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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2804_Библиотеки_им_академика_М_И_Перельмана
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OxygenassessmentbypulseoximetryandCXRareusefulinmostpatients.
Otherdiagnosticmeasuresshouldbedirectedbythefindingsintheinitialevaluation.
TREATMENT
Oxygenshouldbeadministeredpromptlyifneeded.Othertherapeuticmeasuresshouldbedirectedbythe
findingsintheinitialevaluation.
AcuteHypertensiveEpisodes
GENERALPRINCIPLES
Acute hypertensive episodes inthe hospital are most often caused by inadequately treated essential
hypertension.Ifthereisevidenceofendorgandamage,IVmedicationsareindicated.Oralagentsare
moreappropriateforhypertensiveurgencywithoutendorgandamage.
Hypertensionassociatedwithwithdrawalsyndromes(e.g.,alcohol,cocaine)andreboundhypertension
associated with sudden withdrawal of antihypertensive medications (e.g., clonidine, α-adrenergic
antagonists)shouldbeconsidered.
Volume overload and pain mayexacerbate hypertensionand should be recognizedappropriatelyand
treated.
Fever
GENERALPRINCIPLES
Feveraccompaniesmanyillnessesandisavaluablemarkerofdiseaseactivity.Infectionisaprimary
concern.Drugreaction,malignancy,VTE,vasculitis,centralfever,andtissueinfarctionareother
possibilitiesbutarediagnosesofexclusion.
DIAGNOSIS
HistoryandPhysicalExamination
History should include chronology of the fever and associated symptoms, medications, potential
exposures,andacompletesocialandtravelhistory.
In the hospitalized patient, special attention should be paid to any IV lines, asymmetric edema, a
thoroughskinexamination,andindwellingdevicessuchasurinarycatheters.
DiagnosticTesting
Testing includes blood andurine cultures, completeblood count (CBC)with differential, and serum
chemistrieswithliverfunctiontests.
DiagnosticevaluationgenerallyincludesCXR.
Culturesofabnormalfluidcollections,sputum,cerebrospinalfluid,urine,andstoolshouldbe sentif
clinicallyindicated.Culturesareideallyobtainedpriortoinitiationofantibiotics;however,antibiotics
shouldnotbedelayedifseriousinfectionissuspected.
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TREATMENT
Antipyreticdrugsmaybegiventodecreaseassociateddiscomfort.
Empiricantibioticsshouldbeconsideredinhemodynamicallyunstablepatientsinwhominfectionisa
primaryconcern,aswellasinneutropenicandasplenicpatients.
Heatstrokeandmalignanthyperthermiaare medicalemergenciesthatrequirepromptrecognitionand
treatment(seeChapter26,MedicalEmergencies).
Pain
GENERALPRINCIPLES
Painissubjectiveandtherapymustbeindividualized.Chronicpainmaynotbeassociatedwithany
objectivephysicalfindings.Painscalescanbeemployedforquantitation.
TREATMENT
Acute pain usually requires short-term therapy and often improves with acetaminophen-or NSAID-
basedregimens.
Chronicpainrequiresmultimodalitymanagementtokeepopioidusetoaminimumtopreventrisk
ofdependenceandsubsequentescalationofopioiddoses.Higherdosesofopioidshavebeenshown
toincreasetheriskofoverdosewithoutprovidingincreasedpainrelief.
9
If pain is refractory to medical therapy, then nonpharmacologic modalities, such as nerve blocks,
sympathectomy,andcognitivebehavioraltherapy,maybeappropriate.
OpioidAnalgesics
Effects:Opioidanalgesicsarepharmacologicallysimilartoopiumormorphineandareindicatedfor
moderatetoseverepain.
Dosage:Table1-1listsequianalgesicdosages.
