Perioperative Medicine: Managing for Outcome, 2nd Edition

Front Cover
	Front Matter
	Copyright
	Dedication
	Contributors
	Acknowledgment
	Contents
PART I INTRODUCTION AND BACKGROUND
	Implications of Perioperative Morbidity for Long-Term Outcomes
		Cardiac Injury
		Pulmonary Injury
		Neurologic Injury
		Renal Injury
		Association Versus Causality
		Conclusion
		References
	The Inflammatory Response to Surgery
		Introduction
			Defining Acute Systemic Inflammation After Surgery
				Where It All Starts: Cellular Origins of Surgical Inflammation
			PAMPs may also Contribute to Systemic Inflammation After Surgery
				Systemic Processes Triggered by DAMPs/PAMPs
				Autonomic Changes
				Neuroendocrine Response
				Host Influences on Perioperative Inflammatory Response
			Age
			Chronic Kidney Disease
			Diabetes Mellitus
			Perioperative Modulation of the Inflammatory Response
				Anesthesia and Analgesia
				Blood Transfusion
				Steroids
		Conclusions
		References
	The Coagulation Cascade in Perioperative Organ Injury
		Significance of Perioperative Organ Injury
		Current Understanding of Coagulation and the Fibrinolytic Process
		How Does Inflammation Interfere With/Change the Coagulation Process?
		Perioperative Monitoring of Coagulation
		Alteration of Coagulation Status During Perioperative Period
			Intraoperative Activation of Coagulation
				Stress Response or Pain
				Site of Surgery
				Mode of Anesthesia
				Intravenous Fluid Management
				Body Temperature
				Trauma Coagulopathy
		Postoperative Activation of Coagulation
			Pain Control
		Consequences of Dysregulated Coagulation
			Proinflammatory Actions of Coagulation Proteases
		Summary and Recommendations
		References
PART II PREOPERATIVE ASSESSMENT
	The Value of Preoperative Assessment
		Value
		Preoperative Assessment Elements
		Goals of Preoperative Assessment
			Ensuring High-Quality Shared Decision-Making and Appropriateness of Care
			Preoperative Assessment Should Ensure Appropriate Risk Assessment and Optimization
			Preoperative Assessment and Population Management
			Preoperative Assessment and Regulatory Issues
			Preoperative Assessment Should Ensure Appropriate Use of Testing
			Documentation and Transmission of All Important Information to Downstream Providers
			Patient/Family Education and Discharge Planning
		Conclusions
		References
	Perioperative Cardiac Risk Assessment in Noncardiac Surgery
		Introduction
		Preoperative History and Physical Examination
		ECG
		Metabolic Equivalents
		Risk Assessment
		Risk Models
			Cardiac Testing
		Interventions: Preoperative Coronary Revascularization
		Percutaneous Coronary Intervention
		Coronary Artery Bypass Grafting
		Summary
		References
	Cardiovascular Risk Assessment in Cardiac Surgery
		Purpose of Risk Assessment Before Cardiac Surgery
		Outcome Measurement in Cardiac Surgery
		Development of Perioperative Risk Assessment for Cardiac Surgery
		Established Risk Assessment Models in Cardiac Surgery
			Parsonnet
			EuroSCORE
			ACEF
			Society of Thoracic Surgery
			Frailty Versus Age
			Congenital Heart Surgery
			Extracorporeal Mechanical Support
			Ventricular Assist Devices
			Beyond Mortality
		References
	Central Nervous System Risk Assessment: Preventing Postoperative Brain Injury
		Postoperative Delirium
			Definition
			Risk Factors
			Intraoperative Management
		Emergence Delirium
		Treatment of Postoperative Delirium After the Immediate Recovery Period
		Postoperative Cognitive Dysfunction
			Definition
			Incidence
			Risk Factors
			Screening Tools
			Pathophysiology and Association with Anesthesia
			Interventions
		Seizure Disorders and Epilepsy
		Recent Concussion
		Stroke Risk
		Prior Stroke
		Risk for Hypoxic-Ischemic Injury
		Implanted Neurostimulator and Other Devices
		References
	Risk Assessment and Perioperative Renal Dysfunction
		Influence of Surgery and Anesthesia on Renal Perfusion
		Patient Characteristics and the Risk of Postoperative Acute Kidney Injury
			Patient Characteristics Associated with Reduced Renal Reserve
			Patient Characteristics Suggesting Reduced Renal Blood Flow
			Other Preoperative Patient Variables Associated with Kidney Injury
			Other Preoperative Patient Factors Associated with Postoperative Renal Dysfunction
		Surgical Interventions Associated With Substantial Intraoperative Renal Ischemia
			Cardiopulmonary Bypass
			Pharmacologic Management of Post-Cardiopulmonary Bypass AKI
			Major Aortic Surgery
		Perioperative Testing of Renal Function
		Perioperative Renal Risk Scoring Algorithms
		Conclusion
		References
	Pulmonary Risk Assessment
		Introduction
		Epidemiology
		Definition
		Etiology and Pathophysiology
		Preoperative Pulmonary Evaluation for Nonthoracic Surgery
		Patient Factors
			Pulmonary Factors
			STOP-Bang Questionnaire
		Physical Examination
			Extrapulmonary Factors
		Surgical Factors
		Preoperative Tests
		Risk Prediction Scores
		Evaluation Paradigm for Nonthoracic Surgery
		Evaluation of the Lung Resection Candidate
		Conclusion
		References
	Hematologic Risk Assessment
		Red Blood Cell Transfusion
		Hemostasis
		Preoperative Risk Assessment
			Medical History and Physical Examination
		Laboratory Testing
