31–40 pulmonary function tests, 39, 135–136 therapeutic drug levels, 38, 242, 244, 248, 250–255 thyroid function tests, 37, 135–136, 155–156, 156t timing of, 41, 42t timing of assessment, 41, 42t urinalysis, 39 white blood cell count, 34, 176 Preterm labor, 351–352 Procarbazine, and cancer patients, 328–329 Procedure-indicated testing, screening batteries v., 19–20 Propofol, seizure disorders with, 241 Propranolol See Beta blockers myasthenia gravis with, 242 Prostate cancer, 333 Prosthetic heart valves, preoperative evaluation for, 99 Protease inhibitors, 338t Proteinuria, in CKD, 196 Prothrombin time (PT) coagulopathy, 177 for liver disease, 223 neuraxial block and, 406 for preoperative testing, 18t, 35 Pruritus with liver disease, 221–222 renal disease and, 204 PS See Physical status Pseudocholinesterase deficiency, 372–376 causes of decreased plasma cholinesterase, 372, 375t genetic classification of, 372–376, 375t for medical history, 21 501 Psychiatric disease, 281–288 drug considerations for, 282–288 anticonvulsants, 284t–286t, 287 anxiolytics, 284t–286t, 287–288 atypical antidepressants, 284t–286t, 287 atypical neuroleptics, 284t–286t, 288 MAOIs, 284t–286t, 287 mood stabilizers, 284t–286t, 288 SSRIs, 283, 284t–286t TCAs, 283, 284t–286t typical neuroleptics, 284t–286t, 288 overview of, 281, 282t preoperative assessment of, 443–444 preoperative preparation for, 281–282, 283t PT See Prothrombin time PTCA See Percutaneous transluminal coronary angioplasty PTH See Parathyroid hormone PTT See Activated partial thromboplastin time Pulmonary artery catheterization, for aortic stenosis, 96 Pulmonary artery pressures (PAP), 206 Pulmonary aspiration prevalence of, 391 risk factors for, 391–392, 392t Pulmonary complications diagnostic testing for, 140–142, 141t factors of, 140 incidence of, 139–140 prevention of, 142–143, 143f Pulmonary disease, 124–144 asthma, 124–125, 366 COPD, 125–130 clinical aspects of, 128–129 surgical treatment of, 129–130 cystic fibrosis, 131–132, 366 dyspnea, 133–136 diagnostic testing for, 135–136 9:58 P1: PCX/OVY P2: PCX/OVY GRBT273-Index 502 QC: PCX/OVY Sweitzer-3499G T1: PCX GRBT273-Sweitzer-v1.cls Printer: RRD December 12, 2007 Index Pulmonary disease (contd.) history and physical examination for, 133–135 inhalers, 410 lung transplant patient, 130–131 overview of, 124 PFTs for dyspnea, 135 for extreme obesity, 324–325 for lung transplant, 131 for myasthenia gravis, 242 for preoperative testing, 39 for SLE, 267 preoperative risk assessment for, 137–140, 138t age, 137 cigarette smoking, 139 comorbid conditions and exercise capacity, 140 diagnostic testing for, 140–142, 141t obesity, 139 surgery and anesthesia type, 139–140 restrictive lung disease, 132–133 smoking and, 136–137 Pulmonary evaluation overview, 124 for systemic sclerosis, 270–271, 271f Pulmonary examination, for medical history, 24, 29 Pulmonary function tests (PFTs), 136f for dyspnea, 135 for extreme obesity, 324–325 for lung transplant, 131 for myasthenia gravis, 242 for preoperative testing, 39 for SLE, 267 Pulmonary system of extremely obese patients, 321, 322t of geriatric patients, 315t of pregnant patient, 343–344, 344f, 347t Pulmonary thromboembolism, dyspnea with, 135 Pulsus paradoxus, dyspnea with, 135 PVD See Peripheral vascular disease Pyridostigmine, for Lambert-Eaton syndrome, 244 RA See Rheumatoid arthritis Radiation