The Medical clinics of North America
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Med. Clin. North Am. · Nov 2024
ReviewMedical Clinics of North America-Periprocedural Antithrombotics: Prophylaxis and Interruption.
Anticoagulation management in the surgical patient requires clinical expertise and careful attention. For patients already receiving anticoagulation for a defined indication (ie, stroke prevention for atrial fibrillation, treatment of venous thromboembolism (VTE), or presence of a mechanical heart valve), understanding how to manage these agents by weighing the risks of thromboembolic events and bleeding is paramount. Additionally, prevention of VTE in the surgical patient involves the identification of patient-specific and procedure-specific risk factors for both VTE and bleeding. With this information, as well as familiarity with the several antithrombotic options available, an appropriate prophylaxis strategy can be employed.
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Med. Clin. North Am. · Nov 2024
ReviewEndocrine Care for the Surgical Patient: Diabetes Mellitus, Thyroid and Adrenal Conditions.
Patients with hyperglycemia, thyroid dysfunction, and adrenal insufficiency face increased perioperative risk, which may be mitigated by appropriate management. This review addresses preoperative glycemic control, makes evidence-based recommendations for the increasingly complex perioperative management of noninsulin diabetes medications, and provides guideline-supported strategies for the perioperative management of insulin, including suggested indications for continuous intravenous insulin. The authors propose a strategy for determining when surgery should be delayed in patients with thyroid dysfunction and present a matrix for managing perioperative stress dose corticosteroids based on the limited evidence available.
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Med. Clin. North Am. · Nov 2024
ReviewEvaluation and Management of Perioperative Pulmonary Complications.
Pulmonary complications are very common after noncardiac surgery and can be easily overlooked. If not properly screened for or evaluated these can in many instances lead to postoperative respiratory failure or even death. Decisions regarding ambulatory versus inpatient surgery, modality of anesthesia, protective ventilation and method of weaning, type of analgesia, and postoperative monitoring can be crucial to avoid such complications.
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Med. Clin. North Am. · Nov 2024
ReviewCoronary Disease Risk Prediction, Risk Reduction, and Postoperative Myocardial Injury.
For patients considering surgery, the preoperative evaluation allows physicians to identify and treat acute cardiac conditions before less-urgent surgery, predict the benefits and harms of a proposed surgery, and make temporary management changes to reduce operative risk. Multiple risk prediction tools are reasonable for use in estimating perioperative cardiac risk, but management changes to reduce risk have proven elusive. For all but the most urgent surgical procedures, patients with active coronary syndromes or decompensated heart failure should have surgery postponed.
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Preoperative medical evaluation can minimize inefficiencies and improve outcomes. Thoughtful use of preoperative testing can aid in that effort, but, conversely, indiscriminate testing can detract from it. ⋯ Testing is supported only when clinical indications are present. Particularly in low-risk patients, such as those with an ASA classification of 1 or 2 who are undergoing ambulatory procedures, evidence suggests that preoperative testing fails to reduce the risk of complications.