			Tests of Primary Hemostasis: Platelet Count and Function
			Tests of Secondary Hemostasis: PT and aPTT
			Point-of-Care Testing
		Management of Patients Under Antiplatelet Therapy
			Aspirin
			Dual Antiplatelet Therapy
		Management of Patients on Anticoagulation Therapy
			Neuraxial Blockade
		Summary
		References
PART III PRESERVATION OF ORGAN FUNCTION AND PREVENTION AND MANAGEMENT OF PERIOPERATIVE ORGAN DYSFUNCTION
	Prevention of Ischemic Injury in Cardiac Surgery
		Perioperative Ischemia Prevention Strategies
			Optimal Timing of Cardiac Surgery after Acute Myocardial Infarction
		Intraoperative Ischemia-Prevention Strategies
			Nonoperative Strategies
				Anesthesia Considerations
					Monitoring for ischemia
					Anesthetic agents
				Metabolic Considerations
					Systemic temperature
					Myocardial acid-base management
					Blood glucose
					Transfusion strategy
			Operative Strategies to Prevent Ischemia and Ischemia-Reperfusion Injury
				Myocardial Protection Strategies
					Cardioplegia
						Cardioplegia composition: blood versus crystalloid
						Cardioplegia solutions: single dose
						Cardioplegia temperature: warm versus cold
						Cardioplegia route of delivery: antegrade versus retrograde
					Noncardioplegia myocardial protection strategies
						Hypothermia
						Arrest variations
						Hypothermic fibrillatory arrest
						Cannulation techniques
					CPB circuit modifications
						Heparin-bonded circuits
						Cardiotomy suctioning
						Open versus closed circuit
						Pump type
						Blood filtration: leukocyte depletion
					Pharmacologic protection strategies
						Corticosteroids
						Hemostatic agents
						Antioxidants
				Alternative Approaches to Myocardial Protection
					Bypassing CPB: off-pump CABG
					Myocardial conditioning
						Preconditioning
						Postconditioning
		References
	Prevention of Ischemic Injury in Noncardiac Surgery
		Introduction
		Pathophysiology and Natural History of Perioperative Ischemia
		Preoperative Optimization
			Screening and Risk Stratification
			Myocardial Revascularization
			Medication Optimization
			Beta-Blockade
				Current Recommendations
			Statins
				Current Recommendations
			Angiotensin-Converting Enzyme Inhibitors/Angiotensin Receptor Blockers
				Current Recommendations
			Alpha-2 Agonists
				Current Recommendations
			Aspirin and Antiplatelet Agents
				Current Recommendations
		Intraoperative Management
			Anesthetic Selection
			Monitoring for Ischemia
			Management of Intraoperative Ischemia
			Ischemic Preconditioning
		Future Directions in Ischemia Prevention/Management
		References
	Treatment of Perioperative Ischemia, Infarction, and Ventricular Failure in Cardiac Surgery
		Perioperative Myocardial Ischemia and Infarction
			Definition
			Etiology
			Management
				Intraoperative Preprocedural Phase
				Intraoperative Postprocedural Phase
				Postoperative Phase
		Perioperative Ventricular Dysfunction and Failure
			Failure to Wean from Cardiopulmonary Bypass
			Postoperative Low Cardiac Output State
				Assessment
					General Assessment
					Hemodynamic and Echocardiographic Assessment
				Management Strategies for Postoperative Low Cardiac Output
					Optimization of Cardiac Rate and Rhythm
					Preload and Afterload
					Inotropic State
					Intra-aortic Balloon Pump
					Venoarterial Extracorporeal Membrane Oxygenation
					Ventricular Assist Devices
					CentriMag
					Impella System
			Perioperative Right Ventricular Dysfunction
				Etiology
				Diagnosis
				Management
		References
	Perioperative Management of Valvular Heart Disease
		Preoperative Assessment
		Preoperative Preparation
			Antimicrobial Prophylaxis
			Anticoagulation
			Chronic Medications
		Intraoperative Management
			Pathophysiology of Disease and Physiologic Principles of Management
			Nonpharmacologic Management
			Premedication
			Type of Anesthesia: General, Regional, or Local with Monitored Sedation
			Monitoring Options
		Postoperative Management
		Specific Valvular Lesions
			Aortic Stenosis
			Mitral Stenosis
			Aortic Regurgitation
			Mitral Regurgitation
			Tricuspid Valve Disease
			Pulmonic Valve Disease
			Mixed Valvular Lesions
		Summary and Recommendations
		References
	Prevention and Management of Perioperative Dysrhythmias
		Introduction
		Mechanisms of Arrhythmia Generation
		Contributing Factors
			Anesthetic Medications
			Electrolyte Disturbances
			Hemodynamic and Physiologic Causes
			Other Causes
		Types of Tachyarrhythmias
			Narrow QRS Complex Tachycardia
			Sinus Tachycardia
			AV Nodal Reentrant Tachycardia
			Atrial Flutter and Atrial Fibrillation
			Multifocal Atrial Tachycardia
			Wide QRS Complex Tachycardia
			Premature Ventricular Contractions
			Nonsustained Ventricular Tachycardia
			Ventricular Tachycardia
			Supraventricular Tachycardia with Aberrant Conduction
			Ventricular Paced Rhythms
			Wolff-Parkinson-White Syndrome
		Bradyarrhythmias
			Sinus Bradycardia and Asystole
			Bundle Branch Blocks
			Conduction Defects
		Diagnosis and Medical Therapy for Arrhythmias
			Standard Electrocardiography
			Recognition of Artifacts
			Atrial Fibrillation and Flutter
			Ventricular Tachycardia
