Few voluntary experiences in life challenge the psychological equilibrium of persons more than hospitalization due to major physical illness and surgery. Not only must patients face the prospect of death, pain, and disability, they must acquiesce to do so with the loss of personal control, identity, and independence. Patients must willingly agree to all of these terms in a foreign environment that is created not to meet their needs per se, but more to cater to the needs of bureaucratic institutions that dictate what the patients' needs are to the hospital staff. Moreover, under these conditions patients must be ready to tolerate a never-ending onslaught of repetitive personal questions and humiliating and invasive examinations and procedures. It is a wonder that most patients do not respond to their physicians and other hospital staff with anxiety, fear, anger, and dependency.

Reactions to the stressors mentioned above can vary among patients. Factors that may influence resilience include pre-existing psychological strength, amount of family support available, financial resources, type and extent of illness, surgical procedures involved, and overall prognosis. For example, elderly patients in particular may not have family readily available. Older patients with cognitive impairment may become more confused, disoriented, and agitated without familiar faces to provide a sense of environmental stability. For patients whose prognosis, although improved, may sustain a visible loss of a body part or possible function of a body part, such as women undergoing mastectomy, patients receiving an ostomy, and men undergoing urologic surgery, losing love and sexual desirability or function may lead to a profound experience of grief over the loss. Patients facing financial stressors may suffer from intense anxiety associated with the immediate physical incapacitation after surgery and the fear that they may never be well enough again to deal with their financial obligations.

Neuromuscular disease in surgical patients can be divided into disorders of the neuromuscular junction, peripheral nerves, and muscle.

Myasthenia gravis

Of all the neuromuscular diseases, myasthenia gravis probably has the most significant implications for surgical patients [1]. This disorder results from an autoimmune attack on the acetylcholine receptors of the postsynaptic (muscle) side of the neuromuscular junction. Characteristic clinical features include fluctuating weakness and fatigue, usually involving the extraocular muscles and eyelids (producing diplopia and ptosis). Weakness of the limbs can be severe, sometimes resulting in almost total paralysis. Sensation and deep tendon reflexes remain intact. Respiratory muscle weakness is common and can be fatal. The introduction of practical mechanical ventilation has resulted in a dramatic decrease in the mortality rate.

Although the clinical features of myasthenia gravis aresufficiently characteristic in some cases, confirmatory testsare usually necessary [2]. The acetylcholine receptor (AchR)-antibody level is elevated in over 80% of patients with myastheniagravis. Elevated levels of this antibody are extremelyspecific for this disease [3]. As a result the AchR-antibodyserum test is typically the first step in confirming the diagnosis,and the presence of elevated levels eliminates the need foradditional confirmatory testing. In antibody-negative patientsor when faced with an acutely symptomatic patient, the edrophoniumtest is often used. Electrodiagnostic studies (repetitivenerve stimulation and single fiber electromyography) areoften useful, particularly in antibody-negative patients orpatients with cardiac disease or asthma, in whom edrophoniumis relatively contraindicated. The characteristic findingon 2- to 3-Hz repetitive motor nerve stimulation is a progressivedecrease in the amplitude of the motor response. Singlefiber electromyography may reveal the presence of jitter orblocking (a difference in the timing of activation or a failure of neuromuscular transmission in one of a pair of muscle fiberswithin a motor unit).

Introduction

The acute confusional state known as delirium is the most common cause of altered mental status in surgical patients. The cardinal feature of delirium is an alteration in the level of consciousness that fluctuates over time. Despite its common occurrence delirium can often go unrecognized, leading to delays in treatment. This can have significant implications as patients with delirium suffer from higher postoperative complication rates, longer lengths of stay, and delayed functional recovery [1].

Delirium is usually acute in onset but may develop gradually. It can persist for hours to days and can fluctuate throughout the course of a day. A clouding of consciousness is most common but patients can also show hyperalert, irritable, or agitated behavior. The sleep–wake cycle is often markedly disrupted. Sleep is usually fragmented, with restlessness and agitation. Psychomotor abnormalities may range from hyperactivity to lethargy, stupor, obtundation, and catatonia. Most cases of delirium improve or resolve within 1–4 weeks if sufficient attention is given to correcting the underlying disorder causing the cerebral dysfunction. However, the development of delirium, particularly in frail, elderly patients is a marker for progressive decline [2].

