Cleveland Clinic journal of medicine
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Inhaled and intravenous anesthetic agents have diverse effects on the nervous, cardiovascular, and respiratory systems. Spinal and epidural anesthetics also produce significant physiologic changes. ⋯ Evidence is just beginning to emerge, however, on the relation between specific anesthetics and anesthetic techniques and long-term clinical outcomes. A proposed relationship between anesthetics, inflammation, and long-term outcomes has attracted increasing research interest but has yet to be well defined.
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The medical consultant should have a high index of suspicion for sepsis. Early goal-directed therapy is recommended and includes early, aggressive fluid resuscitation, antibiotics, and vasoactive agents, if needed. ⋯ Empiric use of steroids and early use of activated protein C also need to be considered. Vasopressin should be considered if hypotension persists or if the situation requires escalating doses of norepinephrine.
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Patients with an elevated serum creatinine or whose serum creatinine levels increase postoperatively, regardless of baseline levels, are at increased risk for elevated mortality. Women have a higher risk from acute renal failure than men at every level of serum creatinine. Acute renal failure confers an increased risk of mortality, chronic renal insufficiency, and postoperative infection independent of other postoperative complications. Preoperative measures to reduce risk of acute renal failure include optimizing volume and solute status, ensuring adequate urine flow, avoiding high doses of diuretics, optimizing hematocrit levels, and avoiding contrast agents.
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The history and the physical examination remain the most important elements in cardiac risk stratification of patients prior to noncardiac surgery. Indications for further cardiac tests and interventions are usually the same as in the nonsurgical setting. No test should be performed unless the results will affect patient management. In many cases, noninvasive testing is being replaced by prophylactic medical therapy, a topic explored in the next article in this supplement.
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Tumor necrosis factor (TNF) inhibitors have proven highly effective against a number of autoimmune diseases but have been disappointing in treating others. An increase in the risk of Mycobacterium tuberculosis and other opportunistic infections has been noted in patients treated with these agents. If we use these drugs, we need to weigh their beneficial and adverse effects.