TABLE1-1
EQUIPOTENTDOSESOFOPIOIDANALGESICS
Drug Onset(min) Duration(h) IM/IV/SC(mg) PO(mg)
Fentanyl 7–8 1–2 0.1 NA
Levorphanol 30–90 4–6 2 4
Hydromorphone 15–30 2–4 1.5–2.0 7.5
Methadone 30–60 4–12 10 20
Morphine 15–30 2–4 10 30
a
Oxycodone 15–30 3–4 NA 20
Codeine 15–30 4–6 120 200
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a
AnIM:POratioof1:2–1:3usedforrepetitivedosing.
Note:Equivalencesarebasedonsingle-dosestudies.
NA,notapplicable.
Foracutepainmanagement,thelowesteffectivedoseofimmediate-releaseopioidsshouldbegiven.
Patientswithdemonstratedtoleranceoftenrequirehigherdoses.
Use ofnonopioid painmedications andnonpharmacological painmanagementstrategies tominimize
opioidneedsisencouraged.
Both parenteral and transdermal administration are useful in the setting of dysphagia, emesis, or
decreasedgastrointestinal(GI)absorption.
Patient-controlledanalgesia often isusedto controlpainina postoperativeor terminallyill patient.
Opioid-naïvepatientsshouldnothavebasalratesprescribedduetoriskofoverdose.
If apatient requirescontinuous(basal)analgesia, supplementaryPRNdosesforbreakthroughpainof
roughly 5%–15% ofthe daily basal dose canbe provided. If frequent PRN doses are required, the
maintenancedoseshouldbeincreased,orthedosingintervalshouldbedecreased.
Severe pain uncontrolled with large doses of opiates, particularly while using patient-controlled
analgesiawithbasalrates,maywarrantconsultationwithapainspecialist.
Opioidsarerelativelycontraindicatedinacutediseasestatesinwhichthepatternanddegreeofpain
areimportantdiagnosticsigns(e.g.,headinjuries).Theyalsomayincreaseintracranialpressure.
Opioiddosageshouldbeadjustedforpatientswithimpairedhepaticorrenalfunction.
Drugs that potentiate the adverse effects of opioids include phenothiazines, antidepressants,
benzodiazepines,andalcohol.
Tolerancedevelopswithchronicuseandcoincideswiththe development ofphysicaldependence,
whichischaracterizedbyawithdrawalsyndromewhenthedrug isstoppedabruptly.Itmayoccur
afteronly2weeksoftherapy.
Administrationofanopioidantagonistmayprecipitatewithdrawalafteronly3daysoftherapy.
The quantityof opioid tablets prescribed atdischargeshould notexceed theexpecteddurationof
pain.Aquantitytocover3daysorlessshouldbesufficient.Prescribingaquantityatdischargeto
covermorethan7daysdurationofpainshouldnotbenecessaryandisdiscouraged.
9
Adverseandtoxiceffects
Centralnervoussystemeffectsincludesedation,euphoria,andpupillaryconstriction.
RespiratorydepressionisdoserelatedandpronouncedafterIVadministration.
Cardiovasculareffectsincludeperipheralvasodilationandhypotension.
GI effects include constipation, nausea, and vomiting. Stool softeners and laxatives should be
prescribed to prevent constipation. Opioids may precipitate toxic megacolon in patients with
inflammatoryboweldisease.
Genitourinaryeffectsincludeurinaryretention.
Pruritusoccursmostcommonlywithspinaladministration.
Opioidoverdose
Naloxone, an opioid antagonist, should be readily available for administration in the case of
accidentalorintentionaloverdose.
Naloxone home rescue kits have been shown to reduce opioid overdose mortality.10 Patients
being discharged home on more than 50 morphine milligram equivalents per day have a
higherriskofoverdoseandmaybenefitfromaprescriptionforintranasalnaloxoneatdischarge.
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AlteredMentalStatus
GENERALPRINCIPLES
Mentalstatuschangeshaveabroaddifferentialdiagnosisthatincludesneurologic(e.g.,stroke,seizure,
delirium),metabolic(e.g.,hypoxemia,hypoglycemia),toxic(e.g.,drugeffects,alcoholwithdrawal),and
otheretiologies.Infectionisacommoncauseofmentalstatuschangesintheelderlyandinpatientswith
underlyingneurologicdisease.Sundownsyndromereferstotheappearanceofworseningconfusioninthe
eveningandisassociatedwithdementia,delirium,andunfamiliarenvironments.
