Perioperative Care Of Surgical Patients Research Articles

REDISCOVER International Guidelines on the Perioperative Care of Surgical Patients With Borderline-resectable and Locally Advanced Pancreatic Cancer.

The REDISCOVER consensus conference aimed at developing and validate guidelines on the perioperative care of patients with borderline resectable (BR-) and locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC). Coupled with improvements in chemotherapy and radiation, the contemporary approach to pancreatic surgery supports resection of BR-PDAC and, to a lesser extent, LA-PDAC. Guidelines outlining the selection and perioperative care for these patients are lacking. The Scottish Intercollegiate Guidelines Network (SIGN) methodology was used to develop the REDISCOVER guidelines and create recommendations. The Delphi approach was used to reach consensus (agreement ≥80%) among experts. Recommendations were approved after a debate and vote among international experts in pancreatic surgery and pancreatic cancer management. A Validation Committee used the AGREE II-GRS tool to assess the methodological quality of the guidelines. Moreover, an independent multidisciplinary advisory group revised the statements to ensure adherence to non-surgical guidelines. Overall, 34 recommendations were created targeting centralization, training, staging, patient selection for surgery, possibility of surgery in uncommon scenarios, timing of surgery, avoidance of vascular reconstruction, details of vascular resection/reconstruction, arterial divestment, frozen section histology of perivascular tissue, extent of lymphadenectomy, anticoagulation prophylaxis and role of minimally invasive surgery. The level of evidence was however low for 29 of 34 clinical questions. Participants agreed that the most conducive mean to promptly advance our understanding in this field is to establish an international registry addressing this patient population ( https://rediscover.unipi.it/ ). The REDISCOVER guidelines provide clinical recommendations pertaining to pancreatectomy with vascular resection for patients with BR- and LA-PDAC, and serve as the basis of a new international registry for this patient population.

Effect Analysis of Positive Molecular Therapy in Surgical Nursing Based on Data Transformation Analysis.

This paper briefly introduces the concept, classification, and mechanism of action of positive thinking therapy; reviews the application and research progress of positive thinking therapy in perioperative care of surgical patients at home and abroad; presents the shortcomings and defects in the development; and aims to provide intervention, reference, and basis for the development of positive thinking therapy in perioperative care of surgical patients. One hundred and eight patients are undergoing PCI surgery in our cardiology department; 50 patients undergoing percutaneous coronary intervention were selected as the control group, and 58 patients undergoing percutaneous coronary intervention were selected as the observation group. Traditional health education was employed in the control group, while empowerment education based on timing theory was used in the observation group. The two groups were observed and compared in terms of self-care competence, anxiety and depression, medication adherence score, and exercise adherence. Conclusion. Empowerment education based on timing theory can improve self-care ability of PCI patients, reduce patients' anxiety and depression, and improve patients' medication and exercise compliance.

Predictive Power of the "Trigger Tool" for the detection of adverse events in general surgery: a multicenter observational validation study

BackgroundIn spite of the global implementation of standardized surgical safety checklists and evidence-based practices, general surgery remains associated with a high residual risk of preventable perioperative complications and adverse events. This study was designed to validate the hypothesis that a new “Trigger Tool” represents a sensitive predictor of adverse events in general surgery.MethodsAn observational multicenter validation study was performed among 31 hospitals in Spain. The previously described “Trigger Tool” based on 40 specific triggers was applied to validate the predictive power of predicting adverse events in the perioperative care of surgical patients. A prediction model was used by means of a binary logistic regression analysis.ResultsThe prevalence of adverse events among a total of 1,132 surgical cases included in this study was 31.53%. The “Trigger Tool” had a sensitivity and specificity of 86.27% and 79.55% respectively for predicting these adverse events. A total of 12 selected triggers of overall 40 triggers were identified for optimizing the predictive power of the “Trigger Tool”.ConclusionsThe “Trigger Tool” has a high predictive capacity for predicting adverse events in surgical procedures. We recommend a revision of the original 40 triggers to 12 selected triggers to optimize the predictive power of this tool, which will have to be validated in future studies.