pneumonitis, and cancer patients, 328 Radiation therapy, and cancer patients, 328 Radioallergosorbent test (RAST), for latex allergies, 304 Radionuclide angiography, for HF assessment, 85 Radionuclide ventriculography, for aortic insufficiency, 98 RAST See Radioallergosorbent test Rate modulation, of pacemaker, 109 Raynaud phenomenon, in autoimmune disease, 269, 269t RBF See Renal blood flow RCRI See Revised Cardiac Risk Index Reactive airway disease, preoperative assessment of, 443 Regional anesthesia preanesthetic planning for, 213 with rheumatoid arthritis, 263 in systemic sclerosis, 272 Renal blood flow (RBF) autoregulation of, 198–199 in healthy adults, 198 Renal disease, 196–218, 231–232 acetaminophen and, 214–215 acute renal failure causes of, 197–198, 198t definition of, 196 etiology, 202, 203f risk factors for, 211, 212t CAD with, 55, 211 chronic renal disease classification of, 196, 197t definition of, 196 mortality rates with, 197 prevalence of, 196–197 clinical measurement of, 202–204 contrast-induced nephropathy, 215–216, 216f, 217t 9:58 P1: PCX/OVY GRBT273-Index P2: PCX/OVY QC: PCX/OVY Sweitzer-3499G T1: PCX GRBT273-Sweitzer-v1.cls Printer: RRD December 12, 2007 Index definition of, 196 diagnostic testing for, 210–211 cardiac testing, 211 chest radiograph, 211 DM and, 148, 150 documentation for, 209–210 drug administration, 214–215, 214t history and physical examination for, 204–210, 205t cardiovascular system, 205–206 electrolytes, 208–209 gastrointestinal system, 207–208 hematologic system, 206–207 neurologic system, 208 hypocalcemia with, 157 kidney transplant, 213 medical history, 25 PAD and, 111 pathophysiology of, 198–200 acid-base disturbance, 199–200 nephrotic syndrome, 199 potassium homeostasis disorders, 200 sodium homeostasis disorders, 200 pharmacologic renoprotective strategies for, 216–218 dopamine agonists, 216–218 preanesthetic planning for, 211–213, 212t dialysis patients, 212 hyperkalemia, 212–213 regional anesthesia, 213 for preoperative testing, 39–40 prevalence of, 196–197 Renal system of extremely obese patients, 321 of geriatric patients, 317t overview, 196 of pregnant patient, 346, 347t Renal tubular acidosis, 199–200 Renal vasculitis, with rheumatoid arthritis, 259 Respiratory infections See also Upper respiratory infection in case study 2, 452 COPD with, 128 503 Respiratory irritants, asthma and, 124 Respiratory tract, bacterial infective endocarditis prevention in, 396 Restrictive lung disease, 132–133 etiology of, 132 management of, 133 Reticulocyte count, for anemia, 175, 175f Review of systems (ROS), for medical history, 22f, 23 Revised Cardiac Risk Index (RCRI) calculation of, 52–53 for cardiac morbidity and mortality, 52 clinical predictors, 58–61 overview of, 53, 53t Rhabdomyolysis Duchenne and Becker muscular dystrophy and, 245 hypocalcemia with, 157 statin use and risk of, 72 Rheumatoid arthritis (RA), 259–263 anesthetic implications of, 263 associated symptoms of, 259–260 cardiac, 259 dermatologic, 260 hematologic, 260 neurologic, 259 pulmonary, 260 renal, 260 diagnostic testing for, 261–263 cardiac evaluation, 261–263 laboratory testing, 261 pulmonary evaluation, 261 radiology, 261 history for, 260 for medical history, 25 overview of, 259 physical examination for, 260–261 airway examination, 260 cardiopulmonary, 260 preoperative medication and instructions for, 