		Interventions for Cardiac Arrhythmias
			Catheter Ablation for Atrial Fibrillation
			Surgical Ablation for Atrial Fibrillation
			Left Atrial Appendage Occlusion
			Catheter Ablation for Ventricular Tachycardia
			Implantable Cardioverter-Defibrillators for Ventricular Tachycardia
			Neuromodulation Therapies for Ventricular Tachycardia
			Pacemakers for Bradyarrhythmias
		Conclusion
		References
	Perioperative Fluid Management
		Overview
		Physiological Stressors of Venous and Arterial Volume
		Liberal Versus Restrictive Fluid Therapy
			Dangers of Fluid Overload
			Preoperative Fluid Management
		Maintaining Normal Intravascular Volume During Perioperative Period
			Goal-Directed Fluid Therapy
			Higher Levels of Cardiovascular Monitoring
			Maintaining Adequate Mean Arterial Pressure
				Background
			Fixing Flow, Then Maintaining Mean Arterial Pressure
			Choice of Intravenous Perioperative Fluid and Postoperative IV Fluid Maintenance Rate
		Maintaining Optimal Hemoglobin Levels and Nadir Hematocrit
		Laparoscopic Surgery
		Emergency General Surgery
		Summary: Perioperative Fluid and Hemodynamic Plan
		References
	Preservation of Renal Function
		Introduction
		Renal Physiology
			Medullary Hypoxia
			Unique Physiology/Vulnerable Populations
				The Immature Kidney
				The Kidney During Pregnancy
				Geriatrics and Renal Function
			Cardiac Surgery-Associated AKI as a Generalizable Model for Perioperative AKI
		Diagnosis of Acute Kidney Stress/Injury
			Current Consensus Diagnostic Criteria for AKI and Related Adverse Outcomes
			Future (Early) AKI Biomarkers
				Measures of Kidney Stress
				Measures of Kidney Function
				Measures of Kidney Tubular Damage
		Mechanisms of Surgery-Related Acute Renal Injury
			Ischemia/Reperfusion
			Inflammatory
			Embolic
			Pigment (Hemoglobin and Myoglobin)
			Nephrotoxins
		Renal Preservation: Best Practices
			Preoperative Management and Planning
				Procedural Selection
				Cardiac Surgery Modifications
					Reduction of Tissue Trauma
						Smaller incisions: mini-thoracotomy/mini-sternotomy
						Endovascular approaches
				Neuraxial Analgesia
			Nonpharmacologic Interventions
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					Procedure Delay Versus Avoidance of Contrast Agents
					Ischemic Preconditioning Reflex
				Pharmacologic Agents
			Intraoperative Management
				Intraoperative Fluid Choice
				Intraoperative Volume Management
				Blood Pressure Management
				Cardiopulmonary Bypass Management
					Modifiers of Renal Oxygen Delivery
					Modifiers of Renal Oxygen Demand
					Avoidance of Ascending Aortic Atheroembolism
					Selection of Antifibrinolytic Agent
				Selection of Vasoactive Agents
				Pharmacologic Agents
					Fenoldopam
					Dopexamine
					Mannitol
					N-Acetylcysteine
			Postoperative Management
				Intravenous Fluid Choice
				Fluid Removal/Diuretics
					Loop Diuretics
					Natriuretic Peptides
				Glucose Management
				Pharmacologic Agents
					Steroids
					Non-steroidal Anti-Inflammatory Drugs: Aspirin and Cyclo-Oxygenase-2 Inhibitors
					Alpha 2 Adrenergic Agonist Agents
					Calcium Channel Blockers
					Renin-angiotensin System (RAS) Blockers
					Endothelin Receptor Antagonists
					Erythropoietin
					Growth factors (IGF-I, EGF, HGF)
					Pulmonary Vasodilators (PGE1, PGI2, NO)
				Kidney Protective Bundle
				Kidney Failure Requiring RRT
		Summary and Future Directions in Renal Preservation
		References
	Evaluation and Treatment of Acute Oliguria
		Pathophysiology
			Prerenal Oliguria
			Oliguria as a Consequence of Renal Tubular Injury
			Obstructive Oliguria
		Evaluation of Patients With Oliguria
			Obstructive Oliguria
			Functional Oliguria versus AKI
				History
				Clinical Parameters
				Laboratory Parameters
		Treatment
			Hypovolemia and Shock
			Cardiac Dysfunction and ACS
			Oliguria Secondary to AKI
			Oliguria Secondary to Obstruction
		Conclusion
		References
	Perioperative Management of Renal Failure and Renal Transplant
		Introduction
		Acute Renal Failure
		Chronic Renal Failure
			Chronic Kidney Disease Is Common
			Chronic Kidney Disease Increases Cardiovascular Risk
			Chronic Kidney Disease Is a Risk Factor for Acute Kidney Injury
			Acute Kidney Injury Accelerates the Progression of Chronic Kidney Disease
		Pathophysiology of Chronic Renal Failure
			Uremia
			Fluid and Electrolyte Balance
				Sodium and Water Homeostasis
				Potassium Balance
				Magnesium Balance
				Calcium Phosphate Balance
					Metabolic Acidosis
					Vascular Access
			Hematologic Abnormalities
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					Anemia
					Uremic Bleeding Diathesis
			Gastrointestinal Abnormalities
			Nutritional and Metabolic Disturbances
			Neurologic Disturbances
			Immunologic Dysfunction
		Pharmacology in Chronic Renal Failure
			Choice of Anesthetic Technique
				General Considerations
				General Anesthesia
					Induction Agents
					Muscle Relaxants
					Opioids
					Inhaled Anesthetics
					Total Intravenous Anesthesia
				Regional Anesthesia
		Intraoperative Considerations
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					Monitoring
				Fluid Management
				What type of fluid is best?
