Anesthesia for Patients Too Sick for Anesthesia, An Issue of Anesthesiology Clinics

Stanley H. Rosenbaum, Benjamin A. Kohl

Description

One of the anesthesiologist’s greatest challenges is managing high-risk patients with acute or severe conditions. This issue brings the anesthesiologist up to date on the most important and latest approaches to management of the sickest of patients. Topics covered include managing the patient with sepsis or septic shock; anesthetic considerations for patients in respiratory failure; anesthetic concerns in patients presenting with renal failure; perioperative management of patients with liver failure; management of acute coronary syndrome in the OR; intraoperative concerns in patients presenting with sever aortic stenosis, aortic insufficiency, mitral regurgitation, or mitral stenosis; intraoperative management of patients with cardiac tamponade; anesthetic concerns in trauma victims requiring operative intervention; patients presenting with acute toxin indigestion; anesthetic concerns in patients with known neurologic insufficiency; management of endocrine insufficiency in the OR; and management of patients with mediastinal mass or tracheal stenosis.

Sujets

• Médecine
• Spécialités médicales
• Anesthesiology
• Medical

Informations

• Publié par: Saunders
• Date de parution: 14 mai 2010
• Nombre de lectures: 0
• EAN13: 9781455700141
• Langue: English
• Poids de l'ouvrage: 1 Mo

Extrait

Anesthesiology Clinics , Vol. 28, No. 1, March 2010
ISSN: 1932-2275
doi: 10.1016/S1932-2275(10)00032-7

Contributors
Anesthesiology Clinics
Anesthesia for Patients Too Sick for Anesthesia
Benjamin A. Kohl, MD
Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, 3400 Spruce Street, Dulles 680, Philadelphia, PA 19104, USA
Stanley H. Rosenbaum, MD
Department of Anesthesiology, Yale University School of Medicine, Yale-New Haven Hospital, 789 Howard Avenue, PO Box 208051,New Haven, CT 06520, USA
CONSULTING EDITOR Lee A. Fleisher, MD, FACC
ISSN  1932-2275
Volume 28 • Number 1 • March 2010

Contents
Cover
Contributors
Forthcoming issues
Foreword
Preface
Anesthetic Concerns in Patients with Known Cerebrovascular Insufficiency
Taking the Septic Patient to the Operating Room
Anesthesia for Patients Requiring Advanced Ventilatory Support
Anesthetic Concerns in Patients Presenting with Renal Failure
The Anesthesia Patient with Acute Coronary Syndrome
Anesthetic Considerations for Patients with Advanced Valvular Heart Disease Undergoing Noncardiac Surgery
The Intraoperative Management of Patients with Pericardial Tamponade
Anesthetic Concerns in Trauma Victims Requiring Operative Intervention: The Patient Too Sick to Anesthetize
Patients Presenting with Acute Toxin Ingestion
How to Manage Perioperative Endocrine Insufficiency
Anesthesia for the Patient with Tracheal Stenosis
Index
Anesthesiology Clinics , Vol. 28, No. 1, March 2010
ISSN: 1932-2275
doi: 10.1016/S1932-2275(10)00034-0

Forthcoming issues
Anesthesiology Clinics , Vol. 28, No. 1, March 2010
ISSN: 1932-2275
doi: 10.1016/j.anclin.2010.02.001

Foreword

Lee A. Fleisher, MD
University of Pennsylvania School of Medicine, 3400 Spruce Street, Dulles 680, Philadelphia, PA 19104, USA
E-mail address: [e-mail]


Lee A. Fleisher, MD Consulting Editor
With the constant advances in anesthesiology, patients with increasing comorbidities are being brought to the operating room by our surgical colleagues. Patients who were once too sick for anesthesia are now routinely cared for with good outcomes. Yet, our goal must be to get these patients through the surgery without a further deterioration in organ dysfunction. In this issue of the Anesthesiology Clinics , an outstanding group of contributors have provided us with insights into how best care for these patients.
As Guest Editors for this issue, we are fortunate to have Benjamin A. Kohl, MD and Stanley H. Rosenbaum, MD. They both have the unique background of training in internal medicine, anesthesiology, cardiac anesthesia, and critical care. Ben is Assistant Professor of Anesthesiology and Critical Care at the University of Pennsylvania and Director of the Fellowship in Critical Care. He has extensive clinical research experience related to perioperative glucose management. Stan is Professor of Anesthesiology, Medicine and Surgery at Yale University School of Medicine where he is Vice Chair for Academic Affairs and Director of the Section of Perioperative and Adult Anesthesia. He is currently focusing his interests on medical ethics. Together they have developed an outstanding issue.
Anesthesiology Clinics , Vol. 28, No. 1, March 2010
ISSN: 1932-2275
doi: 10.1016/j.anclin.2010.01.012

Preface
Anesthesia for Patients Too Sick for Anesthesia

Benjamin A. Kohl, MD
Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, 3400 Spruce Street, Dulles 680, Philadelphia, PA 19104, USA
E-mail address: [e-mail]
E-mail address: [e-mail]

Stanley H. Rosenbaum, MD ,
Department of Anesthesiology, Yale University School of Medicine, Yale-New Haven Hospital, 789 Howard Avenue, PO Box 208051, New Haven, CT 06520, USA
E-mail address: [e-mail]
E-mail address: [e-mail]


