Cleveland Clinic journal of medicine
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Obstructive sleep apnea (OSA) is associated with increased risks of cardiovascular disease and stroke and with elevated rates of postoperative complications (including cardiac ischemia and respiratory failure) in surgical patients. Additionally, the prevalence of OSA is higher in surgical patients than in the general population. Screening for OSA prior to surgery is recommended to identify patients at risk for postoperative complications. The presence of moderate or severe OSA calls for modified strategies of perioperative anesthesia, pain management, and postoperative monitoring to reduce the chance of OSA-associated complications.
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Perioperative anemia is associated with excess morbidity and mortality. Transfusion of allogeneic blood has been a longstanding strategy for managing perioperative anemia, but the blood supply is insufficient to meet transfusion needs, and complications such as infection, renal injury, and acute lung injury are fairly common. ⋯ Though ESAs reduce the need for perioperative blood transfusion compared with placebo, they are associated with an increased risk of thrombotic events in surgical patients. Cleveland Clinic has been developing a blood management program aimed at reducing allogeneic blood exposure for greater patient safety; the program has achieved some reduction in blood utilization in its first 7 months.
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Most surgical patients who require hospitalization are at high risk for venous thromboembolism (VTE) and should receive VTE prophylaxis, usually including pharmacologic prophylaxis. Nevertheless, rates of appropriate perioperative thromboprophylaxis remain stubbornly low, though an expansion in quality-improvement efforts has led to widespread hospital implementation of prophylaxis strategies in recent years. This article reviews important principles and recent developments in perioperative VTE prophylaxis, with a focus on key recommendations and changes in the 2008 update of the American College Chest Physicians' (ACCP) evidence-based guidelines on antithrombotic therapy.
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Postoperative pulmonary complications are common, serious, and expensive. Important predictors of risk are advanced age, poor health as assessed by American Society of Anesthesiologists class, and surgery near the diaphragm. Effective strategies to reduce risk include postoperative lung expansion techniques, preoperative intensive inspiratory muscle training, postoperative thoracic epidural analgesia, selective rather than routine use of nasogastric tubes, and laparoscopic rather than open bariatric surgery.
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Anesthesiologists are the primary users of preoperative medical consultations (consults), but the information in consults is often of limited usefulness to anesthesiologists and the rest of the surgical and perioperative team. The purpose of a consult is not to "clear" a patient for surgery but rather to optimize a patient's underlying disease states before they are compounded by the insult of surgery. Too often consults provide advice on subjects that are in the realm of expertise of the anesthesiologist--such as the type of anesthesia to administer or what intraoperative monitoring to use--and thus risk being ignored. Consults should instead provide specific data about the patient that are pertinent to the surgery, as well as guidance on preoperative and postoperative disease management.