					Balanced Crystalloid Solution
					Colloids vs crystalloids
					Liberal vs restrictive
					Positioning
		Kidney Transplantation
			Kidney Donor Criteria
			Living-Donor Kidney Transplantation
			Recipient Selection
			Cardiac Disease Evaluation and Management
			Postoperative Management
			Transplantation Immunology
			Anesthesia Management
			Kidney Viability in Transplant Surgery
				Living Kidney Donor
				Deceased Donor Kidney (DDK)
				Kidney Preservation
					Experimental Techniques to Increase Viability
			Intraoperative Management of Kidney Recipients
				Hemodynamics and Intravascular Volume
				Choice of Resuscitation Fluid
					Albumin
					Diuretics
				Calcium Channel Antagonists
				Dopamine
		Summary
		References
	Prevention and Treatment of Postoperative Pulmonary Complications
		Introduction
			What Are Postoperative Pulmonary Complications (PPC)?
			How Common Are Postoperative Pulmonary Complications?
			How Important?
			Prediction of Postoperative Pulmonary Complications
				ACS NSQIP
				ARISCAT
			Pathophysiology
				Pulmonary Aspiration
				Atelectasis, Sputum Retention, and Loss of Airway Patency
				Pneumonia
				Pulmonary Inflammation
				Other Perioperative PPC
		Prevention
			Preoperative
				Smoking Cessation Therapy
				Oral Decontamination
				Specific Therapies to Reduce Pulmonary Inflammation
			Intraoperative
				Ventilation
				Residual Effects of Neuromuscular Blocking Agents (NMBA)
			Postoperative
				Ventilatory Support
				CPAP and NIV
				High-Flow Nasal Oxygen (HFNO2)
			Care Bundles and Enhanced Recovery After Surgery
		Treatment of PPC
			Specific to the Diagnosis
			Ventilatory Support in Respiratory Failure
		Conclusions
		References
	Carotid and Intracranial Surgery
		Anesthesia for Carotid Surgery
			Carotid Endarterectomy
			Preoperative Assessment
				Cardiovascular System
				Preoperative Risk Factors for Perioperative Stroke
			Anesthetic Management
				Physiologic Management
				General Anesthesia
				Regional Anesthesia
			Cerebral Monitoring to Detect Ischemia During CEA
				Postoperative Management
			Endovascular Carotid Artery Angioplasty and Stenting for Carotid Stenosis
		Anesthesia for Intracranial Surgery
			Preoperative Evaluation
			Anesthesia Induction
			Anesthesia Maintenance
			Management of Arterial Blood Pressure
			Management of Ventilation
			Intraoperative Fluid Management
			Muscle Relaxants
			Management of Emergence
		Procedure-Specific Issues
			Awake Craniotomy
				The Wada Test: Determining Whether Speech Mapping Is Required
				Intraoperative Electrophysiologic and Anatomic Components of Speech Mapping
				Comparing Neurolept and General Anesthesia for Awake Cortical Mapping
			Cerebral Aneurysm Clipping and Coiling Procedures
				Preoperative Management
					Neurologic
					Cardiopulmonary
						Electrocardiographic abnormalities and cardiac injury
						Hypertension
				Anesthetic Management for Aneurysm Clipping
					Premedication
					Monitoring
					Induction
					Maintenance
					Emergence
				Special Situations
					Temporary Vessel Occlusion
					Adenosine-Induced Circulatory Flow Arrest
					Intraoperative Cerebral Protection
					Intraoperative Rupture
				Anesthetic Management for Aneurysm Embolization
					Induction and Maintenance of Anesthesia
					General Anesthesia Versus Sedation
				Management of Procedural Complications
					Aneurysm Rupture
					Thrombotic Complications
		Management of Intracranial Hypertension
			Reducing Intracranial Contents
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						Removal of mass lesions
						Head positioning
						Ventricular CSF drainage
						Hyperventilation
						Cerebral perfusion pressure
						Hyperosmotic therapy
			Reducing Cerebral Metabolism
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						Anesthetic depth
						Hypothermia
		Summary
		References
	Protecting the Central Nervous System During Cardiac Surgery
		Introduction
		Neurological Injury After Cardiac Surgery with Cardiopulmonary Bypass
			Incidence and Significance
			Risk Factors
			Etiologic Factors
				Embolic Events
				Hypotension, Hypoperfusion, and Cerebral Autoregulation
				The Inflammatory Response
				Genomic Factors
				Temperature
			Neuroprotective Strategies
				Modifications to the Cardiopulmonary Circuit
				Aortic Cannulation Strategy
				Reducing Gaseous Emboli with Carbon Dioxide
				Assessment of Aortic Atheroma
				Blood Gas Management During Cardiopulmonary Bypass
				Temperature Management: Hypothermia and Hyperthermia
				Blood Pressure Management During Cardiopulmonary Bypass
				Pulsatile Perfusion During Cardiopulmonary Bypass
				Pharmacologic Therapies
		Neurologic Injury After Off-pump Coronary Artery Bypass Grafting
			Incidence and Significance
			Etiologic Factors
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					Inflammation
				Manipulation of the Heart and Aorta
				Cerebral Emboli
			Strategies for Neuroprotection