Implementing Perioperative Evidence-Based Interventions for OSA: Increasing Risk Awareness, Enhancing Patient Care

<h3>Introduction</h3> The majority of Obstructive Sleep Apnea (OSA) cases are reported to be undiagnosed, including surgery patients. Perioperative nurses are in a unique position to recognize OSA not diagnosed in the perianesthesia period. <h3>Identification of the problem</h3> OSA has been identified as a factor for prolonging PACU stays and, more importantly, a contributing factor to respiratory compromise for those receiving opioids postoperatively. This population has an increased risk for adverse respiratory events once discharged. Implementing and sustaining interventions to safely discharge the patient can be a challenge. <h3>EBP Question/Purpose</h3> . <h3>PICO question. Databases utilized</h3> Can increasing nursing knowledge of OSA risk and perioperative nursing interventions optimize perioperative care for surgical patients with diagnosed and undiagnosed OSA? The American Society of Anesthesiologist published guidelines for perioperative management of patients with OSA in 2006. Since then, the ASPM published guidelines for monitoring opioid induced sedation in 2011 and in 2012 ASPAN published practice recommendation for obstructive sleep apnea in the adult patient. Various literature has been published on implementing these guidelines. <h3>Methods/Evidence</h3> Initial data showed patients with oxygen desaturation less than 92%, had STOPBANG scores of 4-8 52%. A pre-survey was distributed to nurses working in the pre-op and post-op area to assess their knowledge of OSA, OSA risk identification, and interventions to initiate with OSA and at-risk populations. Education was then given regarding identification of undiagnosed sleep apnea, recognition of post-operative hypoventilation and apneic events, and implementation of enhanced monitoring and nursing interventions. OSA screening information was added to electronic documentation, including assessments of at home CPAP/BiPAP use. A literature review identified post-anesthesia patient education points for patient diagnosed with or at risk for OSA. Educational points were incorporated into discharge teaching and discharge documents. A post survey was completed. <h3>Significance of Findings/Outcomes</h3> The initial desaturation data was thought to be skewed as nurses were unwilling to document low saturations on their patients, waiting to document until the patient was encouraged to take deep breaths, repositioned the airway, or provided other interventions. <h3>Implications for perianesthesia nurses and future research</h3> Encourage frontline nurses to recognize the significance of respiratory compromise and improve quality of care with resources and increased knowledge of interventions.

Working towards an ERAS Protocol for Pancreatic Transplantation: A Narrative Review.

Enhanced recovery after surgery (ERAS) initially started in the early 2000s as a series of protocols to improve the perioperative care of surgical patients. They aimed to increase patient satisfaction while reducing postoperative complications and postoperative length of stay. Despite these protocols being widely adopted in many fields of surgery, they are yet to be adopted in pancreatic transplantation: a high-risk surgery with often prolonged length of postoperative stay and high rate of complications. We have analysed the literature in pancreatic and transplantation surgery to identify the necessary preoperative, intra-operative and postoperative components of an ERAS pathway in pancreas transplantation.

The individualised Pharmacologic approach of Enhanced Recovery After Surgery (ERAS) pathways: Analgesics and local anaesthetics

Background: Enhanced Recovery After Surgery (ERAS) is multidisciplinary, evidence-based approach in the perioperative care of surgical patients that aims to reduce postoperative complications, length of hospital stay, readmissions and healthcare costs by implementing protocols throughout patient’s perioperative journey. (1) The purpose of this review is to highlight the pharmacologic perspective of the most common drugs utilised in ERAS protocols, present current evidence regarding optimal and individualised use of them, discuss ways how clinicians can maximise the benefits of their patients and outline future advancements in the field. Methods: A wide literature search was performed to identify high quality evidence on the pharmacology of common analgesics and local anaesthetics used in ERAS protocols. PubMed, Embase and Scopus databases were searched using various combinations of terms related to perioperative analgesia, personalised/precision/individualised medicine, local anaesthetics and Enhanced Recovery after Surgery protocols, up to January 2021. Results: Literature search revealed known and less known pharmacological properties of common analgesics and local anaesthetics, unveiled pharmacodynamic, pharmacokinetic and pharmacogenomic properties of drugs that can improve efficiency and reduce adverse-effects with a more individualised patient approach and suggested evidence-based ways of serving the purposes of ERAS protocols. Conclusions: Clinical Pharmacology plays an essential role in improving patient care within ERAS pathways by implementing basic and advanced pharmacologic properties and pharmacogenomic data towards a more patient-centered approach.