Ventral hernias encompass a wide variety of abdominal wall defects, including incisional, epigastric, umbilical, and spigelian types; for the purposes of this chapter, the term ventral hernia is restricted to the incisional type. A ventral hernia with a small ring predisposes patients to incarceration and possible strangulation of a segment of small or large intestine. Patients with significant ascites are at risk for rupture of a ventral hernia if there is only skin covering the defect. Patients with large ventral hernias have difficulty wearing regular clothing and are often embarrassed by their appearance. Not infrequently, these hernias can be associated with abdominal pain; however this is not universally true. It is also possible for patients to suffer obstructive symptoms such as abdominal distension, nausea, or vomiting if there is involvement of the intestinal loops in the hernia defect. In patients with very large incisional hernias, there is lateral displacement of the abdominal wall muscles which leads to very poor function of the abdominal wall and resultant issues with back pain, difficulty with mobility, and loss of intra-abdominal domain. For these reasons, elective repair of ventral hernias is indicated in patients who are healthy enough to undergo mechanical bowel cleaning and general anesthesia.

Over 100,000 ventral hernia repairs are performed in the USA each year. Hernias are a complication that can occur in up to 5% of patients undergoing abdominal surgery; these rates are potentially much higher in obese patients, those taking steroids, or smokers. Patients who suffer a wound infection at the time of the initial operation are also at greatly increased risk of developing incisional hernias since the entire fascial closure often heals improperly and, in many cases, the hernia can be quite large. The finding of an incisional hernia is one of the most common reasons for consultation in general surgical clinics.

Intra-abdominal adhesions are the most common reason for mechanical small bowel obstruction (SBO) and are implicated in infertility and complex abdominal and pelvic pain. Recent studies suggest that 10% of patients who have undergone colectomy will be re-admitted for SBO within 3 years. The annual cost of managing this condition is well over 1 billion dollars.

Hyaluronate/carboxymethyl cellulose (Seprafilm), oxidized regenerated cellulose (Intercede), and other agents are available to attempt to limit postoperative adhesion formation. These agents have been shown to reduce adhesion formation, but have not been proven to decrease the incidence of SBO. Furthermore, there is a possible link to an increased incidence of anastamotic leak. Thus, utilization of these products varies by institution and surgeon. Other techniques that have been shown to decrease postoperative adhesion include a laparoscopic approach, minimization of foreign material (sutures/mesh), and use of powder-free gloves.

Patients usually present with nausea and emesis if theobstruction is complete. If the obstruction is only partial, patientsmay have less severe symptoms and may still be passing flatus.Many patients are profoundly dehydrated and hypokalemic andrequire significant resuscitation and electrolyte repletion.Patients with limited cramping and abdominal distension, andno signs of peritonitis, often benefit from fluid and electrolyterepletion, nasogastric tube decompression and observation. Thisapproach may allow laparotomy to be avoided, but mandatesclose observation for signs of threatened bowel. Patients with arising white blood cell count, fever, peritonitis, and persistent orincreasing pain (possible closed loop obstruction) will likely needsurgical exploration. Obstructed small bowel may becomeischemic or necrotic without classical signs and symptoms; whena non-operative approach is taken, serial evaluations and a highindex of suspicion are necessary.

The femur is the largest bone in the body and has a large soft tissue muscle mass surrounding it. The femoral shaft includes the region 5 cm below the lesser trochanter and 9 cm above the knee joint, and is termed the diaphysis. The estimated incidence of fractures of the femoral shaft in the USA is around one fracture per 10,000 persons per year. There is a bimodal age distribution of femur fractures with one peak in the 20s and one peak in the 60s.

Most femur fractures tend to occur secondary to high-energy trauma such as motor vehicle accidents, pedestrians struck by vehicles, falls from a height, or gunshots. The force required to fracture a femur may also cause a multitude of other associated injuries, most commonly to the head and chest. Therefore, a thorough and complete evaluation by a systematic protocol is warranted followed by any needed resuscitation. High-energy femoral shaft fractures may lose up to 1–3 units of blood into the thigh musculature causing hemodynamic instability, so close monitoring is indicated.