		Neurological Injury After Transcatheter Aortic Valve Replacement
			Incidence and Significance
			Etiologies of Neurological Injury after TAVR
				Embolic Injury
				Nonembolic Etiologies
			Neuroprotective Strategies
				Preoperative Neuroprotection
				Intraoperative Neuroprotection
					Heart team experience
					Embolic protection
				Postoperative Neuroprotection
		Neurologic Injury During Thoracic Aortic Surgery
			Introduction
			Etiologic Mechanisms for Neurological Injury
				Aortic Arch Repair
			Thoracoabdominal Aortic Repair
			Neuroprotective Strategies: Aortic Arch Repair
				Axillary Artery Cannulation
				Hypothermia and Selective Cerebral Perfusion
				Monitoring for Neurological Injury
					Electroencephalography for aortic arch repair
					Cerebral oximetry
				Carotid Ultrasound
				Blood Gas Management
				Temperature Management During Cardiopulmonary Bypass
				Pharmacologic Agents
			Neuroprotective Strategies: Thoracoabdominal Aortic Repair
				Early Recognition of Spinal Cord Ischemia
					Intraoperative neuromonitoring
					Postoperative neuromonitoring
				Maximizing Spinal Cord Perfusion Pressure
					Permissive systemic hypertension
					Cerebrospinal fluid drainage
					Segmental spinal artery preservation
				Minimizing Spinal Cord Ischemic Time
				Extending Spinal Tolerance of Ischemia
				Thoracic Endovascular Aortic Repair
		Conclusions
		References
	Preservation of Spinal Cord Function
		Introduction
		Traumatic Spinal Cord Injury
		Paraplegia After Thoracic or Thoracoabdominal Aortic Aneurysm Repair
		Spinal Cord Injury From Central Neuraxial Anesthesia and Analgesia
		Spinal Cord Injury and Spine Surgery
		Anesthetic and Medical Management of the Patient With Existing or Prior Spinal Cord Injury
		References
	Perioperative Management of Acute Central Nervous System Injury
		Introduction
		Monitoring Neurologic Examination
		Mental Status, Cranial Nerves, Motor and Sensorial Function, and Reflexes
			Mental Status
		Intracranial Hypertension
			Physiology
		Factors That Exacerbate Intracranial Hypertension
		Two Types of Intracranial Hypertension
		Presentation
		ICP Monitoring
		Waveform Analysis
		Treatment of Intracranial Hypertension
		Intracranial Hypertension/Cerebral Herniation Treatment Algorithm
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					Level Tier zero: L0
				Airway, Breathing, and Circulation (ABCs)
				Head of Bed Elevation
				Antipyretics and Antishivering Drugs
				Steroids
				Imaging
					Level Tier 1: L1 Cerebral Blood Volume Reduction
		Hyperventilation
			Cerebral and Systemic Effects of Hyperventilation
			Hyperventilation in TBI
			Target PaCO2 Recommendations in TBI
		Hyperosmolar Therapy
		Efficacy of HTS for Reduction of ICP
			Intracranial Complications
			Systemic Complications
		CSF Drainage
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					Level Tier 2: L2
		CBV Decreasing Drugs
			Propofol
			Etomidate
			Lidocaine
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					Level Tier 3: L3
			Barbiturates
			Hypothermia
				Surgical Decompression
		Decompressive Craniectomy
			Decompressive Craniectomy and TBI
			Decompressive Craniectomy and Stroke
			Physiologic Issues
				Cerebrovascular Reserve
		Airway Evaluation and Management
			Concerns
			Evaluation
			Therapeutic Options
				Awake Versus Asleep
					Cricoid or No Cricoid Pressure?
					Cervical Spine Distraction During Airway Instrumentation
			Oxygenation
				PaO2 Physiology
				Outcome Data
				PEEP and Intracranial Hypertension
			Ventilation
				PaCO2 Physiology
			Hyperventilation
				Optimal PaCO2
			Temperature
				Why Hypothermia for Neuroprotection?
				Hypothermia and TBI
				Hypothermia for Rescue ICP Therapy
				Hypothermia and Hypoxic-Ischemic Encephalopathy After Cardiac Arrest
				Timing and Duration of Targeted Temperature
					Target Temperature
					Temperature Monitoring and Rewarming
					Complications Associated With TH
			Fever
			Glycemic Control
		Cardiovascular
			Blood Pressure Effects on ICP-Plateau Waves and Determination of the Blood Pressure Optimum
			Blood Pressure Management
				Hypertension
				Hypotension Treatment and Induced Hypertension
			Optimal Hemoglobin Level
				Neurophysiologic Effects of Anemia
		Perioperative Management of Adults With Acute Spinal Cord Injury
			Spinal Shock
			Cardiovascular Complications
			Pulmonary Complications
			Miscellaneous
			Anesthetic Management and Considerations
				Airway Evaluation
				Monitors
					Induction of Anesthesia
					Airway Management
					Hemodynamic Management
			Anesthesia for Endovascular Therapy in Acute Ischemic Stroke
				Planning the Anesthetic
					Anesthesia Type
					Blood Pressure Goals
					Oxygenation and Ventilation
					Fluid and Glucose Management
		References
	Prevention and Treatment of Gastrointestinal Morbidity
		Aspiration of Gastric Contents
			Incidence, Etiology, and Pathogenesis
			Risk Factors
			Risk Reduction
			NPO Guidelines
			Management Strategy