Patients of risk groups in the perioperative period: the review of modern guidelines

Background. According to the Decree of the Ministry of Health of Ukraine № 275 issued on 11.09.2018, there is a list of measures to ensure surgical safety and patient’s safety. These measures can be divided into those that should be performed 1) before anesthesia; 2) before skin dissection; 3) before the patient leaves the operating room. Perioperative medicine (POM) is a patient-centered and interdisciplinary perioperative care for surgical patients.&#x0D; Objective. To describe the current recommendations for POM.&#x0D; Materials and methods. Review of available guidance documents.&#x0D; Results and discussion. The pathophysiology of postoperative complications (infectious processes, intestinal paralysis, respiratory failure, kidney damage, etc.) includes the following factors: triggers (anxiety, pain, surgical trauma), patient factors (age, comorbid conditions), the consequences of general operative stress (autonomous system imbalance, inflammation, coagulopathy, metabolic imbalance). Clinical evaluation or biomarkers should be used to identify high-risk patients in the perioperative period. Measures to improve postoperative rehabilitation should be carried out in the pre-, intra- and postoperative period. Thus, in the preoperative period it is necessary to examine the patient, to provide the carbohydrate load 2 hours before the intervention, to conduct antibiotic prophylaxis, to correct or stabilize the comorbid diseases (especially cardiovascular and renal diseases, diabetes, anemia). In the intraoperative period it is necessary to maintain normovolemia and normothermia, to use protective mechanical lung ventilation, to limit the use of opioids, to perform extubation immediately after the intervention. In the postoperative period early activation, early enteral nutrition and early removal of drainages and catheters should be used. The key components of POM include the identification of low-risk patients in order to save resources, the identification of high-risk patients with the possible use of alternative management strategies, and the frequent risk reassessment. The main components of the success of anesthesia include preoperative assessment of the patient’s somatic status and risk, use of controlled hypnotics and effective and predictable muscle relaxant, use of analgesics that break down quickly and have no ability to accumulate, control of the hemodynamics stability, blood gases and acid-base balance. To prevent the perioperative myocardial ischemia, it is advisable to use esmolol – a cardioselective β-blocker of ultrashort action. Preoperative anxiety, intubation and extubation, surgical manipulations lead to the excessive adrenergic response, which justifies the use of β-blockers. The pharmacological effects of esmolol (Biblok, “Yuria-Pharm”) include the reduction of myocardial oxygen consumption, increase of the diastole duration, limitation of the free radicals’ production, control of the activity of metalloproteinases, and the reduction of inflammation around atherosclerotic plaques. In addition, esmolol (Biblok) is able to reduce intra- and postoperative use of opioids, and therefore its use as a component of multimodal total intravenous anesthesia has been proposed. Preoperative administration of esmolol may also be an effective and safe method of myocardial protection in patients undergoing cardiac surgery. β-blockers are well tolerated in patients with acute hypovolaemia during anesthesia, however, episodes of hypercapnia should be avoided during their use.&#x0D; Conclusions. 1. For the optimal POM, the individual risk of perioperative complications should be determined. 2. POM includes a number of pre-, intra- and postoperative measures. 3. The use of ultrashort-acting β-blocker esmolol prevents intraoperative myocardial ischemia, has antioxidant and anti-inflammatory effects, reduces the need for opioids.

The concept of peri-operative medicine to prevent major adverse events and improve outcome in surgical patients: A narrative review.

: Peri-operative Medicine is the patient-centred and value-based multidisciplinary peri-operative care of surgical patients. Peri-operative stress, that is the collective response to stimuli occurring before, during and after surgery, is, together with pre-existing comorbidities, the pathophysiological basis of major adverse events. The ultimate goal of Peri-operative Medicine is to promote high quality recovery after surgery. Clinical scores and/or biomarkers should be used to identify patients at high risk of developing major adverse events throughout the peri-operative period. Allocation of high-risk patients to specific care pathways with peri-operative organ protection, close surveillance and specific early interventions is likely to improve patient-relevant outcomes, such as disability, health-related quality of life and mortality.