262t, 263 preoperative preparation for, 263 9:58 P1: PCX/OVY P2: PCX/OVY GRBT273-Index 504 QC: PCX/OVY Sweitzer-3499G T1: PCX GRBT273-Sweitzer-v1.cls Printer: RRD December 12, 2007 Index Risk of anesthesia, in pediatric patients, 357, 357t anesthesiology relation to, assessment of, algorithmic, 8–9 computational complexity v applicability of, human, 9–11 for pulmonary disease, 137–140, 138t strengths of, 10–11 weaknesses of, 9–10 definition of, 1–2 mitigation of known, 412–414 perioperative sources of, 1–2 anesthetic management, health care delivery, medical factors, surgical procedure, reduction and assessment, 1–11 goals of, 2–3 historical background of, 3–8 introduction to, 1–2 summary of, 11 translating research to clinical medicine, 8–11 Risk stratification after acute MI, 54 in CARP study, 64–66 of contrast-induced nephropathy, 215, 217t for noncardiac surgical procedures, 61t, 434t for PONV, 380–381 systems for, for ischemic heart disease, 52–53 Ristocetin cofactor, von Willebrand disease and, 180 ROS See Review of systems Ryanodine, in MH, 377 SAS See Sleep apnea syndrome SBE See Subacute bacterial endocarditis SCD See Sickle cell disease Schizophrenia, 282 Scleroderma See also Systemic sclerosis diagnostic testing for, 18t localized, 269 for medical history, 25 Scopolamine, for PONV, 381 Seizure disorders, 239–241 diagnostic testing for, 18t for medical history, 24–25 of pediatric patient, 367 preanesthetic evaluation for, 239–241 treatment modalities for, 239, 240t Selective serotonin reuptake inhibitors (SSRIs), for psychiatric disease, 281, 283, 284t–286t Selegiline, for dementia, 249 Sepsis hypocalcemia with, 157 with liver disease, 220–221 Serotonin in carcinoid tumors, 164 SSRIs with, 283 Sevoflurane and hepatobiliary disease, 233–234 seizure disorders with, 241 SIAD See Syndrome of inappropriate diuresis Sickle cell anemia See Sickle cell disease Sickle cell disease (SCD), 178–179 overview of, 178 perioperative complications with, 178 preoperative assessment of, 444 regimens for, 178–179 Sick sinus syndrome (SSS), 106–107 management of, 107 symptoms of, 106, 106f Sinoatrial node, SVT in, 102 SLE See Systemic lupus erythematosus Sleep apnea syndrome (SAS) diagnostic testing for, 18t patients with, 325–327 Smoking See also Tobacco use cessation of and PAD, 111 and pulmonary complication prevention, 142 diagnostic testing for, 18t lung cancer and, 330 9:58 P1: PCX/OVY GRBT273-Index P2: PCX/OVY QC: PCX/OVY Sweitzer-3499G T1: PCX GRBT273-Sweitzer-v1.cls Printer: RRD December 12, 2007 Index and pediatric patient, 361 pulmonary disease and, 136–137 pulmonary disease risk assessment and, 139 Sodium homeostasis, disorders of, 200 Sodium levels See also Hypernatremia; Hyponatremia in pituitary gland disorders, 164 Sodium valproate, for psychiatric disease, 284t–286t, 287 Spirometry See also Pulmonary function tests for asthma, 124 for COPD, 129 for lung transplant, 131 for pulmonary complication prevention, 142 Sputum, with COPD, 128 SSRIs See Selective serotonin reuptake inhibitors SSS See Sick sinus syndrome Statins for cardiac risk reduction, 64, 65t efficacy of, 71 function of, 71 for pharmacologic interventions, 71–72 preoperative management of, 401 rhabdomyolysis risk from, 72 risks of, 72 Stent thrombosis, reports of, 66 Steroids for brain tumors, 254 for heart transplant, 114 preoperative management of, 