		Postoperative Nausea and Vomiting
			Background and Incidence
			Risk Factors
			Management of PONV
				Pharmacologic Prophylaxis and Treatment
					5-HT3 Receptor Antagonists
					Dopamine Receptor Antagonists
					Anticholinergics and Antihistaminergics
					Other Antiemetics
				Nonpharmacologic Therapies
			Strategy for the Prevention of PONV
			Treatment of Established PONV
		Postoperative Ileus
			Etiology
				Role of Postoperative Opioids
				Role of General Anesthesia
			Prevention and Treatment of Postoperative Ileus
				Nonpharmacologic Methods
					Nasogastric Drainage
					Early Enteral Nutrition
					Postoperative Fluid Administration
					Mobilization
					Coffee
					Chewing gum
				Pharmacologic Therapies for the Treatment of POI
					Agents Acting on the Autonomic Nervous System
					Prokinetic Agents
					Laxatives
					Opioid Antagonists
					Nonsteroidal Anti-Inflammatory Agents
					Multimodal Analgesics
					Epidural Analgesia
			Goal-Directed Therapy and Gastrointestinal Outcome
			Role of Fluid Composition
		Conclusions
		References
	Prevention and Management of Deep Vein Thrombosis and Pulmonary Embolism
		Pathophysiology
		Prevention
		Diagnosis
			Diagnosis of Deep Vein Thrombosis
			Diagnosis of Pulmonary Embolism
		Treatment of Venous Thromboembolism
		Complications of Treatment
		Reversal of Anticoagulation
		Special Considerations
			Cancer
			Pregnancy
			Obesity
			Renal Impairment
			Liver Impairment/Coagulopathy
			Trauma
			Orthopedics
			Critically Ill
		References
	Perioperative Management of Bleeding and Transfusion
		Introduction
			Patient Blood Management and Preoperative Evaluation
		Preoperative Assessment of Bleeding Risk
			Common Disease States Associated with Excessive Bleeding
				Hepatic Insufficiency
				Renal Failure
				Clotting Factor Deficiency
				Platelet Deficiency
				Heparin-Induced Thrombocytopenia
		Intraoperative Management
			Anticoagulation Reversal
			Antifibrinolytic Therapy
			Intraoperative Blood Management
			Cell Salvage
			Acute Normovolemic Hemodilution (ANH)
		References
	Prevention of Perioperative Surgical Site Infection
		Introduction
		Surgical Site Infection
			Classification of SSI
			Microbiology
			Sources of Pathogens
			Risk Factors
		Prevention of Surgical Site Infection
			Preoperative Setting
				Patient-Related Factors
					Diabetes Status and Control
					Smoking Cessation
					Malnutrition
				Procedure-Related Factors
					Preoperative Bathing and Showering
					MRSA Screening and Decolonization
					Bowel Preparations
			Intraoperative Setting
				Procedure-Related Factors
					Asepsis and Surgical Technique
					Hair Removal
					Skin Preparation
					Surgical Hand Scrub
					Surgical Attire
					Gowns and Drapes
					Antimicrobial Prophylaxis
				Special Considerations: MRSA Prophylaxis
					Wound Protectors
					Antibiotic Sutures
					Wound Closure
					Perioperative Normothermia
					Perioperative Supplemental Oxygen
					Perioperative Glycemic Control
				Facility-Related Factors
					Ventilation
					Traffic Control
					Cleaning Environmental Surfaces
					Microbiologic Sampling
					Sterilization of Surgical Instruments
					Flash Sterilization
			Postoperative and PostDischarge Setting
				Postoperative Antibiotics
				Postoperative Showering
				Surveillance
		Prion Disease and the Operating Room
		References
	Perioperative Protection of the Pregnant Woman
		Introduction
		Causes of Maternal Morbidity and Mortality
		Anesthetic Causes of Morbidity and Mortality
		Thromboembolism and Thrombophilia
		Hypertensive Disorders of Pregnancy
			Management of Maternal Hypertension and Preeclampsia
				Magnesium Sulfate
				Labetalol, Hydralazine, and Nifedipine
				Other Antihypertensives
				Central Monitoring
				Anesthetic Considerations in the Management of Hypertensive Disorders of Pregnancy
				Thrombocytopenia and Coagulopathy
				Fluid Management and Pulmonary Edema
		Cardiac Disease in Pregnancy
			Cardiomyopathy
			Myocardial Infarction
			Aortic Dissection
			Chronic Cardiac Disease
			Congenital Heart Disease
		Pulmonary Hypertension
		Reduction of Perioperative Anesthesia Risk
			Maternal Hypotension during Regional Block
				Vasopressor Selection: Ephedrine Versus Phenylephrine Versus Norepinephrine
				Fluid Management: Preload Versus Coload
		Obesity
		Airway Management
			Advanced Planning for the Difficult Airway
		Peripartum and Postpartum Hemorrhage
		References
	Preservation of Fetal Viability During Noncardiac Surgery
		Should the Pregnant Patient Undergoing Surgery During Pregnancy Be Tilted?
		Does Anesthesia During Pregnancy Have an Effect on the Fetus?
		Management of Hypotension During Surgery on Pregnant Patients
		Monitoring Fetal Heart Rate During Nonobstetric Surgery
		Do Pregnant Patients Undergoing Nonobstetric Surgery Have Full Stomachs?
		Use of 100% Oxygen During Nonobstetric Surgery
		Should Hyperventilation Be Avoided in Pregnant Patients Undergoing Nonobstetric Surgery?