Complications and liability related to regional and neuraxial anesthesia.

Regional anesthesia is responsible for approximately one-fifth of professional liability claims. The present investigation evaluated common and rare complications related to regional and neuraxial anesthesia, including postdural puncture headache, backache, transient neurological symptoms, inadvertent intrathecal injection, epidural hematoma and abscess, meningitis, arachnoiditis, postoperative urinary retention, local anesthetic systemic toxicity, and cardiac arrest. Regional anesthetic techniques are increasingly used in perioperative care of surgical patients for acute pain management and for chronic pain states. This manuscript also provides an overview and analysis of the existing literature and makes some recommendations in terms of strategies to prevent or minimize the potential patient injury, with a focus on those more commonly associated with patient injury and liability exposure. The role of ultrasound in preventing patient injury during regional anesthesia is also discussed.

Predictors of Readmission After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BackgroundRisk factors for hospital readmission after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are poorly understood. MethodsThe American College of Surgeons–National Surgical Quality Improvement Program databases from 2011 to 2016 were used to identify all patients who underwent CRS-HIPEC. Demographic, clinical, and perioperative variables were examined using logistic regression to identify factors associated with 30-d postoperative readmission. ResultsAmong 618 patients who underwent CRS-HIPEC, 96 (15.5%) required hospital readmission within 30 d of surgery. The incidence of readmission decreased over the study period (18.3% in 2011 to 4.8% in 2016). Among the 59 patients who were readmitted and had complete data available, readmission occurred on mean postoperative day 18.5 ± 5.5; the most common reasons for readmission were digestive complications (39.0%), postoperative infections (25.4%), uncontrolled pain (8.5%), and venous thromboembolism (5.1%). On multivariate logistic regression analysis, increasing age (OR 1.02, 95% CI 1.00-1.05), number of operative procedures (OR 1.12, 95% CI 1.00-1.25), perioperative complication (OR 7.06, 95% CI 3.96-12.59), need for reoperation (OR 10.21, 95% CI 3.50-29.83), and length of stay (OR 0.93, 0.90-0.97) were associated with hospital readmission. ConclusionsIn this population-based analysis of patients undergoing CRS-HIPEC, older age, perioperative complications, need for reoperation, and extent of cytoreduction were associated with hospital readmission. The American College of Surgeons–National Surgical Quality Improvement Program database is a powerful research tool that can be used to identify opportunities to improve the perioperative care of surgical patients.