Benjamin A. Kohl, MD Guest Editor

Stanley H. Rosenbaum, MD Guest Editor
By their very nature, surgical patients are “sick”—some more so than others. Anesthesiologists, however, are accustomed to creating a very low-risk environment for their patients. Hence, in the setting of severe disease , the anesthesiologist has a very powerful tendency to want to view such a patient as “too sick for anesthesia.” We believe that this viewpoint, while long-standing and deeply ingrained in traditional anesthesiology practice, is in conflict with a modern view of aggressive surgical care. Severe surgical disease necessitating urgent or emergency surgery often coexists with severe medical illnesses.
If anesthesiologists canceled every patient who presented with multiple comorbidities, our operating rooms would be empty. Indeed, it is because of our unique training and skill-set that we are in a position to care for these critically ill patients. The balance between underlying medical problems and the need to provide surgical therapy must include careful consideration of the risks and benefits. However, only with a comprehensive understanding of the underlying pathology and its effect on anesthesia can a decision be made to proceed with the surgery despite significant medical dangers. Hence we have created this volume entitled (only partially facetiously), “Anesthesia for patients [traditionally regarded as] too sick for anesthesia.”
We and our authors have focused on a group of common, but potentially severe, medical conditions in the environment of surgical disease in an effort to provide a guide and resource for the anesthesiologist to become more familiar with these medical problems.
We are grateful to Lee. A. Fleisher, MD, the series editor for Anesthesiology Clinics of North America , for his guidance and advice. We are also thankful for the support of Rachel Glover and the publishing team at Elsevier.
Anesthesiology Clinics , Vol. 28, No. 1, March 2010
ISSN: 1932-2275
doi: 10.1016/j.anclin.2010.01.007

Anesthetic Concerns in Patients with Known Cerebrovascular Insufficiency

Anna V. Logvinova, MD , Lawrence Litt, MD, PhD , William L. Young, MD , Chanhung Z. Lee, MD, PhD *
Department of Anesthesia and Perioperative Care, University of California, San Francisco, 1001 Potrero Avenue, Room 3C-38, San Francisco, CA 94110, USA
* Corresponding author.
E-mail address: [e-mail]

Abstract
This review outlines the perioperative anesthesia considerations of patients with vascular diseases of the central nervous system, including occlusive cerebrovascular diseases with ischemic risks and various cerebrovascular malformations with hemorrhagic potential. The discussion emphasizes perioperative management strategies to prevent complications and minimize their effects if they occur. Planning the anesthetic and perioperative management is predicated on understanding the goals of the therapeutic intervention and anticipating potential problems.

Keywords
• Anesthesia • Cerebrovascular disease • Cerebral ischemia • Brain vascular malformation • Intracranial hemorrhage
Insufficient blood flow to all or part of the brain, or cerebrovascular insufficiency , can be caused by cerebrovascular diseases , whereby one or more blood vessels that supply brain tissue have structural and functional abnormalities that cause permanent or episodic brain ischemia or hemorrhage. Cerebrovascular diseases can often be characterized as either occlusive (eg, carotid and intracranial arterial stenosis), or hemorrhagic , with this term applying to vascular disorders whose natural course proceeds to hemorrhage, as with various cerebrovascular malformations (eg, intracranial aneurysms and arteriovenous malformations). Cerebrovascular diseases have remained a third leading cause of death in the United States, with an estimated 500,000 new cerebrovascular accidents (CVAs) each year. 1 Cerebrovascular diseases are the most disabling of all neurologic disorders, causing a residual neurologic deficit in more than 50% of survivors, and necessitating chronic care for more than 25% of survivors. 1
Advances in acute CVA management have steadily increased survival at different stages of recovery. For intracranial cerebrovascular malformations, as a result of the trend in favor of more conservative medical management, 2, 3 there will be an increase in the group of patients at risk for hemorrhagic stroke. Thus the population of patients who need to be anesthetized for nonneurologic surgeries and interventions includes an increasing number with cerebrovascular diseases, causing additional, unique, anesthesia-related challenges and concerns. Prevention strategies to avoid cerebral ischemia or hemorrhage must be embedded in plans for anesthesia management at all stages of perioperative care. The preoperative assessment should include an evaluation of the patient’s cerebrovascular status as a potential source of perioperative morbidity and mortality. A comprehensive review is needed of concurrent pathologies, comorbidities, and medications that might influence the perioperative course. Defining cerebrovascular reserve and ischemic and hemorrhagic risks in the type of surgery that is planned must be tailored to each patient’s particular lesions. Plans and preparations need to be made in advance of interventions that might be needed to deal with complications or emergencies. Anesthetic planning should be especially clear about hemodynamic goals and monitoring. This article presents detailed anesthetic concerns for the most common cerebrovascular diseases.

Anesthetic concerns for occlusive cerebrovascular diseases

Carotid and Vertebral Arteries
Carotid arteries provide approximately 80% of cerebral blood flow (CBF) while vertebral arteries supply the remaining 20%. Between 5% and 10% of people older than 65 years were found to have carotid stenosis of more than 50%. 4, 5 The etiology of occlusive diseases is complex, and includes