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Perioperative Medicine for the Junior Clinician, Enhanced Edition E-Book

Joel Symons

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Herausgeber: John Wiley & Sons
Kategorie: Fachliteratur
Sprache: Englisch

Beschreibung

Perioperative Medicine for the Junior Clinician is the first easy-to-read, digital resource on how to manage a diverse range of patients in the perioperative period, providing up-to-date practical knowledge and advice from a broad range of medical specialists caring for surgical patients.

Perioperative Medicine for the Junior Clinician provides a guide to perioperative care, covering principles and practices of care; risk assessment; laboratory investigations; medication management; specific medical conditions and complications; postoperative care and pain management. Ideal for final year medical students and junior clinicians, this digital resource will be an invaluable tool when working in this multidisciplinary, team-based specialty.

The enhanced eBook features bite-size videos further explaining key concepts which have been embedded for ease of reference. Complete with additional resources such as case studies, investigations and quizzes, this enables the eBook to be either a source of ready reference or in-depth information on perioperative care.

Perioperative Medicine for the Junior Clinician:

Is based on a sell-out course run at the Alfred Hospital and Monash University in Melbourne, Australia
Is a practical resource available in flexible and portable content
is structured around guidelines and protocols
Features clinically relevant case studies which allow the reader to synthesize and apply pre-learned information and apply it to a clinical situation
Includes several self-assessment quizzes with full explanations to answers

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Seitenzahl: 896

Veröffentlichungsjahr: 2015

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Leseprobe

Cover

Title Page

Contributors (Online Only)

Foreword

Preface

Acknowledgements

Abbreviations (Online Only)

About the companion website

Part I: Introduction

1 The role of the perioperative medicine physician

The scope of perioperative medicine

Clinical data

The future

References

2 The role of the preadmission clinic

Patient assessment

Risk factor identification and management, and patient optimisation

Improve safety and quality of patient care

Improve hospital efficiency

Patient support, education and awareness

Record keeping and research

References

3 Consent

Ethical and legal basis of consent

Elements of a valid consent

Consent by junior doctors

Documenting consent

Special circumstances

References

4 The early postoperative round

Establish rapport

Scan the record

Take a history

Examine the patient

Troubleshoot the basics

Manage pain effectively

Detecting deterioration

Communicate with other staff and formulate an early postoperative plan

References

5 Quality improvement and patient safety

Introduction

The individual and the system

Safety of the perioperative patient

Quality improvement

Individual factors

Team training

Organisational and regulatory factors

References

6 Intraoperative and postoperative monitoring

Cardiovascular system

Respiratory system

Cerebral monitoring

Major organ function

References

7 Drugs used for anaesthesia and sedation

Definitions

Mechanism of action of anaesthetic and sedative drugs

Basic pharmacological concepts

Medications used as sole anaesthetic agents

Sedative agents

References

8 The recovery room

What is the recovery room?

Design of the recovery room [1]

Monitoring, equipment and drugs

Recovery room staff

Handover of care to the recovery room staff

Management of patients in the recovery room

Common management issues in the recovery room

Discharge of patients from the recovery room

References

9 Perioperative genomics

Perioperative genomic investigations

Pharmacogenomics and altered drug response (clopidogrel)

Epigenomics and chronic pain

Perioperative biobanks

References

Part II: Preoperative risk assessment

10 Perioperative medication management

Cardiovascular medications

Aspirin and other antiplatelet drugs

Warfarin and other anticoagulants

Corticosteroids

Antidepressants

Antiepileptics

Antiparkinson medications

Chronic opioid therapy

Herbal medications

References

11 The cardiac patient for non-cardiac surgery

Preoperative assessment

Intraoperative management

Postoperative care

References

12 Cardiovascular risk assessment in cardiac surgery

Scoring systems

Practical application

Conclusion

References

13 Preoperative cardiac testing

Which patients require preoperative cardiac testing?

Functional capacity

Assessment of cardiac structure and function

Assessment of coronary artery disease and myocardial ischaemia

References

14 Airway assessment and planning

Physical assessment

References

15 Pulmonary risk assessment

Clinical features associated with PPC

Patient-related factors

Surgery-related factors

Scoring systems to predict PPC

Conclusion

References

16 Preoperative cardiopulmonary exercise testing

History

Preoperative rationale

Physiological background

Conduct of the CPET test

References

17 Anaemia

Patient blood management

Preoperative optimisation of anaemia

Intraoperative management of anaemia

Postoperative optimisation of anaemia

References

18 Central nervous system risk assessment

Parkinson’s disease

Multiple sclerosis

Headache

References

19 Risk assessment for perioperative renal dysfunction

Aetiology

Epidemiology

Risk factors for perioperative AKI

Diagnostic challenges

Prevention and treatment

Management of perioperative AKI

References

20 Medical futility and end-of-life care

Definitions

Medical futility

Misconceptions

Obligations of the treating doctor

Conclusion

References

21 The surgical safety checklist

Development of a surgical safety checklist

The WHO checklist

References

Part III: Perioperative investigations

22 Preoperative investigations (non-cardiac surgery)

Common preoperative investigations

Specific tests

References

23 Postoperative investigations

Bedside tests

Blood tests

Transthoracic echocardiogram (TTE)

