Cleveland Clinic journal of medicine
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Three directors of dedicated preoperative assessment clinics share their experience in setting up and running their programs. Standardizing and centralizing all or part of the preoperative evaluation process--obtaining patient records; the history and physical examination; the surgical, anesthesiology, and nursing assessments; ordering tests; and documentation and billing--increases efficiency. The savings achieved from minimizing redundancy, avoiding surgery delays and cancellations, and improved reimbursement coding offset the increased costs of setting up and running the clinic.
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Elderly patients pose unique challenges perioperatively. They are more likely than younger surgical patients to be mentally and physically compromised at baseline, which increases the risk of delirium and postoperative cognitive dysfunction. Postoperative cognitive risk can be predicted, however, and effective strategies exist to reduce this risk. ⋯ General recommendations for the perioperative care of elderly patients include avoiding drugs that raise the risk of delirium, ensuring adequate caloric and fluid intake, getting the patient out of bed and into physical therapy as soon as possible, and early planning for discharge. An elderly patient's postoperative cognitive risk and its impact on quality of life should be factored into the decision whether to undergo surgery. Family conferences are recommended to address the many questions and challenges that surgery in an elderly person can pose.
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Anesthesiologists are the primary users of preoperative medical consultations (consults), but the information in consults is often of limited usefulness to anesthesiologists and the rest of the surgical and perioperative team. The purpose of a consult is not to "clear" a patient for surgery but rather to optimize a patient's underlying disease states before they are compounded by the insult of surgery. Too often consults provide advice on subjects that are in the realm of expertise of the anesthesiologist--such as the type of anesthesia to administer or what intraoperative monitoring to use--and thus risk being ignored. Consults should instead provide specific data about the patient that are pertinent to the surgery, as well as guidance on preoperative and postoperative disease management.
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Case Reports
Case studies in perioperative management: challenges, controversies, and common ground.
This collection of case studies is designed to illustrate challenging and controversial aspects of perioperative medicine. The authors guide readers through four case narratives punctuated by practical multiple-choice questions followed by the authors' commentary on the evidence supporting various answer choices and related considerations. The objective is to examine issues and key evidence that should inform the decision-making process in important aspects of perioperative management.
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Perioperative fluid management remains controversial. Nevertheless, its optimization is essential to reducing the risk of postoperative complications, which have been shown to profoundly affect patients' short- and long-term outcomes. ⋯ The optimal fluid is controversial, although colloids appear to have some physiologic advantages over crystalloids. Minimally invasive technologies have emerged for intraoperative monitoring of blood flow, which may enable more precise fluid titration.