DIAGNOSIS
HistoryandPhysicalExamination
Focus particularly on medications, underlying dementia, cognitive impairment, neurologic or
psychiatricdisorders,andahistoryofalcoholand/ordruguse.
Physical examination generally includes vital signs, a search for sites of infection, a complete
cardiopulmonary examination, and a detailed neurologic examination including mental status
evaluation.
DiagnosticTesting
Testing includes blood glucose, serum electrolytes, creatinine, CBC, urinalysis, and oxygen
assessment.
Other evaluation, including lumbar puncture, toxicology screen, cultures, thyroid function tests,
noncontrastheadCT,electroencephalogram,CXR,orECG,shouldbedirectedbyinitialfindings.
TREATMENT
ManagementofspecificdisordersisdiscussedinChapter27,NeurologicDisorders.
Medications
Agitationandpsychosismaybefeaturesofachangeinmentalstatus.Theantipsychotichaloperidoland
thebenzodiazepinelorazepamarecommonlyusedintheacutemanagementofthesesymptoms.Secondgenerationantipsychotics(risperidone,olanzapine,quetiapine,clozapine,ziprasidone,aripiprazole,
paliperidone)arealternativeagentsthatmayleadtodecreasedincidenceofextrapyramidalsymptoms.
Alloftheseagentsposeriskstoelderlypatientsandthosewithdementiaifgivenlongterm.
Haloperidolistheinitialdrugofchoiceforacutemanagementofagitationandpsychosis.Ithasfewer
active metabolites and fewer anticholinergic, sedative, and hypotensive effects than other
antipsychoticsbutmayhavemoreextrapyramidalsideeffects.
In low dosages, haloperidol rarely causes hypotension, cardiovascular compromise, or excessive
sedation.
Postural hypotensionmay occasionallybe acute andsevere after administration. IV fluids should be
giveninitiallyfortreatment.
UseshouldbediscontinuedwithprolongationofQTc>450msor25%abovebaseline.
Neurolepticmalignantsyndrome(seeChapter27,NeurologicDisorders).
Lorazepam canalso be used for agitation.Lorazepam has a short duration of action andfew active
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metabolites.Excessivesedationandrespiratorydepressioncanoccur.
NonpharmacologicTherapies
Patientswithdeliriumofanyetiologyoftenrespondtofrequentreorientation,observanceoftheday–night
lightcycle,andmaintenanceofafamiliarenvironment.Thesemethodsshouldbetrialedbeforetheuse
oftheabovemedicationsifthepatientisnotathreattothemselvesorcareteams.
PerioperativeMedicine
Theroleofthemedicalconsultantistoestimatethelevelofriskassociatedwithagivenprocedure,
determinetheneedforfurtherevaluationbasedonthisriskestimate,andprescribeinterventionsto
mitigaterisk.
PreoperativeCardiacEvaluation
GENERALPRINCIPLES
Perioperativecardiaccomplicationsaregenerallydefinedascardiacdeath,MIs(bothSTandnon-ST
elevation),CHF,andclinicallysignificantrhythmdisturbances.
DIAGNOSIS
ClinicalPresentation
HISTORY
Patientfactorsandcomorbidconditionsthataffectperioperativecardiacriskincludethefollowing:
Clinicalriskfactorsforcoronaryarterydisease(CAD)
Preexisting,stableCAD
Unstablecoronarysyndromes
RecentMI(definedas>7but<30days)
Decompensated CHF (New York Heart Association class IV, worsening or new-onset heart failure
[HF])
Arrhythmias
Severevalvulardisease
CompensatedorpriorCHF
Diabetesmellitus
Priorcerebrovascularaccident(CVA)ortransientischemicattack(TIA)
Chronickidneydisease
Poorlycontrolledhypertension
AbnormalECG(e.g.,leftventricularhypertrophy,leftbundlebranchblock,ST–Twaveabnormalities)
Age >70 years identifiedinseveral studies as asignificantriskfactorbutnot uniformlyacceptedas
independent.
