Anesthesiology Clinics RSS feed: Current Issue. Anesthesiology Clinics updates you on the latest trends in patient management; keeps you up to date on the newest advances; and provides a sound basis for choosing treatment options. Each issue focuses on a single topic in anesthesiology and is presented under the direction of an experienced guest editor.http://www.anesthesiology.theclinics.com/?rss=yesElsevier Inc.en © 2009 Published by Elsevier Inc. All rights reserved. Anesthesiology Clinics1932-2275274December 2009 © 2009 Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.anesthesiology.theclinics.com/article/PIIS1932227509001141/abstract?rss=yesContents10.1016/S1932-2275(09)00114-1Anesthesiology Clinics 27, 4 (2009)2009-12-01Anesthesiology Clinics2009-12-01274S1932-2275(09)X0004-2viixihttp://www.anesthesiology.theclinics.com/article/PIIS1932227509001153/abstract?rss=yesForthcoming issues10.1016/S1932-2275(09)00115-3Anesthesiology Clinics 27, 4 (2009)2009-12-01Anesthesiology Clinics2009-12-01274S1932-2275(09)X0004-2xiixiihttp://www.anesthesiology.theclinics.com/article/PIIS1932227509000937/abstract?rss=yes The preoperative evaluation and preparation of complex medical patients for anesthesia and surgery requires a multidisciplinary approach involving internists (and medical subspecialists), anesthesiologists, and surgeons. Medical Clinics of North America recently solicited my coeditor and me to create an issue on this topic and we chose to have each issue cowritten by practitioners from at least two specialties. As the consulting editor of Anesthesiology Clinics, it became apparent that concurrent publication of this issue of Medical Clinics of North America would benefit all of the specialties involved in perioperative care.ForewordLee A. Fleisher10.1016/j.anclin.2009.08.003Anesthesiology Clinics 27, 4 (2009)2009-12-01Anesthesiology Clinics2009-12-01274S1932-2275(09)X0004-2xiiixiiihttp://www.anesthesiology.theclinics.com/article/PIIS1932227509000949/abstract?rss=yesAssessment of the presurgical patient requires interdisciplinary cooperation over the continuum of documentation and optimization of existing disorders, determination of patient resilience and reserve, and planning for subsequent interventions and care. For many patients, evident or suspected morbidities or anticipated surgical disturbance warrant specialty consultation. There may be uncertainty as to the optimal processes for a given patient, a limitation attributable to myriad factors, not the least of which is that there is often a paucity of evidence that is directly relevant to a given patient in a given setting. The present article discusses these limitations and describes a framework for documentation, optimization, risk assessment, and planning, as well as a uniform grading of existing morbidities and anticipated perioperative disturbances for patients requiring integrated assessment and consultation.Integrated Assessment and Consultation for the Preoperative PatientDavid G. Silverman, Stanley H. Rosenbaum10.1016/j.anclin.2009.09.001Anesthesiology Clinics 27, 4 (2009)2009-12-01Anesthesiology Clinics2009-12-01274S1932-2275(09)X0004-2617631http://www.anesthesiology.theclinics.com/article/PIIS1932227509000950/abstract?rss=yesCardiac surgery is associated with significant morbidity, mortality, and socioeconomic costs. Preoperative assessment assists the clinician in identifying potential complications and facilitates discussion of these risks with the patient. Careful patient selection and preparation during preoperative evaluation may minimize morbidity, mortality, and resource use. This article outlines a system-based approach to preoperative evaluation and preparation of the patient undergoing cardiac surgery.Preoperative Evaluation and Preparation of the Patient for Cardiac SurgeryAlec D. Weisberg, Emily L. Weisberg, James M. Wilson, Charles D. Collard10.1016/j.anclin.2009.09.002Anesthesiology Clinics 27, 4 (2009)2009-12-01Anesthesiology Clinics2009-12-01274S1932-2275(09)X0004-2633648http://www.anesthesiology.theclinics.com/article/PIIS1932227509000962/abstract?rss=yesClinicians are increasingly asked what they can do to evaluate and lower the risk of perioperative cardiac complications. Approximately 4 decades ago, there were few tools to guide