Computed tomography (CT scan)

Conclusion

List of Tables

Chapter 06

TABLE 6.1 Typical regimes for intra- and postoperative monitoring for patients undergoing general anaesthesia for major and minor surgery

Chapter 07

TABLE 7.1 Use of different sedative/anaesthetics by anaesthetists (full operations, endoscopies)

Chapter 10

TABLE 10.1 Recommendations for perioperative medication management

Chapter 107

TABLE 107.1 FBE

TABLE 107.2 Coagulation profile

TABLE 107.3 Serial full blood examinations

TABLE 107.4 Serial full blood examinations

TABLE 107.5 Coagulation profile

TABLE 107.6 Coagulation profile

Chapter 108

TABLE 108.1 Biochemistry

TABLE 108.2 Biochemistry

TABLE 108.3 Biochemistry

TABLE 108.4 Biochemistry

TABLE 108.5a Biochemistry

TABLE 108.5b Liver function tests

TABLE 108.6a Biochemistry

TABLE 108.6b Liver function tests

Chapter 109

TABLE 109.1 Spirometry results

TABLE 109.2 Spirometry

TABLE 109.3 Spirometry

Chapter 11

TABLE 11.1 Surgical risk estimate. Risk of myocardial infarction and cardiac death within 30 days after surgery

Chapter 12

TABLE 12.1 Canadian Cardiovascular Society angina scale [5]

Chapter 14

TABLE 14.1 Core elements of airway assessment

TABLE 14.2 Modified Cormack and Lehane Classification of Direct Laryngoscopy [7]

TABLE 14.3 High-risk factors for airway management

TABLE 14.4 Factors that may indicate increased difficulty with different airway management strategies

Chapter 17

TABLE 17.1 NHMRC practice guidelines for red cell transfusion

Chapter 19

TABLE 19.1 Acute kidney injury definition and staging

Chapter 20

TABLE 20.1 Perioperative factors associated with increased 30-day postoperative mortality (% 30-day mortality)

Chapter 22

TABLE 22.1 Components of the FBE, normal range and indication for each

Chapter 24

TABLE 24.1 Caprini risk assessment model

TABLE 24.2 Recommendations for thromboprophylaxis in various risk groups

TABLE 24.3 Suggested risk stratification for perioperative thromboembolism

Chapter 25

TABLE 25.1 Suggested dose of Prothrombinex-VF to reverse the anticoagulant effect of warfarin according to initial and targeted INR

TABLE 25.2 The CHADS

and CHA

-VASc risk stratification scores for subjects with non-valvular AF

TABLE 25.3 Does my patient need bridging therapy?

TABLE 25.4 Management of patients on warfarin therapy undergoing invasive procedures

TABLE 25.5 Preoperative interruption of direct-acting oral anticoagulants

TABLE 25.6 Pharmacokinetics of anticoagulants in patients with normal creatinine clearance

Chapter 26

TABLE 26.1 Oral hypoglycaemic agents

TABLE 26.2 Pharmacokinetics of subcutaneous injectables used for diabetes

Chapter 27

TABLE 27.1 Glucocorticoid management for various procedures

Chapter 29

TABLE 29.1 Examples of recommended antibiotics for use in selected surgical procedures

TABLE 29.2 Characteristics of antibiotics commonly used for surgical prophylaxis

Chapter 30

TABLE 30.1 Examples of recommended regimens for patients with a cardiac condition (Box 30.1) undergoing a high-risk procedure (see Box 30.2)

Chapter 32

TABLE 32.1 Suggested options to treat perioperative hypertension

Chapter 34

TABLE 34.1 Generic pacemaker and implanted cardioverter-defibrillator (ICD) codes

TABLE 34.2 Management of a patient with an unknown type of pacemaker or ICD

Chapter 35

TABLE 35.1 Epidemiology and aetiology of heart failure

TABLE 35.2 Clinical evaluation of heart failure

TABLE 35.3 Preoperative investigations in patients with suspected heart failure

Chapter 36

TABLE 36.1 Severity of aortic stenosis

Chapter 38

TABLE 38.1 Causes of myocarditis

TABLE 38.2 Features of specific cardiomyopathies

Chapter 39

TABLE 39.1 ARDS diagnostic criteria and mortality prediction

TABLE 39.2 Common causes of acute lung injury

TABLE 39.3 Initial ventilator settings in ALI

TABLE 39.4 Common rescue therapies used in ALI/ARDS

Chapter 40

TABLE 40.1 Severity of obstructive sleep apnoea

Chapter 41

TABLE 41.1 Assessing asthma control

TABLE 41.2 Risk factors for future asthma exacerbation and fatal asthma attack

TABLE 41.3 Common asthma triggers

TABLE 41.4 Stepwise approach to asthma management

TABLE 41.5 Management of acute asthma exacerbation

Chapter 42

TABLE 42.1 Surgery in chronic obstructive pulmonary disease (COPD) patients: the ‘to do’ list

