Perioperative management of the hospitalized patient

Effectiveness of preoperative medical consultations by internal medicine physicians: a systematic review

OBJECTIVE

Clinics have been established to provide preoperative medical consultations, and enable the anaesthetist and surgeon to deliver the best surgical outcome for patients. However, there is uncertainty regarding the effect of such clinics on surgical, in-hospital and long-term outcomes. A systematic review of the literature was conducted to determine the effectiveness of preoperative medical consultations by internal medicine physicians for patients listed for elective surgery.

DESIGN

Systematic searches of MEDLINE, EMBASE, CINAHL, PubMed, Current Contents and the NHS Centre for Reviews and Dissemination were conducted up to 30 April 2017.

SETTING

Elective surgery.

STUDY SELECTION

Randomised controlled trials and non-randomised comparative studies conducted in adults.

OUTCOME MEASURES

Length of hospital stay, perioperative morbidity and mortality, costs and quality of life.

RESULTS

The one randomised trial reported that preadmission preoperative assessment was more effective than the option of an inpatient medical assessment in reducing the frequency of unnecessary admissions with significantly fewer surgical cancellations following admission for surgery. A small reduction in length of stay in patients was also observed. The three non-randomised studies reported increased lengths of stay, costs and postoperative complications in patients who received preoperative assessment. The timing and delivery of the preoperative medical consultation in the intervention group differed across the included studies.

CONCLUSION

Further research is required to inform the design and implementation of coordinated involvement of physicians and surgeons in the provision of care for high-risk surgical patients. A standardised approach to perioperative decision-making processes should be developed with a clear protocol or guideline for the assessment and management of surgical patients.

Pathogenesis and treatment of post-operative cognitive dysfunction

Cognitive disorders common in the post-operative period, are the post-operative delirium (POD) and the post-operative cognitive dysfunction (POCD). The Diagnostic and Statistical Manual of Mental Disorders (DSM) does not mention POCD as a separate disease entity, and thus little is known about the pathogenesis of this disorder. The aim of this study was to review, detect and highlight the most important data cited, regarding pathogenesis mechanisms and treatment of the post-operative cognitive dysfunction (POCD). The study was carried out from March 2015 to June 2015. Literature review was achieved by searching a number of bibliographic databases including PubMed, Google Scholar and SCOPUS, surveying published articles from 1955 to 2014. As far as the selection criteria, the material consists of scientific articles published mainly over the last fifteen years, while material published before 2000 was selected because it was considered to be important. This review showed that deficits are observed in one or more discrete areas of the patient's mental state, such as attention, concentration, memory, psychomotor speed and more. This condition is usually developed over a period of more than a week or month after surgery and is more common in elderly patients. Mechanisms that have been proposed to explain this phenomenon are hyperventilation, hypotension, cerebral microemboli and inflammatory mechanisms. Its differential diagnosis will be made mainly from delirium. POCD treatment will first include the exclusion of any other serious diseases that can cause organic psychosyndrome and then focus on the actual symptoms.

Pediatric sedation and anesthesia for the oral surgeon

Even simple oral and maxillofacial surgical procedures can become challenging when the child patient has a high degree of fear and anxiety. This article reviews differences in anatomy and physiology between the adult and pediatric patient, preanesthetic assessment, fasting guidelines, and choices of sedation routes, and discusses equipment options for the management of pediatric anesthesia. After reflection on these topics and based on training and experience, oral and maxillofacial surgeons can decide the ages of patients, medical comorbidities, and techniques with which they are comfortable in performing surgery in their offices in a safe and effective manner.

The neuroinflammatory response of postoperative cognitive decline

BACKGROUND

Aseptic surgical trauma provokes a homeostatic neuroinflammatory response to promote healing and protect the organism from further injury. When this response is dysregulated, harmful consequences can follow, including postoperative cognitive decline.

SOURCES OF DATA

We performed a comprehensive search on PubMed related to postoperative cognitive dysfunction (POCD).

AREAS OF AGREEMENT

Although the precise pathogenic mechanisms for POCD remain unclear, certain risk factors are known.

AREAS OF CONTROVERSY

The mechanisms that lead to exaggerated and persistent neuroinflammation and the best way to counteract it are still unknown. AREAS FOR DEVELOPING RESEARCH: It is imperative that we identify the underlying processes that increase the risk of cognitive decline in elderly surgical patients. In this review we explore non-resolution of inflammation as an underlying cause of developing exaggerated and persistent POCD. If interventions can be developed to promote resolution of neuroinflammation, the patient's postoperative recovery will be enhanced and long-term consequences can be prevented.

Postoperative complications: delirium

Delirium is a common feature of the postoperative period, leading to increased morbidity and mortality and significant costs. Multiple factors predispose a patient to delirium in its hypoactive, hyperactive, or mixed forms. Tools have been validated for its quick and accurate identification to ensure timely and effective multidisciplinary intervention and treatment. A significant percentage of patients may require placement in skilled nursing facilities or similar care environments because of the long-lasting effects. The physician must be vigilant in the search for and identification of all forms of delirium and must effectively treat the underlying medical condition and symptoms.

Medical management of hip fracture

The United States population at the greatest risk for hip fracture, those aged 65 years and older, is steadily increasing in size. Today, the incidence of hip fracture is approximately 250,000 per year and it is expected to double in the next 30 years. Hip fracture patients are comorbid at baseline, and there are complications inherent to hip fractures that can occur in almost a predictable fashion. Overall, one in four hip fracture patients will die within one year of injury. Medical comanagement of hip fracture patients offers the best chance for successful outcome.

Current trends in preoperative patient evaluation and management for podiatric surgeons

In preparation for elective foot and ankle surgery, the podiatric surgeon often will refer the patient for a preoperative evaluation. Surgeons rely on the input of that consultant to provide a determination as to the operative risk for the patient. This article reviews the fundamental parts of the preoperative evaluation, perioperative patient management, and recent changes and trends within this arena.