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 Decision Making in
Perioperative Medicine
Clinical Pearls

FM.indd 1 29-01-2021 20:30:52

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 Decision Making in
Perioperative Medicine
Clinical Pearls

EDITOR

Steven L. Cohn, MD, MACP, SFHM

Professor Emeritus
Department of Medicine
University of Miami Miller School of Medicine
Miami, Florida

New York Chicago San Francisco Lisbon London Madrid Mexico City
New Delhi San Juan Seoul Singapore Sydney Toronto

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 To my family, I would like to thank my wife, Debbie, and children Alison and Jeff, for their love and
encouragement. And to my parents, I dedicate this book to you in recognition of the unfaltering
support you provided throughout my educational and professional career; I share this latest
accomplishment in your memory.

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FM.indd 6
 Contents

Contributors...........................................................................xi CHAPTER 8
Preface ...................................................................................xv Prevention of Infective Endocarditis...........................71
Acknowledgements ........................................................ xvii Steven L. Cohn
About the Editor..................................................................xix
SECTION III
SECTION I PREOPERATIVE EVALUATION AND
INTRODUCTION TO PERIOPERATIVE PERIOPERATIVE MANAGEMENT:
PATIENT CARE........................................................1 CO-EXISTING DISEASES AND SPECIAL
POPULATIONS......................................................77
CHAPTER 1
Role of the Perioperative Medical Consultant........... 3 CHAPTER 9
Steven L. Cohn Cardiac Risk Calculators...................................................79
Steven L. Cohn
CHAPTER 2
Preoperative Testing............................................................ 9
CHAPTER 10
Steven L. Cohn and Gerald W. Smetana
Ischemic Heart Disease....................................................85
CHAPTER 3 Steven L. Cohn
Anesthesia for Nonanesthesiologists..........................17
Jeffrey B. Dobyns and Jeffrey W. Simmons CHAPTER 11
Congestive Heart Failure.................................................97
CHAPTER 4 Gregary D. Marhefka and Howard H. Weitz
Perioperative Medication Management....................27
Paul J. Grant and Steven L. Cohn CHAPTER 12
Valvular Heart Disease....................................................103
CHAPTER 5 Gregary D. Marhefka and Howard H. Weitz
Perioperative Management of Anticoagulants������ 43
Scott Kaatz and James D. Douketis CHAPTER 13
Arrhythmias, Conduction System
SECTION II Disorders, and Cardiovascular Implant
PROPHYLAXIS......................................................51 Electronic Devices............................................................111
Nidhi Rohatgi and Paul J. Wang
CHAPTER 6
Prevention of Venous Thromboembolism................53 CHAPTER 14
Smita Kohli Kalra Hypertension.....................................................................121
Efrén Manjarrez
CHAPTER 7
Prevention of Surgical Site Infections.........................63
J. Njeri Wainaina
vii

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 viii Decision Making in Perioperative Medicine: Clinical Pearls

CHAPTER 15 CHAPTER 26
Pulmonary Disease.........................................................127 Cerebrovascular Disease................................................203
Gerald W. Smetana and Kurt Pfeifer Nidhi Rohatgi

CHAPTER 16 CHAPTER 27
Sleep Apnea and Airway Seizure Disorder, Parkinson’s Disease, and
Management.....................................................................133 Myasthenia Gravis............................................................209
Kurt Pfeifer Nidhi Rohatgi