Introduction

In the USA, blood transfusion is the most common procedure performed in hospitals [1]. Component therapy is the preferred method of blood administration, as it allows blood transfusion to be individualized to the patient's specific needs. Blood components include red cells, platelets, plasma, and cryoprecipitate. Although transfusion is often essential to effective patient care, it is not without risk. Blood transfusion is associated with multiple adverse outcomes, including both non-infectious and infectious complications. Thus, benefits and risks of transfusion must be considered for each patient.

Maximum surgical blood order

A maximum surgical blood order schedule (MSBOS) is used to predict surgical blood needs and to reserve blood products for transfusion for surgery. A MSBOS is created by reviewing institutional blood utilization for each type of surgical procedure and usually set at the number of products required for 80–90% of the procedures. The MSBOS will dictate if either a type and screen (T/S) or a type and cross (T/C) is indicated, as well as the number and type of blood products to be reserved for a particular surgical procedure.

The palatine tonsils, pharyngeal tonsils (adenoids) and lingual tonsils together comprise a ringed, lymphoid tissue complex within the naso- and oropharynx known as Waldeyer's ring. This structure is known to be involved in inducing secretory immunity and regulating secretory immunoglobulin production. Both the adenoids and the tonsils are subject to infection. They can be potential contributors to upper airway obstruction due to hypertrophy. The number of adenotonsillectomies has been decreasing over the last 60 years. Historically, recurrent tonsillitis was the most common indication for adenotonsillectomy. Though this remains an indication for surgical intervention, airway obstruction secondary to adenotonsillar hypertrophy is currently the most common indication. Manifestations of such obstruction fall within the spectrum of sleep-disordered breathing ranging from primary snoring (PS) to upper-airway resistance syndrome (UARS) to obstructive sleep apnea syndrome (OSAS).

Depending on the extent of adenotonsillar hypertrophy, obstructive symptoms can include loud snoring, chronic mouth breathing, hyponasal speech, frequent night-time awakenings, enuresis, parasomnias, daytime somnolence, poor school performance, dysphagia, failure to thrive, and witnessed apneic episodes. On physical exam, adenotonsillar visualization should be performed as well as a speech evaluation to assess for the presence of hyponasality secondary to nasal obstruction. In addition, craniofacial structures should be noted to assess for the stigmata of adenoid facies associated with chronic mouth breathing. The need for preoperative polysomnographic testing to diagnose OSAS should be based primarily on the history and physical examination. Patients with adenotonsillar hypertrophy, clinical stigmata of OSAS, and a history of loud snoring with witnessed obstructive apneic events may be considered for polysomnographic testing. However, this may not always be necessary before proceeding with surgery, and such symptomatology should warrant overnight hospital observation. If the physical examination is inconsistent with the patient's history, preoperative testing should be performed. In addition, polysomnographic testing should be strongly considered for patients with high perioperative risks, including children less than 3 years of age; obese patients; patients with craniofacial anomalies, neuromuscular, or neurologic disease; and patients with other medical conditions (e.g., bleeding diatheses, sickle cell disease, or substantial pulmonary disease) that may complicate postoperative management. The apnea–hypopnea index (AHI), peak end-tidal CO2 and severity of oxygen desaturation are useful data recorded during testing. Based on polysomnography, an AHI of ≥ two events per hour with a clinical history consistent with sleep-disordered breathing is appropriate evidence to proceed with adenotonsillectomy.

The hip joint is a constrained ball and socket joint capable of withstanding repeated forces in excess of ten times body weight. The articulating surfaces of the femoral head (the ball) and the acetabulum (the socket) are covered with articular cartilage which allows smooth and painless motion. Pain, stiffness, and declining function due to cartilage and bone damage in the hip joint are the primary indications for total hip arthroplasty. Most commonly, these symptoms are the result of osteoarthritis, but can also occur with inflammatory arthritis (e.g., rheumatoid arthritis), bone death (e.g., avascular necrosis) or the sequelae of traumatic injury (e.g., previous fracture). It is now recognized that most cases of hip osteoarthritis are a result of subtle variations in the shape of the femoral head and/or acetabulum. These variations result in hip impingement (abnormal contact forces across the joint that eventually result in destruction of articular cartilage).