11,12
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PHYSICALEXAMINATION
Specificattentionshouldbepaidtothefollowing:
Vitalsigns,inparticularelevatedBP.Systolicbloodpressure(SBP)<180mmHganddiastolicblood
pressure (DBP) <110 mm Hg are generally considered permissible. The management of stage III
hypertension(SBP >180 mm HgorDBP >110mmHg) iscontroversial.Thoughpostposingelective
surgerytoallowadequateBPcontrolinthissettingseemsreasonable,howlongtowaitaftertreatment
implementation to proceed remains unclear. Evidence of decompensated CHF (elevated jugular
venouspressure,rales,S3,edema).
Murmurs suggestive of significant valvular lesions. According to the 2014 American Heart
Association(AHA)/AmericanCollegeofCardiology(ACC)GuidelinefortheManagementofPatients
withValvularHeartDisease,theriskofnoncardiacsurgeryisincreasedinallpatientswithsignificant
valvularheartdisease,althoughsymptomaticaorticstenosis(AS)isthoughttocarrythegreatestrisk.
The estimated rate of cardiac complications in patients with undiagnosed severe AS undergoing
noncardiac surgery is 10%–30%. However, aortic valve replacement is also associated with
considerable risk. Risk–benefit analysis appears to favor proceeding to intermediate-risk elective
noncardiac surgery (see below) with appropriate intra- and postoperative hemodynamic monitoring
(including intraoperative right heart catheter or transesophageal echocardiogram) as opposed to
prophylactic aortic valve replacement in the context of asymptomatic severe disease. The same
recommendations (albeit with less supporting evidence) apply to asymptomatic severe mitral
regurgitation,asymptomaticsevereaorticregurgitationwithnormalejectionfraction,andasymptomatic
severe mitral stenosis (assuming valve morphology is not amenable to percutaneous balloon mitral
commissurotomy,whichshouldotherwisebeconsideredtooptimizecardiacstatuspriortoproceeding
tosurgery).Symptomaticseverevalvulardisease ofany typeshouldpromptpreoperativecardiology
consultation.
DiagnosticCriteria
The2014ACC/AHAGuidelineonPerioperativeCardiovascularEvaluationandManagementofPatients
UndergoingNoncardiacSurgeryoffersastepwiseapproachtopreoperativeevaluationandrisk
stratification(Figure1-1).
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Figure 1-1 Cardiac evaluation algorithm for noncardiac surgery.ACS, acute coronary syndrome; CAD, coronary artery
disease;OR,operatingroom;RCRI,RevisedCardiacRiskIndex.(ModifiedfromFleisherLA,FleischmannKE,AuerbachAD,
etal.2014ACC/AHAguidelineonperioperative cardiovascular evaluationandmanagementofpatientsundergoingnoncardiac
surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
Circulation.2014;130(24):e278-e333.)
Step1: Establishthe urgencyofsurgery. Many surgeries are unlikelytoallow fora time-consuming
evaluation.
Step2:Assessforactivecardiacconditions(see“History,”above).
Step3:Determinethesurgery-specificriskasfollows:
Low-risksurgeries (<1%expectedriskofadversecardiacevents) includesuperficialprocedures,
cataract/breastsurgery, endoscopic procedures, and most procedures that can be performed in an
ambulatorysetting.
Intermediate-risksurgeries(1%–5%riskofadversecardiacevents)includecarotidendarterectomy,
intraperitoneal/intrathoracic surgery, orthopedic surgery, head and neck surgery, and prostate
surgery.
Vascularsurgeryinvolvingextremityrevascularizationoraorticrepairgenerallycarriesthehighest
risk(>5%riskofadversecardiacevents).
Step4:Assessthepatient’sfunctionalcapacity.
Poorfunctionalcapacity(<4metabolicequivalents[METs])isassociatedwithanincreasedriskof
perioperativecardiacevents.