CHAPTER 17 CHAPTER 28
Pulmonary Hypertension..............................................139 Rheumatoid Arthritis, Lupus, and
Kurt Pfeifer Other Systemic Autoimmune
Diseases...............................................................................219
CHAPTER 18 Linda A. Russell
Diabetes Mellitus..............................................................145
Leonard Feldman CHAPTER 29
The Obese Patient ...........................................................225
CHAPTER 19 Christopher M. Whinney and Sunil K. Sahai
Thyroid Disease.................................................................153
Christopher M. Whinney CHAPTER 30
The Cancer Patient...........................................................233
CHAPTER 20 Sunil K. Sahai
Adrenal Disease (Including
Pheochromocytoma)......................................................161 CHAPTER 31
Christopher M. Whinney and Sunil K. Sahai Surgery and the Older Adult........................................239
Heather E. Nye
CHAPTER 21
Anemia and Transfusion Medicine.............................167 CHAPTER 32
Barbara Slawski Enhanced Recovery Programs.....................................249
Jeffrey W. Simmons and Sunil K. Sahai
CHAPTER 22
Coagulation Disorders ...................................................175 CHAPTER 33
Patrick C. Foy and Kurt Pfeifer Substance Use Disorder.................................................257
Avital Y. O’Glasser
CHAPTER 23
Human Immunodeficiency Virus (HIV).....................185 SECTION IV
J. Njeri Wainaina COMMON POSTOPERATIVE PROBLEMS.......... 265

CHAPTER 24 CHAPTER 34
Chronic Kidney Disease..................................................189 Fever......................................................................................267
Barbara Slawski and Brahm Vasudev J. Njeri Wainaina

CHAPTER 25 CHAPTER 35
Liver Disease......................................................................195 Hypertension and Hypotension.................................271
Avital Y. O’Glasser Efrén Manjarrez

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 Contents ix

CHAPTER 36 CHAPTER 40
Myocardial Injury after Noncardiac Acute Kidney Injury.........................................................295
Surgery (MINS)..................................................................279 Barbara Slawski and Brahm Vasudev
Steven L. Cohn
CHAPTER 41
CHAPTER 37 Delirium...............................................................................299
Atrial Fibrillation...............................................................283 Heather E. Nye
Nidhi Rohatgi and Paul J. Wang
CHAPTER 42
CHAPTER 38 Pain Management............................................................303
Pneumonia and Respiratory Failure..........................287 Darin J. Correll
Cornelia Taylor
Index.....................................................................................315
CHAPTER 39
Deep Venous Thrombosis and Pulmonary
Embolism............................................................................291
Scott Kaatz

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FM.indd 10
 Contributors

Steven L. Cohn, MD, MACP, SFHM Leonard Feldman, MD, FACP, SFHM, FAAP
Professor Emeritus Program Director
Department of Medicine Combined Internal Medicine-Pediatrics
University of Miami Miller School of Medicine Urban Health Residency Program Director
Miami, Florida Comprehensive General Medicine Consult Service
Chapters 1, 2, 4, 8, 9, 10, 36 Associate Program Director
Osler Medical Residency
Darin J. Correll, MD Associate Professor
Associate Medical Director for Clinical Development Department of Medicine and Pediatrics
Pain Division Johns Hopkins School of Medicine
Vertex Pharmaceuticals Baltimore, Maryland
Boston, Massachusetts Chapter 18
Chapter 42
Patrick C. Foy, MD
Jeffrey B. Dobyns, DO, MSHA, MSHQS, FASA Associate Program Director
Associate Medical Director Hematology–Oncology Fellowship
UAB Perioperative Optimization and Transition Units Assistant Professor
Associate Professor Department of Medicine and Hematology
Department of Anesthesiology Medical College of Wisconsin
University of Alabama Milwaukee, Wisconsin
Tuscaloosa, Alabama Chapter 22
Chapter 3
Paul J. Grant, MD, SFHM, FACP
James D. Douketis, MD, FRCP(C), FACP, FCCP Chief Medical Information Officer
Director Perioperative and Consultative Medicine
Staff Physiciain in Vascular Medicine and General
Associate Professor
Internal Medicine
Department of Medicine
St. Joseph’s Healthcare
University of Michigan
Professor
Ann Arbor, Michigan
Department of Medicine
Chapter 4
McMaster University
Hamiton, Ontario
Chapter 5

xi

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 xii Decision Making in Perioperative Medicine: Clinical Pearls