TABLE 42.2 Anaesthetic, chronic obstructive pulmonary disease (COPD) and functional class severity assessments

Chapter 43

TABLE 43.1 Stage-dependent treatment for non-small cell lung cancer

TABLE 43.2 Lung function measures as predictors of postoperative respiratory compromise

TABLE 43.3 Thoracoscore risk factors for prediction of perioperative mortality in thoracic surgery

TABLE 43.4 Comparison of complication rates following resection for early-stage NSCLC [9]. VATS conversion to open thoracotomy rate 17.6%

Chapter 45

TABLE 45.1 Child Turcotte Pugh Score (CTP) and associated mortality

Chapter 48

TABLE 48.1 Immunosuppressive agents used after renal transplantation

Chapter 50

TABLE 50.1 The prevalence of thyroid disease in the population

TABLE 50.2 The prevalence of thyroid antibodies in health and disease

TABLE 50.3 Alterations in thyroid hormone and TSH levels in various conditions

Chapter 51

Table 51.1 Aetiology, biochemistry and perioperative management of patients with parathyroid disorders

Chapter 53

TABLE 53.1 Presentation of carcinoid syndrome

TABLE 53.2 Somatostatin analogues currently in clinical use

TABLE 53.3 Side effects of somtatostatin analogues

Chapter 54

TABLE 54.1 Factors specific to pathology of lesion

Chapter 55

TABLE 55.1 Specific investigations used in planning carotid procedures

TABLE 55.2 Early postoperative complications and their management

Chapter 57

TABLE 57.1 Neuromuscular disease classifications

Chapter 58

TABLE 58.1 American College of Surgeons advanced trauma life support (ATLS) classification of blood loss based on initial patient presentation

Chapter 59

TABLE 59.1 Modified Glasgow Coma Scale (GCS) score

Chapter 60

TABLE 60.1 Maxillofacial injuries and relevant clinical symptoms and signs

Chapter 62

TABLE 62.1 Spine injury characteristics of 965 trauma patients with spine injuries seen at the Alfred Hospital, Melbourne from 1 May 2009 to 1 January 2011

TABLE 62.2 Subaxial Cervical Spine Injury Classification System (SLIC)

Chapter 65

TABLE 65.1 The Parkland Formula

TABLE 65.2 Signs and symptoms of carbon monoxide poisoning

Chapter 66

TABLE 66.1 Von Willebrand disease

Chapter 67

TABLE 67.1 Summary of the different types of ART drugs currently available

Chapter 68

TABLE 68.1 Recommended follow-up schedule for healthcare workers

Chapter 70

TABLE 70.1 Maternal and fetal goals

TABLE 70.2 Physiological considerations during pregnancy

TABLE 70.3 Pregnancy outcomes following non-obstetric surgery [4]

Chapter 73

TABLE 73.1 Classification of adults according to Body Mass Index (BMI)

Chapter 74

TABLE 74.1 Perioperative factors that reduce oxygen delivery

Chapter 75

TABLE 75.1 Concentration of ions in commonly used IV fluids

Chapter 76

TABLE 76.1 Causes of hypokalaemia

TABLE 76.2 Causes of hyperkalaemia

TABLE 76.3 Consequences of potassium derangements

TABLE 76.4 Oral potassium supplements

TABLE 76.5 Drug treatment of hyperkalaemia

Chapter 77

TABLE 77.1 ABO blood groups

TABLE 77.2 Emergency provision of red cells

TABLE 77.3 Transfusion reactions

Chapter 78

TABLE 78.1 Clinical tests. All brainstem reflexes must be absent in order to determine brain death

TABLE 78.2 Modalities for radiological brain death determination; not all are approved for this purpose [1,3–6]

TABLE 78.3 Care of the potential donor: management goals

Chapter 79

TABLE 79.1 Risk factors associated with postoperative nausea and vomiting (PONV)

TABLE 79.2 An adult ponv scoring system [3]

TABLE 79.3 A paediatric ponv scoring system: Postoperative Vomiting in Children (POVOC) score (for use in children) [10]

TABLE 79.4 First-line antiemetic agents

TABLE 79.5 Second-line antiemetic agents

Chapter 80

TABLE 80.1 Components and pH of different intravenous fluids

TABLE 80.2 Traditional estimates of fluid requirements

Chapter 84

TABLE 84.1 Patient factors affecting wound healing

TABLE 84.2 Technical aspects of wound closure that affect wound healing

Chapter 85

TABLE 85.1 Causes of chest pain and their corresponding clinical symptoms

Chapter 86

TABLE 86.1 An approach to common differential diagnoses for postoperative breathlessness

TABLE 86.2 An approach to rarer differential diagnoses for postoperative breathlessness

Chapter 87

TABLE 87.1 Aetiology of hypotension

TABLE 87.2 Drug therapy for the hypotensive patient

Chapter 88

TABLE 88.1 Clinical outcomes at 30 days after non-cardiac surgery in patients suffering MINS