		Risk of Preterm Labor or Miscarriage in Nonobstetric Surgery
		Conclusions
		References
PART IV EARLY POSTOPERATIVE CARE
	Cardiac Surgery
		Transport and Initial Assessment
			ICU Admission
		Respiratory Management
			Mechanical Ventilation
			Long-Term Ventilation and Weaning
		Stabilization Phase
			Perfusion Pressure
			Blood Pressure
			Cardiac Output
			Modes of Mechanical Support
		Postoperative Complications
			Bleeding
			Cardiac Dysrhythmia
			Cardiac Tamponade
			Postoperative Myocardial Infarction
			Acute Kidney Injury
			Neurologic Complications
			Postoperative Fever and Infections
		Gastrointestinal Complications
		Fast-Tracking
		Summary
		References
	General Thoracic Surgery
		Preoperative Pulmonary Function Assessment
			Pulmonary Function Tests
				Assessment of Pulmonary Function Tests (PFTs)
			Exercise Capacity
			Predicted Postoperative Values
				Special Considerations
		Prevention of Postoperative Pulmonary Complications
			Optimal Timing of Smoking Cessation
			Use of Incentive Spirometer
		Prevention of Arrhythmia
			Preventing Postoperative Atrial Fibrillation
			Treatment of Postoperative Atrial Fibrillation
			Choice of Agent for Treatment
				Rate Control
				Rhythm Control
				Use of Anticoagulation Therapy
		Enhanced Recovery After Thoracic Surgery
		References
	Major Abdominal Surgery
		Introduction
		Pulmonary Management
			Reducing Postoperative Pulmonary Complications
			Pulmonary Management After Bariatric Surgery and in the Morbidly Obese
		Fluid Management
		Postoperative Nausea and Vomiting and Ileus
		Nutrition
		Surgical Site Infections
		Conclusion
		References
	Major Orthopedic Surgery
		Care After Total Joint Arthroplasty
			Venous Thromboembolic Disease
				Total Hip Arthroplasty
				Total Knee Arthroplasty
				Recommendations for Prophylaxis Against VTED
			Fat Embolism Syndrome
			Complications Relating to the Use of Intramedullary Cement
		Care After Spine Surgery
			Unique Issues after Spine Surgery
				Cardiopulmonary Dysfunction
				Acute Vision Loss
				Intraoperative Blood Loss
				Infection
				Syndrome of Inappropriate Antidiuretic Hormone
				Ileus and Colonic Pseudo-Obstruction
				Superior Mesenteric Artery Syndrome
		Conclusions
		References
	Solid Organ Transplantation
		Types of Donors
		Immunosuppression
		Liver Transplantation
			Recipient
			Donor
			Postoperative Management
		Kidney Transplantation
			Recipient
			Donor
			Postoperative Management
		Pancreas Transplantation
			Recipient
			Donor
			Postoperative Management
		Intestinal Transplantation
			Recipient
			Donor
			Postoperative Management
		Heart Transplantation
			Recipient
			Donor
			Postoperative Management
		Lung Transplantation
			Recipient
			Donor
			Postoperative Management
		Infections
		Conclusion
		References
	Multisystem Trauma
		Resuscitation
			Balanced Resuscitation
			Choice of ICU Resuscitation Fluid
			Transfusion Triggers
			Endpoints of Resuscitation
		Special Considerations in Trauma
			Damage Control
			Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)
			Intraabdominal Hypertension and the Abdominal Compartment Syndrome
			Other Compartment Syndromes
			Management of Patients with Brain Injury
			Venous Thromboembolism (VTE)
		Other Postinjury Considerations
			Stress Ulcer Prophylaxis
			Nutrition Support
			Glycemic Control
			Infectious Complications
			Analgesia
		Summary
		References
	Neurosurgery
		Neurologic Support
			Focused Neurologic Examination
			Postoperative Imaging
			Postoperative Intracranial Pressure Monitoring
			Management of Postoperative Complications
		Respiratory Support
			Hypoxia and Hypercarbia in Brain Injury
			Airway Assessment and Management
				Outline placeholder
					Decreased Level of Consciousness
					Raised Intracranial Pressure
					Brainstem Lesions
					Spinal Cord Lesions
			Sedation Strategies
		Cardiovascular Support
			Cerebral Perfusion and Arterial Blood Pressure
			Hypertension and Brain Injury
			Inotropes and Vasodilators
		Fluid and Electrolyte Support
			Hypovolemia and Cerebral Perfusion
			Hyponatremia, Edema, and Seizures
			Routine Fluid Management
			Diabetes Insipidus (DI)
		Hematologic Support
			Role of Anemia in Cerebral Ischemia
			Thromboprophylaxis
		Gastrointestinal and Endocrine Support
			Glucose and Cerebral Injury
			Management of Diabetes Mellitus
			Nutrition
			Postoperative Nausea and Vomiting
		Infectious Disease
			Infectious Risks of Neuraxial Devices
		References
	Sepsis and Septic Shock
		Introduction
		History
		Epidemiology
		Pathophysiology
			Inflammation
			Cardiovascular Function
			Immunoactivation and Paresis
			Hormonal and Metabolic Changes
			Organ Dysfunction
		Clinical Features
			Laboratory Features
				Management
			Antibiotics and Infection Control
			Circulatory Support
			Respiratory Support
			Renal Support
			Nutrition
				Other Organ Support and Therapeutic Strategies
					Immunomodulation
					Hormonal Manipulation
				Other Organ Supports
		Future Directions
		Conclusions
		References
	Acute Respiratory Failure
		Definition
		Hypoxemic Respiratory Failure
		Hypercapnic Respiratory Failure
		Acute Respiratory Failure in the Perioperative Patient
			Postoperative Factors
			Atelectasis
				Clinical Manifestations
				Diagnosis
				Treatment
			Aspiration
				Clinical Manifestations
				Diagnosis
				Treatment
			Pulmonary Embolism
				Clinical Manifestations
				Diagnosis
				Prophylaxis
				Treatment
			Acute Respiratory Distress Syndrome
		Principles of Management
		Summary
		References
	Endocrine and Electrolyte Disorders
		Introduction
		Endocrine Dysfunction
			Diabetes Mellitus
			Medically Significant Obesity
				Preoperative Evaluation
				Treatment with Noninvasive Ventilation
				Cardiovascular Complications of Obesity
