Cleveland Clinic journal of medicine
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The history and the physical examination remain the most important elements in cardiac risk stratification of patients prior to noncardiac surgery. Indications for further cardiac tests and interventions are usually the same as in the nonsurgical setting. No test should be performed unless the results will affect patient management. In many cases, noninvasive testing is being replaced by prophylactic medical therapy, a topic explored in the next article in this supplement.
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The medical consultant should have a high index of suspicion for sepsis. Early goal-directed therapy is recommended and includes early, aggressive fluid resuscitation, antibiotics, and vasoactive agents, if needed. ⋯ Empiric use of steroids and early use of activated protein C also need to be considered. Vasopressin should be considered if hypotension persists or if the situation requires escalating doses of norepinephrine.
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In the last 7 years, 14 randomized controlled trials in patients with acute respiratory distress syndrome (ARDS) have shown that: Mechanical ventilation with a tidal volume of 6 mL/kg of predicted body weight is better than mechanical ventilation with a tidal volume of 12 mL/kg of predicted body weight. Prone positioning improves oxygenation but poses safety concerns. A high level of positive end-expiratory pressure does not improve survival. ⋯ Exogenous surfactant may improve oxygenation but has no significant effect on the death rate or length of use of mechanical ventilation. Low-dose inhaled nitric oxide has no substantial impact on the duration of ventilatory support or on the death rate. Partial liquid ventilation may be beneficial in young patients with acute lung injury or ARDS, although further study is needed to confirm this.
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Patients with hip fracture benefit from a multidisciplinary team approach for preoperative and postoperative care. Team members, consisting of the orthopedic surgeon, internal medicine consultant, and anesthesiologist, should each have a role in determining a patient's readiness for surgery and communicate with one another about appropriate management. ⋯ Nondisplaced (impacted) femoral neck fractures, however, should be repaired within 6 hours if possible to avert avascular necrosis of the femoral head and the need for total hip replacement. The following interventions are helpful for preventing complications following hip fracture repair: perioperative prophylaxis against infection.