TABLE 88.2 Thirty-day mortality rates in patients suffering MINS

Chapter 90

TABLE 90.1 Cognitive tests and neuropsychological domains commonly employed to detect POCD

Chapter 91

TABLE 91.1 Postoperative inflammatory response/sepsis characteristics

TABLE 91.2 Drug-induced hyperthermic syndromes

TABLE 91.3 Presentation of malignant hyperthermia [5]

Chapter 92

TABLE 92.1 Stages of hypothermia. Signs may vary in onset. Temperature thresholds are arbitrary

Chapter 93

TABLE 93.1 Typical postoperative evaluations

TABLE 93.2 Postoperative pain evaluation reviewing effects of treatment

TABLE 93.3 Commonly used analgesics

Chapter 95

TABLE 95.1 Incidence of persistent postsurgical pain after common procedures [2,3]

Chapter 97

TABLE 97.1 Primary survey of the thorax and breathing during the initial assessment of the severely injured adult

Chapter 99

TABLE 99.1 Differential diagnoses of acute opioid withdrawal syndrome

List of Illustrations

Chapter 02

VIDEO 2.1 Roles of the preadmission clinic. The modern preadmission clinic fulfils a vital role in the perioperative management of patients.

Chapter 06

VIDEO 6.1 Invasive arterial pressure monitoring can provide real-time information where blood pressure may fluctuate rapidly in a beat-to-beat fashion. Additionally, serial sampling for blood gas analysis can occur with invasive arterial monitoring.

FIGURE 6.1 The components of haemodynamic assessment. Measurement of cardiac output (CO), mean arterial pressure (MAP) and central venous pressure (CVP) allows calculation of systemic vascular resistance (SVR). These can be manipulated with appropriate combinations of fluid and volume resuscitation, or use of vasoactive drugs.

VIDEO 6.2 Pulse oximetry.

VIDEO 6.3 Capnography allows monitoring of the ventilation, cardiac output and metabolic state of a patient.

VIDEO 6.4 Awareness monitoring by processed electroencephalography allows monitoring of the amounts of anaesthesia agents as well as minimising intraoperative awareness.

Chapter 08

FIGURE 8.1 Modern recovery rooms provide a location for monitoring of the patient in the immediate postoperative period.

Chapter 09

VIDEO 9.1 Polymerase chain reaction (PCR) and microkit analysis provide a way of rapidly identifying genetic sequences that can be of use in perioperative genomics.

FIGURE 9.1 Epigenetic mechanisms. (A) Chromatin is made up of DNA wrapped around histone proteins. (B) Histone proteins may be modified through several processes including acetylation (Ac). This generally opens or relaxes the chromatin structure and facilitates transcription factor (TrF) binding enhancing gene expression (RNA). (C) DNA methylation (Me) of cytosine nucleotides prevents the binding of transcription factors, reducing or silencing gene expression. (D) Post-transcriptional regulation by micro-RNA (miRNA), short interfering RNA (siRNA) and short hairpin RNA (shRNA) that bind RNA to induce its degradation.

Chapter 101

VIDEO 101.1 Airway obstruction can manifest with paradoxical movement of the chest wall, accessory muscle usage and the presence of a tracheal tug.

FIGURE 101.1 Chest X-ray showing negative pressure pulmonary oedema.

Chapter 103

FIGURE 103.1 Initial electrocardiogram.

FIGURE 103.2 Left ventriculogram showing diastole on the left and systole on the right. Note the presence of ‘apical ballooning’ in systole due to akinesis of the middle segments of the left ventricle extending to the apex, consistent with Takotsubo cardiomyopathy.

FIGURE 103.3 Urgent percutaneous coronary angiography. Normal coronary arteries.

FIGURE 103.4 Electrocardiogram 10 days after initial presentation.

Chapter 110

FIGURE 110.1 Supine abdominal X-ray.

FIGURE 110.2 Chest X-ray.

FIGURE 110.3 Chest X-ray.

FIGURE 110.4 Chest X-ray.

FIGURE 110.5a PA chest X-ray.

FIGURE 110.5b Lateral chest X-ray.

FIGURE 110.6 Chest X-ray.

FIGURE 110.7 Chest X-ray.

Chapter 13

FIGURE 13.1 Proposed algorithm for preoperative cardiac testing. ACS, acute coronary syndrome; CAD, coronary artery disease; CPG, clinical practice guidelines; GDMT, guideline-directed medical therapy; MACE, major adverse cardiac event; MET, metabolic equivalent.

FIGURE 13.2 Vasodilator therapy such as dypyridamole (Persantin) is often combined with radionuclide tracer agents such as thallium for cardiac testing. A rotating gamma camera is subsequently used to image the heart and evaluate for the presence of cardiac disease.

FIGURE 13.3 Imaging of the myocardium produced by scintigraphy.

VIDEO 13.1 Dipyridamole (Persantin) thallium scan.

FIGURE 13.4 Dobutamine can be infused at varying doses with simultaneous imaging via transthoracic echocardiography. This allows evaluation of cardiac disease.

VIDEO 13.2 Dobutamine stress echocardiography.

Chapter 14

FIGURE 14.1 The Mallampati scoring system [3].