the evaluation of perioperative risk. The American Society of Anesthesiology Classification System (ASA class) gave only a vague idea of the risk patients faced during surgery, but the modern era of clinical risk assessment for perioperative complications has seen the introduction of tools that allow clinicians to estimate risk, and also the addition of stress testing for assessing perioperative risk. None of these tests, however, were designed to identify perioperative cardiac risk. This article reviews the literature on perioperative risk assessment, risk reduction, and testing modalities in patients with cardiac disease, along with the role of perioperative angioplasty and the current American College of Cardiology/American Heart Association guidelines.Noncardiac Surgery in the Patient with Heart DiseaseJames B. Froehlich, Lee A. Fleisher10.1016/j.anclin.2009.09.003Anesthesiology Clinics 27, 4 (2009)2009-12-01Anesthesiology Clinics2009-12-01274S1932-2275(09)X0004-2649671http://www.anesthesiology.theclinics.com/article/PIIS1932227509000974/abstract?rss=yesPreoperative pulmonary evaluation and optimization improves postoperative patient outcomes. Clinicians frequently evaluate patients with pulmonary disease before surgery who are at increased risk for pulmonary and nonpulmonary perioperative complications. Postoperative pulmonary complications are as common and costly as cardiac complications. In this article, the evaluation of patients with the most common conditions encountered in the preoperative setting, including unexplained dyspnea, asthma, chronic obstructive pulmonary disease, obstructive sleep apnea, and cigarette use, are discussed. Risk stratification for postoperative pulmonary complications and strategies to reduce them for high-risk patients are also discussed. From the available literature, high-risk patients and those patients for whom a multidisciplinary collaboration will be most helpful can be accurately identified.Identification and Evaluation of the Patient with Lung DiseaseBobbie Jean Sweitzer, Gerald W. Smetana10.1016/j.anclin.2009.09.004Anesthesiology Clinics 27, 4 (2009)2009-12-01Anesthesiology Clinics2009-12-01274S1932-2275(09)X0004-2673686http://www.anesthesiology.theclinics.com/article/PIIS1932227509000986/abstract?rss=yesPatients with preoperative endocrinopathies represent a particular challenge not only to anesthesiologists but also to surgeons and perioperative clinicians. The “endocrine axis” is complex and has multiple feedback loops, some of which are endocrine and paracrine related, and others that are strongly influenced by the surgical stress response. Familiarity with several of the common endocrinopathies facilitates management in the perioperative period. This article focuses on 4 of the most common endocrinopathies: diabetes mellitus, hyperthyroidism, hypothyroidism, and adrenal insufficiency. Perioperative challenges in patients presenting with pheochromocytoma are also discussed.Surgery in the Patient with Endocrine DysfunctionBenjamin A. Kohl, Stanley Schwartz10.1016/j.anclin.2009.09.005Anesthesiology Clinics 27, 4 (2009)2009-12-01Anesthesiology Clinics2009-12-01274S1932-2275(09)X0004-2687703http://www.anesthesiology.theclinics.com/article/PIIS1932227509000998/abstract?rss=yesContemporary life, with its sedentary lifestyles, fast foods, processed foodstuff, and desk-bound service employment, is beset by an epidemic of overweight and obese individuals. The World Health Organization reported that worldwide a billion adults are overweight and at least 30% of them are obese. Moreover, increasing numbers of children are obese. In the United States, 2 National Health and Nutrition Examination Surveys of adults aged 20 to 74 years showed that the prevalence of obesity increased from 15% in the 1976 to 1980 survey to 34% in the 2003 to 2004 survey. Obesity and the metabolic syndrome are unfortunately becoming increasingly common perioperative issues. The ultimate aim of caring for such patients is to find ways to minimize the untoward effects of surgery in patients who are obese or have metabolic syndrome.Obesity, Metabolic Syndrome, and the Surgical PatientPhillip D. Levin, Charles Weissman10.1016/j.anclin.2009.09.006Anesthesiology Clinics 27, 4 (2009)2009-12-01Anesthesiology