Cleveland Clinic journal of medicine
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Review
Preoperative pulmonary evaluation: identifying and reducing risks for pulmonary complications.
Postoperative pulmonary complications are among the most common sources of morbidity in patients undergoing major surgery. For this reason, the preoperative patient evaluation should emphasize risk factors for pulmonary complications as well as for traditional cardiac complications, as the former are comparably frequent and associated with longer hospital stays. ⋯ Pulmonary function testing has a limited role and should not be the basis for denying surgery if the surgical indication is compelling. Strategies to reduce the risk of postoperative pulmonary complications include optimizing management of chronic lung disease before surgery, lung expansion maneuvers, pain control, and selective placement of nasogastric tubes.
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Case Reports
Perioperative management of the bariatric surgery patient: focus on cardiac and anesthesia considerations.
Obesity is a major public health problem in developed nations worldwide. Currently, the only treatment for severe obesity (BMI > or = 35 kg/m2 with comorbidity) that provides long-term weight loss is bariatric surgery. Restrictive, malabsorptive, and combination procedures have been developed. ⋯ Candidates for bariatric surgery are often at high risk for complications because of obesity-related comorbidities. Therefore, careful patient selection for bariatric surgery, together with well-designed strategies for preventing and managing complications, are keys to success. Close monitoring for nutritional deficiencies and short- and long-term complications is required to completely assess outcomes of these procedures.
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Patients with hip fracture benefit from a multidisciplinary team approach for preoperative and postoperative care. Team members, consisting of the orthopedic surgeon, internal medicine consultant, and anesthesiologist, should each have a role in determining a patient's readiness for surgery and communicate with one another about appropriate management. ⋯ Nondisplaced (impacted) femoral neck fractures, however, should be repaired within 6 hours if possible to avert avascular necrosis of the femoral head and the need for total hip replacement. The following interventions are helpful for preventing complications following hip fracture repair: perioperative prophylaxis against infection.
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Case Reports
Perioperative management of diabetes mellitus: how should we act on the limited evidence?
Patients with diabetes mellitus are at higher risk for complications from surgery than their nondiabetic counterparts. Evidence-based guidance on the perioperative management of diabetic patients is still very limited. ⋯ Insulin is the mainstay of perioperative glucose management, and intensive insulin therapy (to a target blood glucose of 110 mg/dL or lower) improves a range of clinical outcomes in critically ill patients relative to less aggressive insulin strategies. There is little role for oral antidiabetic medications in the early postoperative phase.