VIDEO 14.1 Airway assessment. This video demonstrates some of the features of airway assessment that should be undertaken in the preoperative planning of patient perioperative care.

FIGURE 14.2 Airway assessment in patients with an easy (on the left) and potentially difficult (on the right) airway.

Chapter 15

VIDEO 15.1 Lung function testing can provide useful information to help predict respiratory risk in certain high-risk groups.

Chapter 16

VIDEO 16.1 Cardiopulmonary exercise testing.

FIGURE 16.1 Graphic representation of peak and maximal oxygen uptake.

FIGURE 16.2 Graphic demonstration of the anaerobic threshold.

Chapter 17

FIGURE 17.1 Algorithm for the investigation and management of anaemia prior to elective surgery. This template is for patients undergoing procedures in which substantial blood loss is anticipated such as cardiac surgery, major orthopaedic, vascular and general surgery. Specific details including reference ranges and therapies may need adaptation for local needs, expertise or patient groups. eGFR, estimated glomerular filtration rate; EPO, erythropoietin; G&H, group and hold; Hb, haemoglobin; IV, intravenous; U&E, urea and electrolytes.

Chapter 18

FIGURE 18.1 Algorithm for estimating parenteral doses of drugs for Parkinson’s disease [3].

Chapter 21

FIGURE 21.1 The WHO surgical safety checklist summarises the more important aspects of safety: correct patient identification, surgical site and side, safe anaesthesia and airway, prevention of infection and successful teamwork [2].

VIDEO 21.1 The surgical safety checklist is an important tool that minimises errors as well as promoting team communication in the operating room.

Chapter 22

VIDEO 22.1 Electrocardiography. The ECG provides a cheap, non-invasive and reproducible method of looking at rhythm disturbances, the presence of ischaemia or other electrolyte abnormalities.

FIGURE 22.1 Algorithm for preoperative ECG testing [3,4]

Chapter 24

FIGURE 24.1 Elastic stockings.

FIGURE 24.2 Intermittent pneumatic compression device.

VIDEO 24.1 Options to provide thromboprophylaxis include mechanical means such as elastic stockings and pneumatic compression devices and chemical means such as low molecular weight heparin.

Chapter 25

VIDEO 25.1 Coagulation involves platelets and clotting factors. These are common targets of agents used to minimise venous thromboembolism in the perioperative period.

FIGURE 25.1 A suggested management plan for patients receiving direct-acting oral anticoagulant (DOAC) requiring urgent surgery. APTT, activated partial thromboplastin time; BP, blood pressure; PT, prothrombin time; TT, thrombin time.

Chapter 26

FIGURE 26.1 Perioperative diabetes management for type 1 and type 2 diabetes. For patients treated with insulin as well as OHAs and/or GLP-1 analogues, follow both sides of the chart. Where there is doubt regarding type of diabetes, treat the patient as if they have type 1 diabetes.

Note

: In type 1 patients treated with premixed insulin or insulin combinations in a syringe, for morning surgery give half normal morning dose as long-acting insulin on admission to the hospital; for afternoon surgery give half usual dose at home with light breakfast. Basal-bolus, long-acting subcutaneous insulin with prandial quick-acting insulin; CSII, continuous subcutaneous insulin infusion (‘insulin pump’); OHA, oral hypoglycaemic agents.

VIDEO 26.1 Insulin pumps come in a variety of forms and allow continuous insulin absorption and improved blood glucose control. They may need to be reprogrammed in the perioperative period.

Chapter 31

VIDEO 31.1 Coronary stents in the management of coronary artery disease.

VIDEO 31.2 This video discusses an approach to the management of patients who need surgery within the recommended period of dual antiplatelet therapy.

Chapter 33

FIGURE 33.1 Atrial fibrillation with rapid ventricular response.

FIGURE 33.2 First-degree heart block.

FIGURE 33.3 Second-degree heart block – Mobitz type I.

FIGURE 33.4 Second-degree heart block – Mobitz type II.

FIGURE 33.5 Complete heart block. The arrows at the top of the diagram indicate the ventricular rate (R wave) of about 40 beats per minute whilst the lower arrows (P wave) indicate the atrial rate (about 100 beats per minute).

FIGURE 33.6 Supraventricular tachycardia.

FIGURE 33.7 Wolff–Parkinson–White (WPW) syndrome. Note how the delta wave broadens the QRS complex and shortens the PR interval.

FIGURE 33.8 Ventricular tachycardia.

FIGURE 33.9 Ventricular fibrillation.

Chapter 34

VIDEO 34.1 Pacemakers and implantable defibrillators.

VIDEO 34.2 Operative considerations for pacemakers.

FIGURE 34.1 Suppression of pacemaker function by diathermy.

FIGURE 34.2 X-ray appearance of pacemaker and ICD. Arrow A shows the right ventricular lead of a pacemaker (dual chamber). Arrow B demonstrates the thicker radiodense coil of an ICD.

Chapter 36

VIDEO 36.1 Aetiology of aortic stenosis.