Clinics2009-12-01274S1932-2275(09)X0004-2705719http://www.anesthesiology.theclinics.com/article/PIIS1932227509001001/abstract?rss=yesLiver dysfunction is a prominent entity in Western medicine that has historically affected patients suffering from chronic viral or alcoholic hepatitis. The incidence of these conditions has not changed dramatically in recent years but the overall number of patients with liver dysfunction has increased considerably with the emergence of the obesity epidemic. Nonalcoholic fatty liver disease (NAFLD) has become increasingly recognized as the most common cause of chronic liver disease in the United States. Although the rate of progression of NAFLD to overt cirrhosis is low, the high prevalence of this condition, combined with the moderate degree of liver dysfunction it engenders, has resulted in a significant increase in the number of patients with liver disease that can be encountered by a surgical practice. Any degree of clinically evident liver disease in a prospective surgical patient should raise concern for the entire surgical team. This particularly applies to intraabdominal surgery whereby the presence of hepatomegaly, portal hypertension, variceal bleeding, and ascites can turn even the most routine operation into a morbid and life-threatening procedure. Nonabdominal surgery avoids some of the technical challenges presented by liver disease but the anesthetic management of a cirrhotic patient still makes any operation potentially more dangerous. In this article, approaches to minimize the risk when surgery becomes necessary in the presence of liver disease are discussed.Surgery in the Patient with Liver DiseaseDiego J. Muilenburg, Amrik Singh, Guido Torzilli, Vijay P. Khatri10.1016/j.anclin.2009.09.007Anesthesiology Clinics 27, 4 (2009)2009-12-01Anesthesiology Clinics2009-12-01274S1932-2275(09)X0004-2721737http://www.anesthesiology.theclinics.com/article/PIIS1932227509001013/abstract?rss=yesPreoperative evaluation of patients with renal dysfunction often requires the collaborative efforts of the primary care physician, nephrologist, surgeon, and anesthesiologist. Renal dysfunction is typically a spectrum of disease with multisystem effects. Optimization of preexisting medical issues is the key, as is a thorough understanding of the potential perioperative risks for further renal injury. Surgical or anesthetic techniques may require alteration for the patient with significant renal dysfunction. Identification of those at risk for renal injury may allow for preventative therapies in the perioperative period. This article focuses on defining the population at risk, a framework for preoperative evaluation, and developments in the area of perioperative renal protection.Surgery in the Patient with Renal DysfunctionDean R. Jones, H.T. Lee10.1016/j.anclin.2009.09.008Anesthesiology Clinics 27, 4 (2009)2009-12-01Anesthesiology Clinics2009-12-01274S1932-2275(09)X0004-2739749http://www.anesthesiology.theclinics.com/article/PIIS1932227509001025/abstract?rss=yesAnemia is commonly encountered in the preoperative patient. Determination of the cause of the anemia can affect perioperative surgical and medical management and outcome. Red blood cell transfusions are often administered during the perioperative time period in patients with preoperative anemia, although evidence to support the optimal transfusion threshold is limited. The authors review the evaluation of anemia and evidence regarding perioperative blood transfusions. Recommendations on the treatment of anemia, including perioperative blood transfusions, are outlined.Anemia in the Preoperative PatientManish S. Patel, Jeffrey L. Carson10.1016/j.anclin.2009.09.009Anesthesiology Clinics 27, 4 (2009)2009-12-01Anesthesiology Clinics2009-12-01274S1932-2275(09)X0004-2751760http://www.anesthesiology.theclinics.com/article/PIIS1932227509001037/abstract?rss=yesThe oral anticoagulant warfarin is a common medication that requires special consideration in the perioperative period. Although some procedures do not require warfarin interruption, the majority will necessitate its temporary cessation due to the risk of bleeding. Determining whether patients will benefit from the temporary use of a heparin product while warfarin is discontinued perioperatively (so-called “bridging” therapy) needs to take into consideration the risk of bleeding balanced with the risk of thromboembolism. Perioperative care also requires minimizing the risk of venous thromboembolism (VTE). Understanding the patient-specific and procedure-specific risks for VTE is paramount to employ optimal risk reduction strategies. This article uses a case-based approach to present the topics of perioperative warfarin management and postoperative VTE prevention.Perioperative Anticoagulant ManagementPaul J. Grant, Daniel J. Brotman, Amir K. Jaffer10.1016/j.anclin.2009.09.010Anesthesiology Clinics 27, 4 (2009)2009-12-01Anesthesiology Clinics2009-12-01274S1932-2275(09)X0004-2761777http://www.anesthesiology.theclinics.com/article/PIIS1932227509001049/abstract?rss=yesThis article emphasizes some key points in the preoperative evaluation of patients with neurologic disease. The amount of neurologic disease in the general population is a difficult number to assess accurately. This is, in part, because of the wide-sweeping scope of neurologic disease. The International Classification of Diseases has the highest number of conditions attributable to neurologic disease. Patients with neurologic disease are commonly encountered, and their illness is often complicated by significant comorbid disease. It is important to think of the patient as a whole rather than the sum of his or her systems. While it is tempting to consider the traditional preoperative evaluation from a “cardiac clearance” point of view, we must resist this urge, and evaluate which risk factors we can modify and hopefully mitigate to optimize the perioperative period.Preoperative Preparation of the Surgical Patient with Neurologic DiseaseAdam Schiavi, Alexander Papangelou, Marek Mirski10.1016/j.anclin.2009.09.011Anesthesiology Clinics 27, 4 (2009)2009-12-01Anesthesiology Clinics2009-12-01274S1932-2275(09)X0004-2779786http://www.anesthesiology.theclinics.com/article/PIIS1932227509001050/abstract?rss=yesPatients presenting with general surgical emergencies are hypovolemic, and require early aggressive resuscitative efforts. Although these efforts may safely be accomplished preoperatively in a select subset of patients, it is often the combined task of surgeons, anesthesiologists, and internists to optimize these critically ill patients in the intraoperative and postoperative period. Early surgical consultation and intervention can be lifesaving. This article presents the current state of emergency surgical care in the United States and the approach to the patient with an emergency surgical illness. The aggressiveness of the surgical intervention is patient- and disease-specific and requires frequent and open communication between all health care providers, the patient, and his or her family. In addition to aggressive resuscitation, life-threatening general surgical conditions often require specific diagnostic and therapeutic interventions.Emergency and Urgent SurgeryKevin M. Schuster, Kimberly A. Davis, Stanley H. Rosenbaum10.1016/j.anclin.2009.09.012Anesthesiology Clinics 27, 4 (2009)2009-12-01Anesthesiology Clinics2009-12-01274S1932-2275(09)X0004-2787804http://www.anesthesiology.theclinics.com/article/PIIS1932227509000925/abstract?rss=yesThis article focuses on the unique perioperative concerns of patients with cancer undergoing surgery. Importantly, not all surgical procedures are intended as cures; cancer patients also undergo surgery for noncancer issues. Many of these patients have undergone prior chemotherapy or radiation therapy that can introduce perioperative concerns. These prior treatments, unique to cancer patients, can affect their cardiovascular, pulmonary, gastrointestinal, renal, and endocrine systems adversely, and this article summarizes many important effects of various chemotherapy agents in use today.Preoperative Evaluation of the Oncology PatientSunil K. Sahai, Ali Zalpour, Marc A. Rozner10.1016/j.anclin.2009.08.002Anesthesiology Clinics 27, 4 (2009)2009-12-01Anesthesiology Clinics2009-12-01274S1932-2275(09)X0004-2805822http://www.anesthesiology.theclinics.com/article/PIIS1932227509001220/abstract?rss=yesIndex10.1016/S1932-2275(09)00122-0Anesthesiology Clinics 27, 4 (2009)2009-12-01Anesthesiology Clinics2009-12-01274S1932-2275(09)X0004-2823833