Advanced Perioperative Crisis Management

Anesthesiologists frequently encounter situations of high acuity that require rapid recognition of a problem, quick and accurate assessment of contributing factors and causes, and swift and skillful action to resolve or ameliorate the crisis. The foundational requirements to successfully perform these tasks are a thorough knowledge and understanding of relevant pathophysiologic factors and an objective approach to the situation and possible resolution. The recently published textbook, Advanced Perioperative Crisis Management, edited by Drs Matthew McEvoy and Cory Furse, provides practitioners with just those tools. The book is designed for those caring for surgical patients and provides an effective strategy for emergencies encountered in this population. The editors hail from 2 large academic centers, with an impressive group of authors from their own and other institutions, many of whom are well respected in their areas of expertise, lending weight to the provided recommendations. This 732-page book appears to be well suited as both a reference and resource in anticipation of critical events or for review during and/or after a critical event. There is an electronic version of the printed material available, which would be useful as a reference in an acute event, but it is not necessary for general review and preparation. Given the wide range of presented situations, the editors might consider hyperlinked text/references and more interactive features in future editions. Additionally, a searchable format that is accessible on handheld devices would be useful to providers during crisis management. The book is comprised of 9 parts. Part I sets the foundation and provides background on techniques, theory, and approach to crisis management, all relevant, topical subject matter for perioperative practitioners. The following 8 parts are organ- and condition-specific, with sensible organization and presentation of topics and chapters. Sections on cardiac crises (including shock as a separate section), pulmonary, metabolic and endocrine crises, and neurologic crises are presented by physiologic system, and there is a separate section devoted to toxicities. The 2 parts related to obstetric and pediatric emergencies stand alone, also divided by physiologic system and specific conditions relevant to each patient group. This approach is consistent with similar topics presented together, which facilitates review and understanding. Although multiauthored, each individual chapter within each part is well edited, and without significant repetition and similar presentation of key subject matter, is likely to be useful to those reviewing for both clinical and examination purposes. Each chapter begins with a clinical vignette, which becomes the basis for discussion of the topic(s) for that chapter. The reader is thus drawn into a real-world scenario that provides context for the subsequent scientific discussion and management recommendations. The chapter ends with well-constructed questions for a case-based review of the presented information. Management and therapeutic options in these learning scenarios are particularly useful to gauge comprehension of the chapter’s information, especially as the “case” progresses in each management step. Some authors have chosen broad questions that can be approached with provider judgment, and others have more specific questions with answers incorporated into the text. Greater consistency in presentation of these question-based clinical scenarios may be helpful in future editions. The substance of the discussion throughout the text is excellent. Analysis of each topic is succinct, well referenced, and algorithms and recommendations are up to date. The text is easy to read and may be especially useful for readers who find themselves less engaged with traditional reference textbooks. Images, tables, and algorithms are used frequently and are very appropriate to demonstrate numerous key concepts. Overall, this is an excellent reference text for crisis management in perioperative patients. It is a valuable addition to several other available comprehensive resources.1,2 The style of Drs McEvoy and Furse lends itself to efficient review, with the use of a clinical case foundation, physiologic and systems-based organization, and use of appropriate figures and algorithms, all of which make the text less dense for the reader. The easily digestible and clear, concise approach to clinical situations that may be encountered is an ideal source for those involved in the perioperative care of surgical patients, and offers specific benefit to those in an acute care setting as well as those preparing for high-stakes examinations. It will be beneficial to purchase for a department or individual collection, and will provide an excellent supplement to other available crisis management resources. Srikanth Sridhar, MDEvan G. Pivalizza, MDDepartment of AnesthesiologyUT Health McGovern Medical School-HoustonHouston, Texas[email protected]

Quality of Postoperative Pain Management After Maxillofacial Fracture Repair.

Effective pain management is an essential component in the perioperative care of surgical patients. However, postoperative pain after maxillofacial fracture repair and its optimal therapy has not been described in detail. In a prospective cohort study, 95 adults rated their pain on the first postoperative day after maxillofacial fracture repair using the questionnaire of the Quality Improvement in Postoperative Pain Management (QUIPS) project. Quality Improvement in Postoperative Pain Management allowed for a standardized assessment of patients' characteristics and pain-related parameters. Overall, the mean maximal pain and pain on activity (numeric rating scales) were significantly higher in patients with mandibular fractures than in patients with midface fractures (P = 0.002 and P = 0.045, respectively). In patients with mandibular fractures, a longer duration of surgery was significantly associated with higher satisfaction with pain intensity (P = 0.015), but was more frequently associated with postoperative vomiting (P = 0.023). A shorter duration of surgery and an absence of preoperative pain counseling in these patients were significantly correlated to desire for more pain medication (P = 0.049 and P = 0.004, respectively). Patients with mandibular fractures that received opioids in the recovery room had significantly higher strain-related pain (P = 0.017). In patients with midface fractures, a longer duration of surgery showed significantly higher levels of decreased mobility (P = 0.003). Patients receiving midazolam for premedication had significantly less minimal pain (P = 0.021). Patients with mandibular fractures seem to have more postoperative pain than patients with midface fractures. Monitoring of postsurgical pain and a procedure-specific pain-treatment protocol should be performed in clinical routine.

Evolving healthcare delivery paradigms and the optimization of 'value' in anesthesiology.