407–408 Streptozocin, and cancer patients, 328–329 Stress imaging, diabetes mellitus, 151 Stress testing See also Dipyridamole-thallium imaging; Dobutamine stress echocardiography for CAD, 56–57 for dyspnea, 135 for HR, 62–63 in hypertensive patients, 82 505 perioperative evaluation and, 57 for perioperative myocardial infarction, 52 pharmacologic, 61t, 62, 62f Stroke, 247–248 with atrial fibrillation, 104 BP and, 79 CABG and, 249 carotid bruit and, 111–112, 249 with diabetes mellitus, 150 hyperglycemia and, 149 PAD and, 110 preanesthetic assessment for, 247–248 risk of, 247 seizures with, 239 Subacute bacterial endocarditis (SBE) See also Infective endocarditis for medical history, 24 Subjective Global Assessment scale, for nutritional evaluation and management, 411–412, 411f Suboxone See Buprenorphine Substance abuse, 293–299 anesthetic implications of, 299 drug considerations for, 294–299, 295t–296t alcohol, 294–297, 295t–296t cocaine, 295t–296t, 298 heroin, 295t–296t, 298–299 marijuana, 295t–296t, 297–298 for medical history, 26 overview of, 293 preoperative preparation for, 294 Subutex See Buprenorphine Sulfonylurea agents, with DM, 150 Supplements medical history, 21 preoperative management of, 408 Supraventricular tachycardias (SVT), 102–103 cause of, 102–103 mechanism of, 102 termination of, 102–103 Surgical procedure See also Medical procedure 9:58 P1: PCX/OVY P2: PCX/OVY GRBT273-Index 506 QC: PCX/OVY Sweitzer-3499G T1: PCX GRBT273-Sweitzer-v1.cls Printer: RRD December 12, 2007 Index Surgical risk ACC/AHA guidelines for, anesthetic risk v., 14 with CAD, 64 of hepatobiliary disease, 227–229 Child’s classification, 227, 227t–228t MELD, 227–229 of hepatobiliary disease with liver disease, 224–226 acute hepatitis, 224–225 cholestasis, 225 chronic hepatitis, 225 cirrhosis, 226 extrahepatic obstruction, 225 intrahepatic obstruction, 225 obstruction jaundice, 225 obstructive disease, 225–226 John Hopkins risk classification system, 5, 5t SVT See Supraventricular tachycardias Syncope with aortic stenosis, 97 with hypertrophic obstructive cardiomyopathy, 89 SSS with, 106 Syndrome of inappropriate diuresis (SIAD), with lung cancer, 332 Systemic lupus erythematosus (SLE), 265–268 anesthetic implications of, 268 associated symptoms of, 265–266 arthritis, 265 cardiac, 265 hematologic, 266 infection, 266, 266t neurologic, 265–266 pulmonary, 265 renal, 265 skin, 265 vascular disease, 265 diagnostic testing for, 267 cardiovascular testing, 267 laboratory testing, 267 pulmonary testing, 267 history for, 266 for medical history, 25 overview of, 265 physical examination for, 266–267 preoperative medications and instructions for, 267, 268t preoperative preparation for, 267 Systemic sclerosis, 269–272 anesthetic implications of, 272 diagnostic testing for, 270 cardiovascular testing, 270 laboratory testing, 270 pulmonary evaluation, 270–271, 271f diffuse cutaneous, 269 history for, 269–270 limited cutaneous, 269 physical examination for, 270 preoperative medication and instructions for, 271–272 preoperative preparation for, 272 T3 See Triiodothyronine T4 See Thyroxine Tachycardia anemia and, 174 SSS, 106–107 SVT, 102–103 with thyroid disorders, 154, 155t ventricular tachycardia, 52–53 Tachypnea, 135 Tacrolimus, for heart transplant, 114 T&C See Type and cross TCAs See Tricyclic antidepressants TEE See Transesophageal echocardiography