Chapter 37

FIGURE 37.1 Management algorithm for pulmonary hypertension. ANA, antinuclear antibody; FBE, full blood examination; COPD, chronic obstructive pulmonary disease; CT, computed tomography; HIV, human immunodeficiency virus; LFT, liver function test; TSH, thyroid-stimulating hormone.

Chapter 38

VIDEO 38.1 Endocarditis is a pathological condition in which the endocardial layers of the heart are infected. Most commonly, this involves the cardiac valves.

FIGURE 38.1 (A) A normal heart. (B) This heart demonstrates features typical of hypertrophic cardiomyopathy, with a hypertrophied septum and increase in ventricular mass. The septal hypertrophy often results in a degree of obstruction to the left ventricular outflow tract, impeding cardiac output.

VIDEO 38.2 Cardiomyopathies are a diverse group of diseases that affect the muscular tissue of the heart. The various types of cardiomyopathy are typically distinguished by echocardiographic features.

Chapter 39

FIGURE 39.1 CT scan in ARDS. Zone represents areas of the lung that are inflated and at risk of overdistension. Zone represents areas of the lung that repetitively collapse and re-expand. Zone represents areas of the lung that remain collapsed throughout tidal ventilation.

Chapter 40

VIDEO 40.1 Polysomnography. An overnight sleep study can provide a variety of useful measures about sleep-related disorders, including a diagnosis of sleep apnoea and severity of sleep apnoea if present.

FIGURE 40.1 A variety of CPAP masks are available including nasal, oral and helmet. Shown here is a patient with an oronasal CPAP mask.

VIDEO 40.2 Continuous positive airway pressure (CPAP) is an effective method for preventing airway collapse in patients with obstructive sleep apnoea.

Chapter 42

FIGURE 42.1 Schematic of the pathophysiology of postoperative pulmonary complications

Chapter 43

FIGURE 43.1 Pre-resection lung function testing algorithm.

For pneumonectomy candidates, perfusion scanning is recommended to calculate

ppo

FEV

oDLCO. For lobectomy patients, segmental counting is indicated.

ppo

FEV

ppo

DLCO cut-off values of 60% predicted values have been chosen based on indirect evidence and expert consensus opinion.

For patients with a positive high-risk cardiac evaluation subsequently assessed as suitable for surgery, both pulmonary function tests and cardiopulmonary exercise test may more precisely define perioperative risk.

Definition of risk:

Low risk

: The expected risk of mortality is below 1%. Major anatomical resections can be safely performed in this group.

Moderate risk

: Morbidity and mortality rates may vary according to the values of split lung functions, exercise tolerance and extent of resection. Risks and benefits of the operation should be thoroughly discussed with the patient.

High risk

: The risk of mortality after standard major anatomical resections may be higher than 10%. Considerable risk of severe cardiopulmonary morbidity and residual functional loss is expected. Patients should be counselled about alternative surgical (minor resections or minimally invasive surgery) or non-surgical options. CPET, cardiopulmonary exercise testing; DLCO, diffusing capacity for carbon dioxide; FEV, forced expiratory volume;

ppo

, predicted postoperative; SCT, stair climb test; SWT, shuttle walk test [3].

Chapter 46

FIGURE 46.1 Oliguria has a number of causes. ACTH, adrenocorticotrophic hormone; ADH, antidiuretic hormone; ANP, Atrial natriuretic peptide.

VIDEO 46.1 Oliguria is an appropriate sign of hypovolaemia, but it may exist in euvolaemia if there is limited fluid intake or in an inflammatory state with vasodilation.

Chapter 49

FIGURE 49.1 Metabolic changes in type 2 diabetes.

Chapter 54

FIGURE 54.1 Intracranial pressure–volume curve.

FIGURE 54.2 External ventricular drain. An external ventricular drain is a method of removing CSF to relieve intracranial pressure, or alternatively to allow serial sampling of CSF for microbiology.

VIDEO 54.1 Intracranial pressure monitoring. There are a number of methods of measuring intracranial pressure, including placement of an external ventricular drain (EVD) or use of a fibreoptic pressure monitor.

Chapter 58

VIDEO 58.1 The focused assessment with sonography in trauma (FAST) scan allows rapid point-of-care testing to exclude major life-threatening haemorrhages. Ultrasound views allow examination of the heart, abdominal contents and pelvis to look for accumulation of fluid or blood.

FIGURE 58.1 FAST scan view of the heart allows both examination of ventricular function and assessment of fluid status.

FIGURE 58.2 FAST scan of the left upper quadrant allows identification of the spleen and left kidney.

FIGURE 58.3 FAST scan of the right upper quadrant allows identification of the liver and right kidney.

FIGURE 58.4 FAST scan of the suprapubic region allows examination of the bladder and pelvis.

Chapter 59

FIGURE 59.1 Acute extradural haemorrhage. A normal brain is shown on the right side for comparison. Note the characteristic ‘lens’ shape which indicates a bleed external to the dura. The bleed has caused a huge increase in intracranial pressure.

FIGURE 59.2 Acute subdural haemorrhage. The bleed is internal to the dura and hence exhibits a different pattern to that of an extradural haemorrhage.