Healthcare worldwide is evolving to yield enhanced care provided at a lowered cost. Patient-centric paradigms that hasten surgical recovery and strengthen collaboration amongst medical professionals are gaining impetus. This review will discuss the changing healthcare landscape and outline its implications on anesthesiology practice. Anesthesiologists must be nimble and versatile as they adapt to healthcare redesign. An increased responsibility for patient outcomes should be embraced by extending the breadth and depth of clinical practice throughout the surgical care continuum. The perioperative surgical home and enhanced recovery after surgery provide paradigms to further integrate expanding clinical opportunities and improved patient outcomes. Investment is needed in perioperative medical education and research efforts to best position anesthesiologists for success both now and in the future. Exemplifying opportunities to demonstrate value-added care, the scope of anesthesiology education and clinical practice should diversify to further integrate perioperative care of surgical patients.

Does implementation of preanesthesia assessment clinics improve surgical patients care in Nigeria?

Introduction: Preanesthesia assessment of patients is a major component of the perioperative care of surgical patients. The benefits of outpatient preoperative assessment clinics (PAC) were recognized over 67 years ago. However, these clinics are not used in Nigeria as part of surgical care. Search of the literature did not reveal any hospital in Nigeria that operates PAC, and therefore, its implementation in this country is still in process. This may not be unconnected with scarce financial, material, and human resources. Materials and Methods: This study was a questionnaire survey of the views of anesthetists, surgeons, and hospital administrators in some Nigerian Federal Teaching Hospitals on the usefulness and limitations of PAC. Structured questionnaires were sent to surgeons, anesthetists and Chairmen, Medical Advisory Committees in the selected Hospitalsand the results were analyzed. Results: Respondents indicated the benefits of preanesthesia assessment clinics as decrease in the incidence of surgery delays and cancelations, shorter lengths of hospital stay, improvement in the logistics of preoperative preparation, improved patient knowledge of anesthesia, and preoperative care as well as the role of the anesthetist in surgical care. Limiting factors to successful preanesthesia clinics were lack of cooperation from anesthetists and surgeons, other medical specialists, lack of supporting staff, finance, and appropriate office space. Conclusions: Preanesthesia assessment clinic increases the overall efficiency of the period of stay of the surgical patient in the hospital. Its benefits outweigh its disadvantages, and its successful implementation requires effort, time, money, and close collaboration with hospital administrators.

Educational review of Perioperative Medicine for the Junior Clinician

• Anesthesia groups and societies have advocated for extension of anesthesiology further into the perioperative care of surgical patients for over 2 decades, often without a blueprint for the extension.

The future of anesthesiology: implications of the changing healthcare environment.

Anesthesiology is at a crossroad, particularly in the USA. We explore the changing and future roles for anesthesiologists, including the implication of new models of care such as the perioperative surgical home, changes in payment methodology, and the impact other refinements in healthcare delivery will have on practice opportunities and training requirements for anesthesiologists. The advances in the practice of anesthesiology are having a significant impact on patient care, allowing a more diverse and complex patient population to benefit from the knowledge, skills and expertise of anesthesiologists. Expanded clinical opportunities, increased utilization of technology and expansion in telemedicine will provide the foundation to care for more patients in diverse settings and to better monitor patients remotely while ensuring immediate intervention as needed. Although the roles of anesthesiologists have been diverse, the scope of practice varies from one country to another. The changing healthcare needs in the USA in particular are creating new opportunities for American anesthesiologists to define expanded roles in healthcare delivery. To fulfill these evolving needs of patients and health systems, resident training, ongoing education and methods to ensure continued competency must incorporate new approaches of education and continued certification to ensure that each anesthesiologist has the full breadth and depth of clinical skills needed to support patient and health system needs. The scope of anesthesia practice has expanded globally, providing anesthesiologists, particularly those in the USA, with unique new opportunities to assume a broader role in perioperative care of surgical patients.

Medical Management of the Surgical Patient: A Textbook of Perioperative Medicine, Fifth Edition