13,14
Althoughexercisetestingisthegoldstandard,functionalcapacitycanbe
reliablyestimatedbypatientself-report.15Examplesofactivitiesthatsuggestatleastmoderatefunctional
capacity(>4METs)includeclimbingonetotwoflightsofstairsorwalkingablockatabriskpace.
Patientswithafunctionalcapacityof>4METswithoutsymptomscanproceedtosurgerywithrelatively
lowrisk.
Step5:Assessthepatient’sclinicalriskfactors.
The number of risk factors combined with the surgery-specific risk (intermediate vs. vascular)
determinesfurther management. Thefollowing riskfactors are adapted from the Revised Cardiac
RiskIndex(RCRI):
16
Ischemicheartdisease
HistoryofTIAorCVA
HistoryofCHF
Preoperativeserumcreatinine≥2mg/dL
Diabetesmellitusrequiringinsulin
Patientswithnoclinicalriskfactorsareatinherentlylowrisk(<1%riskofcardiacevents)andmay
proceedtosurgerywithoutfurthertesting.Patientswithoneortwoclinicalriskfactorsaregenerally
at intermediate risk and may proceed to surgery, although stress testing might help refine risk
assessmentin selected cases. Patients with three or more clinical risk factors are at high riskof
adversecardiacevents,particularlywhenundergoingvascularsurgery.Inthispopulationespecially,
stress testing may provide a better estimate of cardiovascular risk and may be considered if
knowledgeofthis increasedriskwould changemanagement.17A positive stresstestina high-risk
patientportendsasubstantiallyincreasedriskofaperioperativecardiacevent,whereasanegative
studysuggestsalowerriskthanthatpredictedbyclinicalfactorsalone.
11
DiagnosticTesting
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12-LeadECG.ThevalueofaroutineECGiscontroversial.Perthe2014ACC/AHAguidelines(level
ofevidence:B):
ECG is “reasonable” in patients with known CAD, significant arrhythmia, peripheral arterial
disease,cerebrovasculardisease,orothersignificantstructuralheartdiseasepriortointermediaterisksurgeryandabove(classIIa);
“May be considered” for asymptomatic patients without known coronary heart disease prior to
intermediate-andhigh-risksurgery(classIIb);
Is“notuseful”forasymptomaticpatientsundergoinglow-risksurgicalprocedures(classIII).
Resting echocardiogram. In general, the indications for preoperative echocardiographic evaluation
are no different from those in the nonoperative setting. Murmurs found on physical examination
suggestive of significant underlying valvular disease (see above) should be evaluated by
echocardiogram. Assessmentof left ventricular function should be considered when there is clinical
concern for underlying undiagnosed CHF or if there is concern for deterioration since the last
examination.
Noninvasive stress testing. The decision to pursue a stress evaluation should be guided by an
assessmentofpreoperativeriskasdetailedabove.Forfurtherdetailsonstresstesting,seeChapter 4,
IschemicHeartDisease.
SPECIALCONSIDERATIONS
Patients with drug-eluting coronary stents: See “Perioperative Anticoagulation and Antithrombotic
Management.”
Multiple studies have reported a correlation between delayed repair of hip fracture and increased
morbidityandmortality.
18,19
Forurgentsurgicalprocedures (i.e., those thatshould be donewithin48
hours of diagnosis), the value of additional testing is typicallyoutweighed by theriskof worsened
short-andlong-termoutcomesincurredwithsurgicaldelay.Unnecessarypreoperativecardiactesting
maybe an independent riskfactorfor postoperative complications inhip fracture patients.20 In such
cases, it is advisable to optimize the patient’s medical status and modifiable risk factors and then
proceedtotheoperatingroom.
TREATMENT
Medications
β-Blockers
Multiplestudieshaveprovidedsupportforperioperativeβ-blockadeinpatientswithoratriskfor
CADundergoingnoncardiacsurgeries.Themostpronouncedbenefithasbeenobservedinhigh-risk
patients undergoing vascular surgery where β-blocker dose was titrated to heart rate control.