FIGURE 59.3 An example of intracerebral bleeding, particularly affecting the frontal lobes.

VIDEO 59.1 Principles of management of traumatic brain injury involve rapid diagnosis and prevention of secondary brain injury.

FIGURE 59.4 Traumatic brain injury guidelines.

Chapter 60

VIDEO 60.1 Maxillofacial injuries and the Le Fort classification.

FIGURE 60.1 Le Fort I fracture.

FIGURE 60.2 Le Fort II fracture.

FIGURE 60.3 Le Fort III fracture.

FIGURE 60.4 Le Fort II and III and right mandibular parasymphyseal fracture.

Chapter 61

FIGURE 61.1 Columns of the vertebral body in sagittal and axial planes.

FIGURE 61.2 Anterior column injury. (a) Sagittal CT. (b) Axial CT.

FIGURE 61.3 Burst fracture. (a) Sagittal CT. (b) Axial CT.

VIDEO 61.1 Thoracolumbar spinal injuries.

FIGURE 61.4 Algorithm for surgical decision making. CT, computed tomography; MRI, magnetic resonance imaging; XR, X-ray.

FIGURE 61.5 TLICS tables.

FIGURE 61.6 Fracture-dislocation. (a) Sagittal CT through the plane of the right facet. (b) Sagittal CT through the plane of the spinous process.

FIGURE 61.7 Chance fracture. (a) Sagittal CT through the plane of the right pedicle. (b) Sagittal CT through the plane of the spinous process. (c) Sagittal CT through the plane of the left pedicle.

FIGURE 61.8 Carrot-stick fracture. (a) Sagittal CT through the plane of the right facet. (b) Sagittal CT through the plane of the spinous process. (c) Sagittal CT through the plane of the left facet.

FIGURE 61.9 Ligamentous injury lateral X-ray.

FIGURE 61.10 ASIA Standard Neurological Assessment of Spinal Cord Injury. www.asia-spinalinjury.org/elearning/ISNCSCI_Exam_Sheet_r4.pdf

Chapter 62

FIGURE 62.1 (a) Common cervical orthoses include a Philadelphia collar. (b) A halothoracic brace is a method of cervical spine immobilisation.

VIDEO 62.1 This video discusses cervical spine injuries and the various methods used to immobilise them.

FIGURE 62.2 Gardner Well tongs.

Chapter 63

FIGURE 63.1 Left pneumothorax with failure of lung re-expansion despite two intercostal catheters.

FIGURE 63.2 Underwater seal chest drain.

VIDEO 63.1 An intercostal catheter collection system consists of three separate chambers which allow removal of air and fluid and provision of negative pressure to the pleural space.

FIGURE 63.3 Right haemothorax.

FIGURE 63.4 Multiple left posterior rib fractures.

VIDEO 63.2 A video demonstrating a flail chest injury with free-floating flail segment.

Chapter 64

FIGURE 64.1 Injuries of the abdomen.

FIGURE 64.2 Abdominal injuries seen on CT scan. (a) Hepatic laceration with evidence of arterial bleeding. (b) Splenic laceration with evidence of arterial bleeding. (c) Hepatic injury with associated pancreatic laceration and large-volume haemoperitoneum. (d) Periduodenal haematoma and free gas suggestive of duodenal injury.

Chapter 65

FIGURE 65.1 The pathophysiology of burn injury.

FIGURE 65.2 The rule of 9s for assessing burn size.

Chapter 66

FIGURE 66.1 The concurrent processes of primary haemostasis and the coagulation cascade. The result is a process that reduces and eventually stops blood loss. In this figure, activated platelets and thrombin act together to form a plug.

Video 66.1 Coagulation is divided into two processes: primary haemostasis and the coagulation cascade. Whilst conceptually separate, both of these processes occur in parallel. The result is a thrombin mesh to stem bleeding.

Chapter 74

VIDEO 74.1 Goal-directed therapy may assist in optimising fluid therapy during the perioperative period.

FIGURE 74.1 Frank–Starling curve.

FIGURE 74.2 (a) Typical oesophageal doppler velocity profile. The left shows normovolaemia, the right shows hypovolaemia with an initial bolus of fluid. (b) Further oesophageal doppler velocity profiles. A subsequent bolus of additional fluid shows a return to normovolaemia.

Chapter 75

FIGURE 75.1 Body water distribution. ECF, extracellular fluid; ICF, intracellular fluid; RBC, red blood cell.

Chapter 77

FIGURE 77.1 Checking of blood prior to administration.

VIDEO 77.1 Blood transfusion is common in the perioperative period and clinicians must be aware of the risks and benefits for individual patients.

Chapter 79

FIGURE 79.1 Pathophysiology of vomiting and mechanism of action of antiemetics.

VIDEO 79.1 Pathophysiology of vomiting and mechanism of action of antiemetics.

FIGURE 79.2 The five steps to managing PONV.

FIGURE 79.3 Flow diagram for managing postoperative nausea and vomiting (PONV).

Chapter 80

FIGURE 80.1 Decision making in fluid resuscitation. BP, blood pressure.