When the symptoms of hip arthritis are no longer responsive to conservative measures including medication and reduction in hip joint force (e.g., weight loss or use of a cane), total hip arthroplasty may produce dramatic improvements in pain management, function, and quality of life. The operation is performed through an incision over the outside of the hip. The joint is exposed and an osteotomy (bone cut) in the femoral neck allows removal of the femoral head from the acetabulum. The acetabulum is prepared to accept a hemispherical metal socket. A hemispherical socket liner is then snapped into the socket. The hollow canal of the femur bone is prepared to accept a metal stem. A ball that perfectly matches the shape and size of the liner of the socket is attached to the top of the stem. The soft tissues around the hip are then repaired and protected while they heal.

As in all fields of surgery, the current trend in neurosurgery is towards less-invasive procedures and the shorter hospital stays that result from them. Therefore, stereotactic techniques are an indispensable tool for the modern neurosurgeon and have been dramatically improved by the recent revolution in digital image guidance technology. These techniques provide a relatively straightforward, accurate, and safe method to approach intracranial targets that are defined by either anatomical or functional characteristics. Anatomically defined targets include brain tumors and abscesses, as well as other structural lesions. Targeting for anatomical disorders relies entirely on patient-specific anatomy derived from radiographs (e.g., ventriculography, rarely used today) or tomograms (e.g., CT, MRI) for localization. In addition, functional imaging modalities (e.g., fMRI), metabolic imaging modalities (e.g., positron emission tomography (PET)), and MR spectroscopy can be utilized in conjunction with other imaging modalities to help with target planning and visualization. Functionally defined structures include the various nuclei of the basal ganglia and thalamus that are targeted for pain and movement disorders (e.g., Parkinson's disease, essential tremor, and dystonia), as well as other conditions such as obsessive-compulsive disorder. Targeting for functional disorders typically combines computerized imaging with intraoperative electrophysiological mapping for localization, although anatomical techniques can be used alone as well.

Because thyroid hormones exert regulatory effects on multiple organ systems, thyroid function should be aggressively evaluated and abnormal function treated in patients who require surgery. Thyroid hormones also significantly affect the metabolism of many drugs, and dose adjustments may be required when function is abnormal. Medical consultants performing preoperative evaluations should include clinical assessments of thyroid function and perform confirmatory tests when indicated.

The adult thyroid gland weighs 15–20 g, typically consists of two lobes connected by an isthmus, and is located just below the cricoid cartilage. A remnant of the thyroglossal duct, the pyramidal lobe may be noted arising superiorly from the isthmus or medial side of a lobe. Enlargement of the pyramidal lobe indicates a diffuse thyroidal abnormality. The thyroid gland consists of follicles, which are spheres lined by a single layer of cuboidal cells and are filled with a colloid that is composed primarily of thyroglobulin. A rich capillary network surrounds the follicles, explaining why a bruit is sometimes heard over hyperactive, enlarged thyroid glands. Scattered throughout the thyroid are calcitonin-secreting perifollicular cells. Hyperplasic or malignant transformation of these cells does not result in abnormalities of thyroid function [1–3].

Small bowel resection is performed in a variety of settings, the most common of which are traumatic perforation, thrombotic or embolic infarction, Crohn's disease, and concomitant colectomy. Less common indications for resection include benign or malignant neoplasms (leiomyoma, hemangioma, carcinoid, lymphoma, adenocarcinoma, sarcoma), fistula resulting from a previous repair or resection, symptomatic Meckel's diverticulum, neutropenic enterocolitis, and spontaneous perforation in immunosuppressed patients.

The most significant change in the operative management of small bowel disease in recent years has been the increasing use of laparoscopic approaches. In patients with inflammatory small bowel disease, laparoscopic operations now include diversion for complex fistula, take-down of end or loop stoma, segmental resection, stricturoplasty, and lysis of adhesions. Conversion rates to an open approach have ranged from 2–40% in series published since 1993, with the majority of conversions being secondary to dense adhesive disease or excessive intra-abdominal inflammation.