Scott Kaatz, DO, MSc, FACP, SFHM Avital Y. O’Glasser, MD, FACP, FHM
Senior Staff Hospitalist Medical Director
Medical Director for Professional Development and Preoperative Medicine Clinic
Research Assistant Program Director
Clinical Professor Social Media and Scholarship
Department of Medicine Associate Professor
Henry Ford Hospital Department of Medicine
Detroit, Michigan Oregon Health and Science University
Chapters 5, 39 Portland, Oregon
Chapters 25, 33
Smita Kohli Kalra, MD, FHM
Associate Professor Kurt Pfeifer, MD, FACP, SFHM
Department of Medicine Chief
University of California Irvine School of Medicine Section of Perioperative and Consultative Medicine
Orange, California Professor
Chapter 6 Department of Medicine
Efrén Manjarrez, MD, SFHM, FACP Medical College of Wisconsin
Milwaukee, Wisconsin
Associate Professor
Chapters 15, 16, 17, 22
Department of Medicine
University of Miami Miller School of Medicine
Nidhi Rohatgi, MD, MS, FACP, SFHM
Miami, Florida
Chapters 14, 35 Chief
Surgical Co-Management Division of Hospital
Gregary D. Marhefka, MD, FACC, FACP Medicine
Program Director Clinical Associate Professor
Cardiovascular Disease Fellowship Department of Medicine
Co-Director Stanford University Medical Center
Cardiovascular Intensive Care Unit Stanford, California
Associate Professor Chapters 13, 26, 27, 37
Department of Medicine and Cardiology
Sidney Kimmel Medical College at Thomas Jefferson Linda A. Russell, MD
University Ann and Joel Ehrenkranz Chair in Perioperative
Philadelphia, Pennsylvania Medicine
Chapters 11, 12 Director of Perioperative Medicine
Director of the Osteoporosis and Metabolic Bone
Heather E. Nye, MD, PhD, SFHM Center
Associate Chief of Medicine Associate Professor of Clinical Medicine
Director Department of Medicine
Co-management and Consult Service Weill Cornell Medical College–Hospital for Special
VA Healthcare System Surgery
Professor New York City, New York
Department of Medicine and Pediatrics Chapter 28
University of California at San Francisco
San Francisco, California
Chapters 31, 41

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 Contributors xiii

Sunil K. Sahai, MD, FAAP, FACP, SFHM Brahm Vasudev, MD

Division Chief Director
General Medicine Department of Internal Medicine Nephrology Fellowship Training Program
Edna S. & William C. Levin Professorship in Internal Associate Professor
Medicine Medical College of Wisconsin
Professor Milwaukee, Wisconsin
Department of Medicine Chapters 24, 40
University of Texas Medical Branch at Galveston
Galveston, Texas J. Njeri Wainaina, MD, FACP
Chapters 20, 29, 30, 32 Medical Director
Preoperative Clinic
Jeffrey W. Simmons, MD, MSHQS, FASA Froedtert Hospital
Vice President Associate Professor
UAB Health Systems Departmentof Medicine and Surgery
Community Practices Medical College of Wisconsin
Associate Professor Milwaukee, Wisconsin
Department of Anesthesiology and Perioperative Chapters 7, 23, 34
Medicine
University of Alabama Paul J. Wang, MD, FAHA, FACC, FHRS, FESC
Tuscaloosa, Alabama Director
Chapters 3, 32 Cardiac Arrhythmia Service
Professor
Barbara Slawski, MD, MS, SFHM Department of Medicine and Cardiology
Chief Stanford University Medical Center
Section of Hospital Medicine Stanford, California
Professor Chapters 13, 37
Department of Medicine and Orthopaedic Surgery
Medical College of Wisconsin Howard H. Weitz, MD, MACP, FACC, FRCP
Milwaukee, Wisconsin Senior Associate Dean
Chapters 21, 24, 40 Bernard L. Segal Professor of Clinical Cardiology
Department of Medicine and Cardiology
Gerald W. Smetana, MD, MACP Sidney Kimmel Medical College at Thomas Jefferson
Professor University
Department of Medicine Philadelphia, Pennsylvania
Harvard Medical School Chapters 11,12
Beth Israel Deaconess Medical Center
Boston, Massachusetts Christopher M. Whinney, MD, FACP, SFHM
Chapters 2, 15 Chairman
Department of Hospital Medicine
Cornelia Taylor, MD Clinical Assistant Professor
Lead hospitalist Department of Medicine
Perioperative Comanagement Program Cleveland Clinic Lerner College of Medicine
Providence Portland Medical Center Cleveland, Ohio
Portland, Oregon Chapters 19, 20, 29
Chapter 38

