The Medical clinics of North America
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Med. Clin. North Am. · Jan 2003
ReviewPreoperative risk evaluation and perioperative management of patients with coronary artery disease.
We have reviewed the methods of evaluating a patient's cardiac risk preoperatively using a careful history, physical examination, and EKG. Based on this information, various risk indices, guidelines, and algorithms can further assist the physician in deciding which patients can undergo surgery without further testing and which patients might benefit from further cardiac evaluation or medical therapy prior to surgery. The physician must keep in mind that a test should not be ordered if it is unlikely to alter the patient's management, and it is rarely necessary to perform a revascularization procedure with the sole purpose of getting a patient through surgery. Ongoing research is likely to lead to improvement in perioperative medical therapy.
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The perioperative care of patients with cancer can be an exciting challenge. The physician must consider many factors, including the cancer diagnosis, the extent of disease, treatment received, the presence of comorbid conditions, and the patient's prognosis and must understand the impact of these factors on the planned surgical procedure. In this setting, the physician has the opportunity to perform an essential role in the perioperative management of patients with cancer.
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As the population survives longer, surgery has become a much more common consideration. Preoperative management of these patients requires a working knowledge of changes associated with aging and the physiology of surgery and anesthesia. Using this information, patients can be clinically evaluated effectively and plans made for their perioperative care to minimize complications.
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Preoperative risk assessment for postoperative pulmonary complications is essential when counseling patients about the risks of surgery because of their significant associated morbidity and mortality. There are many patient-related, operation-related, and anesthesia-related risk factors for the development of PPCs. ⋯ Reducing PPC risk at the patient level will require a greater understanding of the impact of modifying risk factors through interventional trials. Reducing hospital PPC rates will require future research into the processes of care associated with PPCs through controlled observational and interventional trials.
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In this article, we have shown that almost all "routine" laboratory tests before surgery have limited clinical value. Clinicians should order only a small number of routine tests based on age as noted in Table 13. Selective use of other preoperative tests should be based on history and physical examination findings that identify subgroups of patients who are more likely to have abnormal results. ⋯ For this reason, clinicians can have a low threshold for ordering these tests in patients for whom the frequency of abnormalities is increased compared with a healthy population. We believe that physicians should not be criticized for selective test ordering before surgery. Physicians and institutions recommending routine preoperative testing for all patients provide no clinical value to their patients at considerable cost.