Chapter 81

FIGURE 81.1 Components of airway pressure during mechanical ventilation, illustrated by an inspiratory hold manoeuvre. PEEP, positive end-expiratory pressure.

FIGURE 81.2 Difference between synchronised intermittent mandatory ventilation (SIMV) (top) and assist control (bottom) mode of ventilation. PS, pressure support.

Chapter 85

FIGURE 85.1 Aetiology of postoperative chest pain.

Chapter 86

FIGURE 86.1 Focused examination of the patient with shortness of breath.

FIGURE 86.2 The ECG in pulmonary embolism. Although this ECG does not demonstrate a sinus tachycardia, there is a RBBB, right axis deviation, inverted T waves in V1–V4 and S1Q3T3 (a deep S wave in lead I, Q wave and inverted T wave in lead III).

VIDEO 86.1 Lung pathology ultrasound. Ultrasound is an excellent point-of-care test that can be used to rapidly diagnose and confirm clinical examination of chest pathology.

Chapter 87

FIGURE 87.1 Algorithm for resuscitation and stabilisation of the hypotensive patient. CVP, central venous pressure; Hb, haemoglobin; IV, intravenous.

Chapter 90

FIGURE 90.1 Representation of postoperative cognitive dysfunction [6]. Assuming a starting point for an individual subject of nearly 100% cognition before surgery, subsequent assessment and analysis of cognition may show a decline at day 7 postoperatively which may improve over the following 90 days (

red line

); if the cognitive tests at 90 days show that there is a significant decline in cognition (

black line

), the patient is said to suffer from postoperative cognitive dysfunction.

FIGURE 90.2 Hypothetical model of the clinical trajectory of Alzheimer’s disease. The stage of preclinical AD (biomarker or imaging postive) precedes mild cognitive impairment (MCI) many years before the onset of dementia [8].

Chapter 91

FIGURE 91.1 Thermoregulatory system.

FIGURE 91.2 Cytokines and proposed pathway of fever production. cAMP, cyclic adenosine monophosphate; IFN, interferon; IL, interleukin; PGE, prostaglandin E; TNF, tumour necrosis factor.

VIDEO 91.1 Malignant hyperthermia management.

Chapter 92

VIDEO 92.1 This video discusses the importance of preventing hypothermia in the perioperative period.

FIGURE 92.1 Forced air warming (especially when combined with fluid warming) is superior to other methods in maintaining normal core body temperature.

FIGURE 92.2 Forced air warmer. Forced air warming devices consist of a heating element which forces warmed air into an air blanket that sits on the surface of the body. This device can assist in conserving body heat.

FIGURE 92.3 A fluid warmer is used to warm intravenous fluids to 37–42°C. It connects to the intravenous line attached to the patient.

Chapter 93

FIGURE 93.1 Epidural analgesia is a continuous infusion of local anaesthesia administered by a programmed delivery system into the epidural space. It is important to perform serial assessments of quality of analgesia as well as looking for motor block or other complications of the technique.

VIDEO 93.1 Epidural analgesia.

FIGURE 93.2 Patient-controlled analgesia (PCA) devices can provide an excellent method of controlling pain in the postoperative period.

VIDEO 93.2 Patient-controlled analgesia.

Chapter 94

VIDEO 94.1 A detailed neuropathic pain examination is required to differentiate the causes of neuropathic pain.

Chapter 95

FIGURE 95.1 Risk factors for PPSP.

FIGURE 95.2 CRPS1 in the left arm.

Chapter 96

FIGURE 96.1 Spirometry is a method of evaluating airflow rates and volumes by non-invasive testing. It is a reproducible test that can evaluate severity and track treatment progress.

FIGURE 96.2 Spirometry with obstructive lung diseases. COPD typically produces a ‘scalloped’ shape with reduction of flow in the medium-sized airways.

Chapter 97

FIGURE 97.1 A supine chest X-ray taken on arrival immediately prior to right pleural decompression.

FIGURE 97.2 Supine chest X-ray post right pleural decompression and intercostal catheter insertion.

Chapter 101

VIDEO 101.1 Airway obstruction can manifest with paradoxical movement of the chest wall, accessory muscle usage and the presence of a tracheal tug.

Guide

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Perioperative Medicine for the Junior Clinician

Edited by

Joel Symons

Anaesthetist and Head of Perioperative Medicine EducationDepartment of Anaesthesia and Perioperative MedicineThe Alfred Hospital and Monash UniversityMelbourneVictoria, Australia

Paul Myles

Director, Department of Anaesthesia and Perioperative MedicineThe Alfred Hospital and Monash UniversityMelbourneVictoria, Australia

Rishi Mehra

Anaesthetist and Senior LecturerDepartment of Anaesthesia and Perioperative MedicineThe Alfred Hospital and Monash UniversityMelbourneVictoria, Australia

Christine Ball

Anaesthetist and Adjunct Senior LecturerDepartment of Anaesthesia and Perioperative MedicineThe Alfred Hospital and Monash UniversityMelbourneVictoria, Australia

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