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FM.indd 14
 Preface
Worldwide, over 200 million people undergo major
surgery every year. Although patients are unlikely to
die from anesthesia, the burden of perioperative com-
plications falls more on exacerbations of underlying
medical conditions, in part because we are operating
on older and sicker patients. While it is unrealistic to
believe that perioperative deaths and complications
can be completely eliminated, our goal is to minimize
this risk as much as possible.
With the explosion of medical knowledge, treat-
ment innovation, and increasing specialization, it is
difficult for any physician to keep current with the
constant influx of information. While surgeons, anes-
thesiologists, and some hospitalists may spend a major
portion of their clinical time caring for patients in the
perioperative period, many other hospitalists, pri-
mary care physicians, and their teams of nurse prac-
titioners and physicians assistants may need guidance
to address specific issues for their patients before and/
or after surgery. The goal of this book is to provide
a simple, direct guide to the medical, as opposed to
surgical and anesthetic, aspects of perioperative care.
It is not intended to be a comprehensive textbook, and
references have deliberately been limited to keep the
focus on the practical aspects of patient care. This
book is intended for use by all members of the periop-
erative team - hospitalists, general internists and spe-
cialists, anesthesiologists, surgeons, advanced practice
providers, and residents in-training who are caring for
patients before and after surgery.
The genesis of this book comes from a lecture I
gave at the annual meeting of the American Col-
lege of Physicians. Attendees at the session asked
many questions - which risk calculator should I use,
how long should surgery be delayed after percutane-
ous coronary intervention (PCI), should aspirin be
continued, how long before surgery should I stop a
direct-acting oral anticoagulant (DOAC), who needs
FM.indd 15
bridging, should surgery be delayed for a sleep study,
and many more. They also repeatedly requested lists
of risk factors, tables for medication management, and
algorithms for the approach to evaluation and man-
agement of various comorbid conditions. This book is
a response to these requests. I invited leading experts
to distill their vast knowledge and experience into
focused, need-to-know information that will be use-
ful to clinicians at the point-of-care. Over two-thirds
of the book contributors are senior faculty members
with professor or associate professor appointments
and serve as section chiefs and perioperative clinic
or service directors. The result is this practical deci-
sion-making reference which incorporates infor-
mation from multiple guidelines, clinical trials, and
expert opinion. It uses algorithms, tables, and clinical
pearls to summarize the key concepts and takeaways.
Our collective goal is to navigate clinicians to the
best evidence-based and most cost-effective decisions
that will in turn ensure quality, patient-safety, and
optimal perioperative outcomes. To this end, the con-
tent has been organized into four sections:
1. key takeaways on perioperative evaluation, test-
ing, anesthesia, and medication management;
2. prophylaxis to prevent venous thromboembolism,
surgical site infection, and endocarditis;
3. guidance on specific risk factors by organ system
to help clinicians evaluate the effect of various
comorbidities on surgical outcome and provide
perioperative management to minimize risk; and
4. a brief review of common postoperative medical
complications and their treatment.
The field of perioperative medicine continues to
evolve, and new information may make previous
guidelines and recommendations obsolete. Errors,
xv
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 xvi Decision Making in Perioperative Medicine: Clinical Pearls
inaccuracies, and omissions are an inevitable part
of any human endeavor, and the reader is urged to
use this book in the context of clinical judgment and
confirm information, particularly as it relates to med-
ications and dosing. This book was written during a
difficult time – the COVID-19 pandemic. We have
not witnessed anything like this in the modern era.
At the time this book was going to press, over 2,100,000
lives have been lost worldwide (over 425,000 in the
U.S. alone), and the numbers continue to increase.
It has burdened our health system and changed sur-
gical practice. The coronavirus affects multiple organ
systems, and we do not fully know the extent of its
after-effects. Scheduling and operating room proce-
dures have changed and continue to evolve, guided by
recommendations from various societies, and periop-
erative testing for COVID-19 varies by hospital and
test availability. There are currently no specific guide-
lines for any changes to perioperative evaluation and
FM.indd 16
testing of patients who have had COVID-19. Due to
this lack of information and the evolving nature of the
problem, I have chosen not to include a chapter on
this topic.
With over 30 years of experience in perioperative
medicine and having served as the director of preop-
erative clinics and medical consultation ­services at two
major academic medical centers (SUNY Downstate
Medical Center/Kings County Hospital and University
of Miami Miller School of Medicine/Jackson Memo-
rial Hospital), I have dedicated my medical career to
the field of perioperative medicine. I hope that this
book will provide key information to increase knowl-
edge and instill confidence in ­clinicians p ­roviding
perioperative care, and as a result help ensure ­optimal
patient outcomes.
–Steven L. Cohn, MD, MACP, SFHM
29-01-2021 20:30:55
 Acknowledgements