				Deep Vein Thrombosis
				Intraoperative Concerns
				Postoperative Concerns
				Recommendations
			Corticosteroid Supplementation
				Normal Physiology
				Effect of Chronic Steroid Supplementation on the HPA Axis
				Diagnosis of Adrenal Insufficiency
				Incidence of Adrenal Insufficiency
				Identifying patients at risk for adrenal insufficiency
				Perioperative Steroid Supplementation
				Corticosteroids and Sepsis
			Thyroid Disease and Anesthesia
				Hypothyroidism
				Hyperthyroidism
				Thyroid Hormone and Cardiac Surgery
			Sodium
				Hyponatremia
					Management of Hyponatremia
					Outcomes
				Hypernatremia
					Management of Hypernatremia
					Outcomes
			Potassium
				Hypokalemia
					Treatment
					Outcomes
				Hyperkalemia
			Magnesium
				Hypomagnesemia
				Hypermagnesemia
					Treatment
			Phosphorous
				Hypophosphatemia
				Hyperphosphatemia
			Calcium
				Hypocalcemia
				Hypercalcemia
			Chloride
				Hypochloremia
				Hyperchloremia
		Conclusion
		References
	Improving Pain and Outcomes in the Perioperative Setting
		The Growth of Unidimensional Pain Assessment Tools
		The Importance of Multidimensional Assessment
		An Increased Focus on Perioperative Functional Outcomes
		Future Directions: Risk Predictive Tools and Personalized Pain Medicine
		Clinical Phenotyping: Cluster Analysis
		Genetic Risks Predictors
		Biomarkers of Risk: Cytokine Profiling
		Optimization
		Summary and Recommendations
		References
	Postoperative Cognitive Dysfunction and Delirium
		Introduction
			Perioperative Central Nervous System Injury or Dysfunction
			Postoperative Delirium
			Postoperative Cognitive Dysfunction in Cardiac Surgery
			POCD Associated with Noncardiac Surgery
			Pathophysiology of Neurocognitive Dysfunction after Surgery
			Inflammation
			Embolic Load
			Cerebral Blood Flow, Autoregulation, and Oxygen Delivery
			Temperature Management During Cardiac Surgery
			Glucose Homeostasis During Cardiac Surgery
				Depression
			Genetic Factors
			Anesthesia, Surgery and Alzheimers Disease
			Systems-Level Mechanisms of Postcardiac Surgery Cognitive Dysfunction
			Future Interventions to Prevent or Treat Postoperative Cognitive Dysfunction and/or Delirium
		Conclusions
		References
	Role of Palliative Care
		Defining Palliative Care
		The Multidisciplinary Team
		Palliative Care and Hospice
		Primary versus Specialist Palliative Care
		Advance Care Planning
		Symptom Management
		End-of-life Care
		Impact on Outcomes
		Palliative Care for the Surgical Patient
		Disease-Specific Palliative Care
			Cancer
		Palliative Care for Non-cancer Patients
			Congestive Heart Failure (CHF)
			Chronic Obstructive Pulmonary Disease (COPD)
			Neurodegenerative Disease and Dementia
			End-Stage Renal Disease (ESRD)
			Human Immunodeficiency Virus (HIV)
		Pediatrics
		Conclusions
		References
PART V CONFLICTING OUTCOMES VALUE BASED CARE
	Economic Analysis of Perioperative Optimization
		Health-Care Interventions as Investments
			Costs and (We Hope) Benefits
			The Agency Problem-Providers as Fiduciaries
		Health-Care Economic Studies Offer Challenges
			The Point of View Must Be Clear and Consistent
			Our Goal Is to Know What Works and How Much It Costs
			Barriers to Doing the Right Thing
		Costs-What Exactly Do We Mean?
			Direct Costs
			Indirect Costs
			Intangible Costs
			Costs versus Charges
			Cost-Estimation Techniques
			Skewness in Cost Data
			Future Costs Need to Be Discounted to Present Values
			Good News about Costs: Marginal Costs and the Learning Curve
		Benefits: Clinical Effectiveness and Utility
			Increased Utility (Quality and Duration of Life)
			Benefit
		Types of Economic Analysis
			Cost-Identification (or Cost-Minimization) Analysis
			Cost-Effectiveness Analysis (Which Includes Cost-Utility Analysis)
			Cost-``Benefit´´ Analysis
			Decision Trees
			Sensitivity Analysis
		Conclusion
		References
	Improving Health-Care Quality Through Measurement
		What Is Quality in Health-Care?
		Why Improve Quality?
		Framework for Measuring Quality
		Development and Endorsement of Quality Measures
			NQF Measure Applications Partnership
		Uses of Quality Measures
		Quality Improvement
			Quality Improvement Methodologies
		Accreditation and Verification
			Hospital Accreditation: The Joint Commission
			Health Plan Accreditation: The National Committee for Quality Assurance (NCQA)
			Surgical Specialty Verification: Trauma Care
		Public Reporting and Transparency
		Value-Based Health-Care and Paying for Performance
			Redefining Quality and Cost to Transition to Value
			From Pay-for-Reporting to Pay-for-Performance
			Clinical Care Model Redesign and Health Information Technology
			Legislation to Promote Value-based Care
			Patient Protection and Affordable Care Act (ACA)
			The Quality Payment Program (QPP)
				MIPS
				APMs
			Challenges in Implementing Value-Based Care and the Path Forward
				Value Is Defined by Payers
				Excessive Burden With Lack of Valid and Meaningful Measures
				Challenges in Measuring Cost Alongside Quality
				Lack of Interoperable Meaningful Data
		Conclusions
		References
	Delivering Value Based Care: The UK Perspective
		Introduction: Rising Demand and Resource Constraint
		The Cost and Value of Surgery
		Shared Decision Making
		Preoperative Optimization
			Comorbidity
			Prehabilitation and Behavioral Change
		Intraoperative Care
		Postoperative Care and Recovery
		Conclusions
		References
	Transitions From Hospital to Home
		Paths from Hospital to Home
		Factors Associated with Nonhome Discharge
		Planning for Transitions
		Costs of Failed Transitions
		Ensuring the Transition
		Putting it all Together
		References
Index
	A
	B
	C
	D
	E
	F
	G
	H
	I
	J
	K
	L
	M
	N
	O
	P
	Q
	R
	S
	T
	U
	V
	W
	X