Teratogenicity, of anesthetic agents, 350–351 Testing See also Diagnostic testing overview of, 14–17 Tetany hypocalcemia, 157–160 renal disease and, 205 TFT See Thyroid function tests Therapeutic drug levels, for preoperative testing, 38 Thienopyridines in perioperative use, 71 preoperative instructions for, 398t–399t, 403–404 9:58 P1: PCX/OVY GRBT273-Index P2: PCX/OVY QC: PCX/OVY Sweitzer-3499G T1: PCX GRBT273-Sweitzer-v1.cls Printer: RRD December 12, 2007 Index Thrombocytopenia, 182–184 causes of, 182–183, 182t diagnostic testing for, 183, 183f dialysis and, 207 overview of, 182 in preoperative testing, 34–35 with rheumatoid arthritis, 259 Thrombocytosis, 184–185 overview of, 184 with rheumatoid arthritis, 259 treatment for, 184–185 Thromboembolism See also Venous thromboembolism (VTE) with AF, 104 Thrombolytics, after acute MI, 54 Thrombophilia, 185 Thyroid disorders, 154–157 See also Hyperthyroidism; Hypothyroidism diagnostic testing for, 155–156, 156t implications of, 156–157 interview, history, and physical examination for, 154–155, 155t for medical history, 25 preoperative management for, 398t–399t Thyroid function tests (TFT) for dyspnea, 135 for pituitary gland disorders, 164 for preoperative testing, 37 Thyroid hormones, function of, 154 Thyroid-stimulating hormone (TSH) from pituitary gland, 154 for preoperative testing, 37, 156 Thyrotropin-releasing hormone (TRH), TSH concentration and, 154 Thyroxine (T4) for preoperative testing, 156 production of, 154 TIA See Transient ischemic attack TIBC See Total iron binding capacity 507 Ticlopidine in antithrombotic therapy, 188, 189t in perioperative use, 71 preoperative instructions for, 398t–399t, 403–404 TLC See Total lung capacity Tobacco use See Smoking atherosclerosis and, 55 for medical history, 21 Tooth examination, for medical history, 27–28, 28f, 29t Total iron binding capacity (TIBC), for anemia, 175–176 Total lung capacity (TLC), with restrictive lung disease, 132 Tracheal intubation, difficulty with history, 385–386, 385t physical, 384–385, 385t Transesophageal echocardiography (TEE) See also Echocardiogram for aortic stenosis, 96 for mitral regurgitation, 93 Transfusions, blood, refusal of, 305, 312–313, 313t Transient ischemic attack (TIA), 247–248 carotid bruit and, 112 with diabetes mellitus, 150 PAD and, 110 preanesthetic assessment for, 247–248 risk of, 247 seizures with, 239 Transthoracic echocardiogram, for dyspnea, 135 Trauma, hyperglycemia and, 149 Tremors, with thyroid disorders, 154, 155t TRH See Thyrotropin-releasing hormone Tricyclic antidepressants (TCAs), for psychiatric disease, 283, 284t–286t Triiodothyronine (T3) for preoperative testing, 156 production of, 154 Troponin levels, dialysis and, 206 T&S See Type and screen 9:58 P1: PCX/OVY P2: PCX/OVY GRBT273-Index 508 QC: PCX/OVY Sweitzer-3499G T1: PCX GRBT273-Sweitzer-v1.cls Printer: RRD December 12, 2007 Index TSH See Thyroid-stimulating hormone Tuberculosis adrenal insufficiency with, 161 COPD v., 128 Type and cross (T&C), for anemia, 176 Type and screen (T&S) for anemia, 176 for preoperative testing, 35–36 Upper respiratory infection (URI), of pediatric patient, 364–365 Uremic neuropathy, dialysis and, 208 URI See Upper respiratory infection Urinalysis economics of, 40 for pediatric patient, 364 for preoperative testing, 39 Valsalva maneuver, with hypertrophic obstructive