Like it or not, modern anesthesiology is at a crossroad. We are in need of a makeover! During the past few decades, the emphasis in our specialty has gradually shifted from a purely specialty-based clinical perspective to a more holistic and multidisciplinary approach to patient care and experience. The image of us being the “Tube & Bag Docs” is long gone, and thankfully so. In the modern environment of comprehensive patient care, we are perfectly positioned to take on newer and uncharted leadership roles in this exciting sphere of perioperative medicine. This is where books like the Medical Management of the Surgical Patient: A Textbook of Perioperative Medicine by Dr. Lubin and colleagues are especially relevant to us as anesthesiologists. If we fashion ourselves to be the perioperative physicians in the hospital, texts like this could prove to be useful tools in our armamentarium.In its 5th edition, this book has a challenging task at hand. To be able to satisfy the needs of a broad spectrum of perioperative physician consultants, from internists to family practitioners, from surgical specialists to anesthesiologists, and from cardiologists to nephrologists, can be unnerving. Kudos to Dr. Lubin and his team for assembling contributors from various specialties from all over United States for this book. As can be expected from a textbook of this genre, there are 26 sections and 145 chapters spread over 839 pages. It is definitely not for the faint hearted!The chapters are well organized into parts and sections. The book has mainly two parts. The first part deals with the perioperative care of surgical patients and has chapters dedicated to systemic medical problems encountered in the perioperative period. The second part deals with specific complications associated with surgical procedures. Overall, the chapters are well written, with succinct and relevant information. There are well-documented references at the end of each chapter. To the purists, the material may seem a little too brief and, dare I say, inadequate at times but, again, this is a comprehensive book with a wide scope of practice, and this genre often falls victim to this impression. Overall, the wide range of topics and chapters seems to cover the bases well and adheres to the objectives stated by the editors at the very outset.Now comes the most important question, for whom is this book useful? Although the authors in their preface mention that this book is aimed at a wide spectrum of clinicians and consultants in the perioperative period, that same goal could sometimes prove to be the Achilles’ heel! I just cannot shake the notion that this book is in a kind of medical no man’s land! However, in the same breath, I must also confess that in its 5th edition, this book should appeal to a wide range of residents and perioperative physicians, including anesthesiologists. Hopefully in the modern era of perioperative surgical homes and patient centered care, texts like this will become even more relevant. I can imagine texts like this will be more commonly found on the desks of future busy perioperative physicians and consultants, like it or not!

The Genetic Basis of Coronary Artery Disease and Atrial Fibrillation: A Search for Disease Mechanisms and Therapeutic Targets.

ORONARY ARTERY disease (CAD) and arrhythmias such as atrial fibrillation (AF) significantly contribute to perioperative mortality and morbidity. The 30-day postoperative mortality rate is increased significantly in patients with AF (6.4%) and (CAD) (2.9%). 1 The VISION trial found that 11.6% of patients undergoing noncardiac surgery had increased troponin levels postoperatively, and these patients had an increased 30-day mortality compared with the reference group. 2 Postoperative AF patients have longer hospital stays and increased mortality. 3–6 Postoperative AF is common not only after cardiac surgery, but is seen after major noncardiac surgery as well. As anesthesiologists continue to focus on perioperative care for surgical patients, they must examine all options for decreasing mortality and morbidity for patients with coronary artery disease and arrhythmias undergoing noncardiac surgery. The genetic predisposition for CAD and AF has garnered more attention in the past decade due to innovative technology and ready access to human genomic information that has improved the ability to identify single nucleotide polymorphisms in the genome. Although advances continue to be made in the management of CAD and AF, prevention likely will be the most effective way to decrease ischemic heart disease and atrial fibrillation in the patient population. Medical management has an important role for perioperative prevention of major adverse cardiac events; however, the 2014 ACC/AHA guidelines reflect important contributions from recent studies regarding the safety and efficacy of perioperative beta-blockade. The only class I recommendation for perioperative beta-blockade is the continuation of beta-blockers for patients who have been taking them chronically. 1 The initiation of beta-blockers for patients with high-risk myocardial ischemia or for patients with multiple risk factors is a class IIb recommendation. There is continued concern about the risk of perioperative stroke related to betablockers and the safest time to initiate beta-blockers before surgery. Perioperative myocardial revascularization has been examined as a method to decrease major perioperative adverse cardiac events. The CARP trial showed that at medial longterm follow-up, there was no difference in mortality between revascularized and nonrevascularized patients undergoing vascular surgery even in high-risk groups such as those with multivessel coronary artery disease 7 Therefore, medical and surgical interventions have limited ability to decrease perioperative risk when there is a clear unmet need for better risk assessment and management strategy. This review will focus on the recent progress made in establishing the genetic basis for coronary artery disease and atrial fibrillation. The clinical relevance of CAD and perioperative myocardial infarction are closely linked; however, they do not share many genetic variants. These genetic differences will be highlighted using specific genes as examples, including 9p21. A thorough understanding of the genes and their contribution to these disease processes may lead to improved risk stratification and prevention of these common perioperative complications.