17,21
However, a subsequent analysis has called into question the role of dose titration.22 Although
reductioninperioperativecardiaceventshasbeenobservedconsistently,itwarrantsmentioningthat
fewdatasupporttheeffectivenessofperioperativeβ-blockadeinreducingmortality.
Accordingtothe2014ACC/AHAguidelines:
InpatientswiththreeormoreRCRIriskfactors(seeabove)orevidenceofmyocardialischemia
onpreoperativestresstesting,startingpreoperativeβ-blockadeisreasonable(levelofevidence:
B).
β-Blockadeshouldnotbestartedonthedayofsurgery,as itisatminimumineffectiveleveland
mayactuallybeharmful(levelofevidence:B).
Patientsalreadytakingβ-blockersshouldbecontinuedontheirmedication(levelofevidence:B).
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Statins
Multipletrialshaveshownadecreaseinperioperativecardiaceventsand/ormortalitywith statin
use in patients undergoing vascular surgery. Moreover, a recent cohort study of statin therapy in
patientsundergoing intermediate-risknoncardiac, nonvascular surgery revealed a fivefold reduced
riskof30-dayall-causemortalityalongwithastatisticallysignificantreductioninthecompositeend
pointof30-dayall-causemortality,atrialfibrillation(AF),andnonfatalMI.
23
Perthe2014ACC/AHAguidelines:
Patientscurrentlytakingstatinsshouldbemaintainedontherapy(levelofevidence:B).
Patients undergoing vascular surgery, and those with risk factors undergoing intermediate-risk
surgery,maybenefitfrominitiationofstatintherapyperioperatively(levelofevidence:BandC,
respectively). Optimal dose, duration of therapy, and target low-density lipoprotein levels for
perioperativeriskreductionareunclear.
Aspirin
Fordiscussion,see“PerioperativeAnticoagulationandAntithromboticManagement.”
Revascularization
The best available data on preoperative revascularization come from the Coronary Artery
Revascularization Prophylaxis (CARP) trial, a prospective study of patients scheduled to undergo
vascularsurgery.24PatientswithprovensignificantCADwererandomizedtorevascularizationversus
norevascularization.TherewasnodifferencebetweenthegroupsintheoccurrenceofMIordeathat
30daysorinmortalitywithlong-termfollow-up.Patientswiththreeormoreclinicalriskfactorsand
extensiveischemiaonstresstestingwereevaluatedinaseparatesmallstudy.25Higheventrateswere
seeninbothstudyarms,andnobenefitwasseenwithrevascularization.Takentogether,thesestudies
suggest that the risk of adverse cardiac events is not altered by attempts at preoperative
revascularization,eveninhigh-riskpopulations.Patientswithleftmaindisease,whoappearedtohave
benefitedfrompreoperativerevascularizationinasubsetanalysisoftheCARPtrialdata,areanotable
possibleexpectation.
26
Based on these cumulative results, a strategy of routinely pursuing coronary revascularization as a
methodofdecreasingperioperativecardiacriskcannotberecommended.However,carefulscreening
ofpatientsisstillessentialtoidentifythosehigh-risksubsetswhomayobtainasurvivalbenefitfrom
revascularizationindependentoftheirneedfornoncardiacsurgery.
Monitoring/Follow-Up
PostoperativeInfarctionandSurveillance
Mosteventswilloccurwithin48–72hoursofsurgery,with themajority inthefirst24hours.27Most
arealsoclinicallysilent.28Althoughoverall30-daymortalityhasbeenlinkedtopostoperativetroponin
elevation,thecauseofdeathisnotpredictable,andnospecificcourseoftherapymaybeoffered.
29
The2014ACC/AHAguidelinesofferthefollowing30:
RoutinepostoperativeECGsandtroponinsarenotrecommended.
ThebenefitoftroponinmeasurementsandECGsinhighcardiacriskpatientsisuncertain.
Symptomatic infarctions should be addressed according to standard therapy of acute coronary
syndromes(see Chapter 4, Ischemic Heart Disease). The major caveat is that bleeding risk with
anticoagulantsmustbecarefullyconsidered.
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