Cleveland Clinic journal of medicine
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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.
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In the last 7 years, 14 randomized controlled trials in patients with acute respiratory distress syndrome (ARDS) have shown that: Mechanical ventilation with a tidal volume of 6 mL/kg of predicted body weight is better than mechanical ventilation with a tidal volume of 12 mL/kg of predicted body weight. Prone positioning improves oxygenation but poses safety concerns. A high level of positive end-expiratory pressure does not improve survival. ⋯ Exogenous surfactant may improve oxygenation but has no significant effect on the death rate or length of use of mechanical ventilation. Low-dose inhaled nitric oxide has no substantial impact on the duration of ventilatory support or on the death rate. Partial liquid ventilation may be beneficial in young patients with acute lung injury or ARDS, although further study is needed to confirm this.
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The quality of postoperative pain management can be improved. Although many safe and effective therapies exist, their utilization varies considerably between and within institutions. Major challenges include the appropriate prescribing of analgesic therapies and the timely response to suboptimal pain control. Patients' satisfaction with their analgesic care may depend less on how well their pain is controlled and more on the attentiveness of their caregivers.
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Most patients with chronic kidney disease eventually become anemic. We should view the management of anemia in these patients as part of the overall management of the many clinically relevant manifestations of chronic kidney disease. Erythropoiesis-stimulating agents (ESAs) are safe and should be used, as treating anemia may forestall some of the target-organ damage of chronic kidney disease.