NMS. Casos Clínicos

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Part I ♦ Foundations PREOPERATIVE CARE PRINCIPLES Critical Surgical Associations If You Hear/See Think Deep venous thrombosis

Best strategy is prevention Likely cardiac disease Coronary angiography Cardiac catheterization/stenting

Vascular disease Unstable angina Positive stress test Acute kidney injury

Acute tubular necrosis Inferior vena cava filter

Bleeding on anticoagulation

Postoperative anemia

Surgical bleeding

Peaked T waves

Hyperkalemia, dysrhythmia Liver transplant candidate

End stage liver disease

Case 1.1 Routine Surgery in a Healthy Patient A 42-year-old fairly active man who can climb stairs and walk for a long distance at a brisk pace has a right inguinal hernia and is planning to undergo elective repair. He has had no other operations. However, the medical history reveals hypertension that is currently untreated. The family history is also important; his father died as the result of an acute myocardial infarction (MI) at 68 years of age. In addition, social history is significant for 20 pack-years of smoking. Review of systems is negative. The blood pressure (BP) is 148/88 mm Hg. Except for an easily reducible right inguinal hernia, examination is otherwise negative. Q: How would you assess the patient’s operative risk? A: The American College of Cardiology/American Heart Association (ACC/AHA) has proposed several clinical predictors of increased perioperative cardiovascular risk (Tables 1-1 and 1-2). This patient has no active cardiac conditions as defined by Table 1-1 but does have hyperten- sion, a positive family history, and a significant smoking history. The surgery is a low-risk am- bulatory procedure. The patient needs to be treated for his hypertension and counseled to stop smoking. You can assess overall functional status using questions that estimate the ability to accomplish physical tasks and then categorizing the level using the metabolic equivalent task (MET) as seen in Table 1-3. This functional status assessment correlates well with maximum oxygen uptake by treadmill testing and can signify a higher cardiac risk. Q: What preoperative tests are necessary? A: Routine preoperative testing has not been shown to be of significant value. Testing should be guided by history and physical examination. Recent guidelines suggest the patient should have a creatinine level, electrolytes, and an electrocardiogram (ECG) test because of his hypertension and a chest radiograph (CXR) because of the history of smoking, although the evidence for value of the CXR to the patient is limited (Table 1-4). SAMPLE

You decide to proceed with the hernia repair.