Open segmental resection and end-to-end anastomosis withsuture or staples usually can be performed in 20 minutes. Simplelaparoscopic segmental small bowel resection can be accomplishedin under an hour. Major laparoscopic resections, particularlythose involving the colon in addition to the small bowel,generally take 2–5 hours. Resection of a wide section of accompanyingmesentery is only required for malignant neoplasm andnot in cases of benign disease. With the exception of resectionsperformed for a neoplasm in the adjacent right colon, mostresections of the small bowel for trauma, infarction, or inflammatorybowel disease cause moderate to severe stress. Generalanesthesia is used, the duration of the procedure depends on theindication, and blood transfusions are necessary only in patientswith trauma, extensive inflammation, or infiltrating neoplasms.

Introduction

Venous thrombosis is a major cause of disability and death in all patient populations. Autopsy studies of hospitalized patients have demonstrated that massive pulmonary embolism (PE) is the cause of death in 5–10% of all hospital deaths and have suggested that two-thirds of all clinically important venous emboli are never recognized during life [1,2]. In a large multi-center study, 30,827 surgical patients were evaluated with respect to venous thromboembolism (VTE) risk and appropriate prophylaxis as recommended by the American College of Chest Physician (ACCP). This study showed that 19,842 surgical patients were considered at risk for VTE but only 11,613 (58.5%) received appropriate ACCP-recommended VTE prophylaxis [3]. More recently, the Surgical Care Improvement Project selected the application of VTE prophylaxis as a nationally reported metric for preventing VTE [4]. The purpose of this chapter is to review the pathophysiology of perioperative deep vein thrombosis (DVT), assess preoperative VTE risk and review the modalities of prophylaxis for preventing postoperative VTE in surgical patients.

Pathophysiology

The pathophysiologic changes of stasis, intimal injury, and hypercoagulability predispose surgical patients to the development of DVT or PE. The supine position on the operating room table, the anatomic position of the extremities for some surgical procedures, and the effect of anesthesia all contribute to stasis during surgery. Venographic contrast studies have shown that the supine position on the operating table decreases venous return [5,6]. In orthopedic, gynecologic, and urologic surgeries, the anatomic position of the body that provides the best surgical access to the operative site impairs adequate venous drainage during the procedure [7]. For example, in total hip replacement and hip fracture repair, the flexion and adduction of the hip that is required for better anatomic access to the surgical field has been shown to impair venous return [7]. Anesthesia causes peripheral venous vasodilation, which results in increased venous capacitance and decreased venous return during the operative procedure [8–10].

Glaucoma is the most common cause of optic neuropathy. Many ocular conditions may lead to the development of glaucomatous nerve damage. In general, therapeutic interventions are directed towards lowering intraocular pressure, a key risk factor for disease progression.

Typically, therapy begins with topical medications, the first and simplest option. These include the prostaglandin analogs, beta adrenergic receptor blockers, carbonic anhydrase inhibitors, alpha adrenergic agonists, and miotics. These agents are used alone or in combination, and are often sufficient to control intraocular pressure. In cases of open-angle glaucoma, laser trabeculoplasty may also be used to lower intraocular pressure. Laser interventions are performed in the clinic either alone or in combination with medical therapy. For cases of angle-closure glaucoma, laser iridotomy may be performed to either treat or prevent pupillary block (iris-lens diaphragm obstruction), an anatomic predisposition that is responsible for the majority of cases. Cyclodestructive surgery (intentional destruction of the ciliary body tissues) is another laser procedure that may be used when other interventions have failed, including incisional surgery. These procedures, which are usually performed in the clinic under local anesthesia, are commonly performed with lasers and, less commonly, cryotherapy.

Introduction

Surgical and anesthetic care have improved markedly in the last half century. It is likely that the greatest benefit of this improvement has been for the elderly population. Older patients can benefit from surgery that would not have been contemplated in the past; thus, patients are living longer and with a better quality of life than ever before.

The literature in surgical care of the elderly patient is extensive and growing rapidly, and indicates that with careful planning and care, the elderly can undergo surgery safely and with approximately the same risk as many younger patients. This section discusses the following topics as they pertain to the elderly population: (a) physiologic decrements of aging; (b) risks of surgery; (c) preoperative evaluation; (d) anesthesia; (e) common surgical procedures; and (f) postoperative care.

Physiologic decrements of aging

Although physicians see many elderly patients who appearold and sick with many underlying health problems, a largepercentage of the elderly population is quite well. These peoplecan function entirely normally and have no limitations to theiractivities. Despite this degree of functional normality, however,all older people experience various decrements in physiologicfunction that are of importance in planning their care, particularlywhen they are under stresses such as surgery [1]. Thesedecrements make even healthy older patients more fragile andmore likely to suffer postoperative complications and deaththan their younger counterparts [2–4]. Physicians must takethese factors into account in their evaluations.

