NMS. Casos Clínicos

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Chapter 1 ♦ Preoperative Care

good physiologic control. In addition, it provides a secure airway. Major drawbacks of general anesthesia are an increased incidence of pulmo- nary complications and the mild cardiodepression that all anesthetics can cause.

This patient will have minimal risk with smoking cessation and if the hypertension is controlled. Excellent outcome should be expected regardless of the type of anesthesia used.

Digging Deep

Understanding the urgency of the surgical intervention and thus the time that you have available to optimize the management of the pre-existing condition can make a large differ- ence in the patient’s outcome and develop-

ment of postoperative complications. A general approach is to consider risk factors in two categories: risks associ- ated with this specific patient and risks associated with the planned procedure. As you go through these cases, try to stratify risks in these two categories as a first step. For specific patients: ◆ ◆ What risks in the patient are pre-existing, and how well are they controlled? (Controlled asthma or diabetes is a much lower risk than uncontrolled.) ◆ ◆ What risks are added because of the new disorder requiring surgical consid- eration? (An abscess causing generalized sepsis, or ischemic bowel incar- cerated in a hernia contributes to a much higher perioperative risk than no sepsis or an uncomplicated hernia.) ◆ ◆ Will treatment of the new disorder return the patient to the pre-existing state or add to the chronic pre-existing problems of the patient? (Removal of a gangrenous appendix should return the patient to the pre-existing state once recovered, whereas amputation of an ischemic foot is an indication of pro- gression of arterial insufficiency as well as a risk for inactivity, postoperative pulmonary embolism, and a prolonged rehabilitation.) For specific planned procedures: ◆ ◆ How invasive and traumatic is the procedure (such as involving vital organs, blood loss, or large fluid shifts vs. none)? ◆ ◆ What body cavity or location is invaded (such as thoracic cavity vs. a lower extremity procedure)? ◆ ◆ What is the risk of a technical complication occurring, and what new risks arise if the complication occurs (such as what is the risk of a bowel anas- tomotic leak in a patient with inflammatory bowel disease on steroids vs. someone with a normal immune system)? ◆ ◆ What is the risk of failing to correct an abnormality (such as leaving an ab- scess undrained or leaving necrotic bowel in the abdomen vs. complete drainage or adequate resection)? The cases and associated tables and figures should be used to assist you in this process, understanding that many risks and mitigation strategies are not always well supported by data or validated. SAMPLE