cardiomyopathy, 89 Valve thrombosis, prosthetic heart valves and, 99 Valvular heart disease, 89–92 balloon valvuloplasty, 98 murmur with characteristics of, 90, 91t intensity grading for, 90, 90t origination of, 90–92, 94t preoperative assessment of, 442 Valvuloplasty, for aortic stenosis, 96 Vascular dementia, 249 Vascular disease aortic insufficiency, 97–98 diagnostic testing for, 98 history and physical examination for, 97–98 atrial fibrillation, 103–104 carotid bruit, 111–113 diagnostic testing for, 112–113 history and physical examination for, 112 heart failure and cardiomyopathy, 83–89 diagnostic testing for, 85–88 history and physical examination for, 85 preoperative preparation for, 88–89 treatment for, 88 ventricular arrhythmias, 104–106 Vasculitis, with rheumatoid arthritis, 259 Vasopressin See Antidiuretic hormone Vecuronium, with hepatobiliary disease, 234 Venous thromboembolism (VTE), 185–187, 393 hemophilia and, prophylaxis, 180 heparin for, 186 heparin-induced thrombocytopenia with, 184 LMWH for, 186 pathogenesis for, 185 prevention of, 185–186, 393 nonpharmacologic, 185–186 pharmacologic, 186, 187t risk categories for, 185 risk factors for, 185 warfarin for, 186 Ventricular arrhythmias, 104–106, 105f, 105t Ventricular premature beats (VPBs), 104–105 in cardiac evaluation, 104 classification of, 104–105, 105t Ventricular tachycardia (VT), RCRI prediction of, 52–53 Visual defects mitigating risks of, 413 with pituitary neoplasms, 252 Vocal cord dysfunction, asthma and, 124 Vomiting with diabetes mellitus, 150 postoperative, 380–381, 380t renal disease and, 204 von Willebrand disease, 180–182 aPTT for, 35, 180 cause of, 180 hematologic issues with, 180–182, 181t types of, 180, 181t VPBs See Ventricular premature beats 9:58 P1: PCX/OVY GRBT273-Index P2: PCX/OVY QC: PCX/OVY Sweitzer-3499G T1: PCX GRBT273-Sweitzer-v1.cls Printer: RRD December 12, 2007 Index VT See Ventricular tachycardia VTE See Venous thromboembolism Wall-motion abnormalities (WMA), on echocardiograms, 63 Warfarin in antithrombotic therapy, 189t–190t, 190–191 for atrial fibrillation, 104 for cerebrovascular disease and stroke, 248 neuraxial blockade with, 194 preoperative management of, 398t–399t, 405–406 for VTE prevention, 186, 187t WBC See White blood cell count Weight gain, with thyroid disorders, 154, 155t Weight loss, with liver disease, 221 509 Weight reduction drugs, for extremely obese, 321, 324 Wernicke-Korsakoff syndrome, with alcohol abuse, 297 Wheezing with COPD, 128 dyspnea with, 135 pulmonary complications and, 140 White blood cell (WBC) count, for preoperative testing, 34 WMA See Wall-motion abnormalities Wolff-Parkinson-White syndrome (WPW) ECG of, 103f SVT in, 102–103 WPW See Wolff-ParkinsonWhite syndrome 9:58 ... pre- and 28 1 P1: KUF/OVY P2: PCX/OVY GRBT273- 12 Sweitzer-3499G 28 2 QC: OVY GRBT273-Sweitzer-v2.cls Printer: RRD December 6, 20 07 Handbook of Preoperative Assessment and Management Table 12. 1 Diagnostic... clear (2) The preoperative P1: KUF/OVY P2: PCX/OVY GRBT273-11 Sweitzer-3499G 26 2 QC: OVY Printer: RRD GRBT273-Sweitzer-v2.cls December 3, 20 07 Handbook of Preoperative Assessment and Management. .. perioperative 8 :22 P1: KUF/OVY P2: PCX/OVY GRBT273- 12 Sweitzer-3499G QC: OVY GRBT273-Sweitzer-v2.cls Printer: RRD December 6, 20 07 12 Psychiatric Disease, Chronic Pain, and Substance Abuse 8 :22 28 9 management