Both in the USA and worldwide, the most common cause of mitral valve pathology in adults is rheumatic fever (RF). Postrheumatic structural changes to the mitral valve typically occur over the 2–10 years following infection, with symptoms appearing over the subsequent 5–10 years. In descending order, secondary etiologies include myxomatous degeneration, endocarditis, idiopathic annular calcification, connective tissue disorders (Marfan syndrome and Ehlers–Danlos syndrome), and hypertrophic cardiomyopathy; however, mitral stenosis (MS) is almost exclusively attributable to rheumatic fever. The onset of decompensated heart failure in MS patients is typically presaged by decreased exercise tolerance with progressive dyspnea secondary to low cardiac output, pulmonary hypertension, and decreased lung compliance. Timely operative intervention early in the symptomatic period can completely reverse heart failure. Mitral regurgitation (MR), where the valve is almost purely regurgitant, is also caused by RF. Ischemic MR is present in up to 20% of patients with coronary artery disease (CAD) requiring operative coronary artery bypass (CAB), and infrequently involves the catastrophic event of ruptured papillary muscle.

Carotid endarterectomy (CEA) is the most commonly performed procedure to prevent stroke, with approximately 99,000 operations performed nationally in 2006. Over the last decade, carotid artery stenting (CAS) has emerged as a minimally invasive alternative to CEA. Recent results from the CREST trial suggest that stroke and death occur less frequently with CEA; however, myocardial infarction occurs more frequently with CEA. While CEA remains the gold-standard therapy, many interventionalists continue to reserve CAS for “high-risk” patients, as defined by anatomic and/or medical criteria.

Usual postoperative course

Expected postoperative hospital stay

Since complications from either procedure typically occur within the first 12–24 hours, patients are usually discharged within the first 1–2 days following the operation.

Operative mortality

Mortality following CAS or CEA is less than 1%, and is mostlydue to complications of stroke or myocardial infarction.

Special monitoring required

Patients in the post-anesthesia care unit are monitored with anarterial line for a period of 2–4 hours to assess for widefluctuations in blood pressure. Ideally, the patient’s postoperativeblood pressure should be similar to the preoperative bloodpressure. If medications are required to maintain a patient’sblood pressure, he/she is then transferred to the ICU for 24hour monitoring and appropriate anti-hypertensive or vasopressormedication administration.

As mentioned in the Introduction, consultation has been a topic of discussion at least since the time of Hippocrates; the introduction also discusses a number of the moral, ethical, and interpersonal minefields in the process.

In this chapter, however, my purpose is to discuss the functional process of consultation so that other problems and obstacles can be avoided. The chapter is primarily addressed to clinicians doing consultations for surgical patients, both preoperative evaluations and postoperative management.

Perhaps the most useful and concise recommendations forconsultation were developed by Goldman and Rudd in 1983 in apaper entitled “Ten commandments for effective consultation”in the Archives of Internal Medicine [1]. These recommendationswere: (1) determine the question; (2) establish urgency; (3)look for yourself; (4) be as brief as appropriate; (5) be specific;(6) provide contingency plans; (7) honor thy turf; (8) teach withtact; (9) talk is cheap and effective; (10) follow up. I will addressall of these commandments as we proceed.

For the consulting physician: A number of papers haveidentified one of the common and problematic difficulties inpreoperative consultation. Consulting physicians frequentlydon’t identify what problem or problems the consultant issupposed to address. It is crucial for the care of the patient(and for more pragmatic billing purposes) for any problemsto be identified. The most common consulting error is thereferral for “surgical clearance.” Clearance for surgery impliesthat the consultant can identify which patients will or will notsurvive surgery, a task that requires more celestial talent thanmost consultants possess. “Preoperative evaluation” and “riskstratification” imply that there are reasons to think that thepatient is at increased risk; if no problem can be identified, thenthere is no medical (or reimbursable) reason for consultation.Identifiable reasons (e.g., hypertension, diabetes, congestiveheart failure) should be the consulting problem or problems.