Surgeon-Family Perioperative Communication: Surgeons' Self-Reported Approaches to the “Surgeon-Family Relationship”

Family members are important in the perioperative care of surgical patients. During the perioperative period, communication about the patient occurs between surgeons and family members. To date, however, surgeon-family perioperative communication remains unexplored in the literature. Surgeons were recruited from the surgical faculty of an academic hospital to participate in an interview regarding their approach to speaking with family members during and immediately after an operative procedure. An iterative process of transcription and theme development among 3 researchers was used to compile a well-defined set of qualitative themes. Thirteen surgeons were interviewed and described what informs their communication, how they practice surgeon-family perioperative communication, and how the skills integral to perioperative communication are taught. Surgeons saw perioperative communication with family members as having a special role of providing support and anxiety alleviation that is distinct from the role of communication during clinic or postoperative visits. Wide variability exists in how interviewed surgeons practice perioperative communication, including who communicates with the family, and the frequency and content of the communication. Surgeons universally reported that residents' instruction in perioperative communication with families was lacking. Surgeons recognize perioperative communication with family members to be a part of their role and responsibility to the patient. However, during the perioperative period, they also acknowledge an independent responsibility to alleviate family members' anxieties. This independent responsibility supports the existence of a distinct "surgeon-family relationship."

Perioperative Assessment of Myocardial Deformation

Evaluation of left ventricular performance improves risk assessment and guides anesthetic decisions. However, the most common echocardiographic measure of myocardial function, the left ventricular ejection fraction (LVEF), has important limitations. LVEF is limited by subjective interpretation that reduces accuracy and reproducibility, and LVEF assesses global function without characterizing regional myocardial abnormalities. An alternative objective echocardiographic measure of myocardial function is thus needed. Myocardial deformation analysis, which performs quantitative assessment of global and regional myocardial function, may be useful for perioperative care of surgical patients. Myocardial deformation analysis evaluates left ventricular mechanics by quantifying strain and strain rate. Strain describes percent change in myocardial length in the longitudinal (from base to apex) and circumferential (encircling the short-axis of the ventricle) direction and change in thickness in the radial direction. Segmental strain describes regional myocardial function. Strain is a negative number when the ventricle shortens longitudinally or circumferentially and is positive with radial thickening. Reference values for normal longitudinal strain from a recent meta-analysis by using transthoracic echocardiography are (mean ± SD) -19.7% ± 0.4%, while radial and circumferential strain are 47.3% ± 1.9% and -23.3% ± 0.7%, respectively. The speed of myocardial deformation is also important and is characterized by strain rate. Longitudinal systolic strain rate in healthy subjects averages -1.10 ± 0.16 s. Assessment of myocardial deformation requires consideration of both strain (change in deformation), which correlates with LVEF, and strain rate (speed of deformation), which correlates with rate of rise of left ventricular pressure (dP/dt). Myocardial deformation analysis also evaluates ventricular relaxation, twist, and untwist, providing new and noninvasive methods to assess components of myocardial systolic and diastolic function. Myocardial deformation analysis is based on either Doppler or a non-Doppler technique, called speckle-tracking echocardiography. Myocardial deformation analysis provides quantitative measures of global and regional myocardial function for use in the perioperative care of the surgical patient. For example, coronary graft occlusion after coronary artery bypass grafting is detected by an acute reduction in strain in the affected coronary artery territory. In addition, assessment of left ventricular mechanics detects underlying myocardial pathology before abnormalities become apparent on conventional echocardiography. Certainly, patients with aortic regurgitation demonstrate reduced longitudinal strain before reduction in LVEF occurs, which allows detection of subclinical left ventricular dysfunction and predicts increased risk for heart failure and impaired myocardial function after surgical repair. In this review, we describe the principles, techniques, and clinical application of myocardial deformation analysis.