NMS. Casos Clínicos

8

Part I ♦ Foundations

Decision-Making and Pre-existing Conditions In the following cases, you are faced with making decisions about patients with pre-existing conditions. In each example, your decision-making requires balancing the urgency for intervening in an illness requiring surgery with the added risk imposed by the medical condition. In some cases, the pre-existing medical condition may have worsened compared with baseline as a result of the new, acute illness. In other cases, the act of intervening with a surgi- cal procedure will cause or be associated with worsening of the pre-existing condition.

Case 1.2 Common Risk Factors Associated with Routine Surgery You evaluate a patient similar to the man in Case 1.1, who is also in need of an inguinal hernia repair.

Q: How would your preoperative assessment and proposed management change in each of the following situations?

Case Variation 1.2.1. The patient takes one aspirin per day. ◆ ◆ Aspirin and nonsteroidal antiinflammatory drugs (NSAIDs) can cause platelet dysfunction due to inhibition of cyclooxygenase, preventing prostaglandin synthesis. Aspirin has an irreversible effect on platelet aggregation; NSAIDs have a reversible effect. In 2 days after cessation of NSAIDS, platelets have recovered normal function. Thus, for an elective procedure, aspirin should be discontinued for 7–10 days prior to the procedure and NSAIDs discontinued for 2 days. Case Variation 1.2.2. The patient’s father and brother both died from acute MIs at 45 years of age. ◆ ◆ The positive family history should prompt concentrated study of the cardiac history. The patient should be asked about anginal symptoms or shortness of breath. An ECG should be performed. An exercise stress test may also be advisable in patients with a strong family history. Case Variation 1.2.3. The patient’s most recent serum cholesterol is 320 mg/dL. ◆ ◆ Hypercholesterolemia increases the risk of coronary artery disease, but this factor alone should not postpone surgery. However, the patient should be treated chronically for hypercholesterolemia with diet modification, fractionation of cholesterol, and possibly medical intervention. Case Variation 1.2.4. The patient’s preoperative ECG provides evidence of a previous inferior MI, but the patient has no knowledge of this MI and is chest pain-free on careful examination. SAMPLE