I would like to acknowledge James Shanahan from McGraw Hill and Diane Scott-Lichter from ACP for inviting
me to edit this book, and Kay Conerly and Christie Naglieri for their advice and support in keeping this project
on track. Special thanks to Dr. Robert Lavender, Professor of Medicine at the University of Arkansas for his
review of and critical feedback on the entire manuscript. I would also like to thank all of the contributors for
their chapters and ability to stick to the deadlines despite the COVID-19 pandemic.

xvii

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FM.indd 18
 About the Editor

Dr. Cohn is Professor Emeritus in the Department of Medicine at the University of Miami Miller School of
Medicine. He is the former Director of the Medical Consultation Service at Jackson Memorial Hospital and
Medical Director of the UHealth P ­ reoperative Assessment Center (UPAC) and M ­ edical Consultation Service
at the University of Miami Hospital, having relocated to Miami after 30 years at the State University of New
York - Downstate Medical Center in Brooklyn. He served as the Chief of the Division of General Internal
Medicine and Associate Medical Director for Performance Improvement at Downstate, and the Director of the
Preoperative Medical Consultation Clinic and Medical Consultation Service at Kings County Hospital Center.
He was responsible for education and supervision of over 1000 senior ­medical residents in both inpatient and
ambulatory care ­settings, and he has evaluated over 30,000 patients preoperatively. After receiving his medical
degree from the University of Monterrey, Dr. Cohn completed his residency in internal medicine at SUNY-
Downstate Medical Center. He is a Master of the American C ­ ollege of Physicians (ACP), a senior fellow of the
Society for Hospital Medicine (SHM), and a board member of the Society for Perioperative Assessment and
Quality Improvement (SPAQI). He has given over 400 lectures, authored/edited three books and over 100 book
chapters and peer-reviewed manuscripts, and in 2017, he received the Society for Hospital Medicine award for
Excellence in Teaching.

xix

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FM.indd 20
 INTRODUCTION
TO PERIOPERATIVE
I
PATIENT CARE

ch01.indd 1 29-01-2021 07:17:29

ch01.indd 2
 Role of the Perioperative
Medical Consultant
Steven L. Cohn, MD, MACP, SFHM
INTRODUCTION
Preoperative medical consultation and perioperative
management of the surgical patient are important roles
in the clinical practice of internists, hospitalists, and
subspecialists. The role of the hospitalist has expanded
to include comanagement for orthopedic, neuro-
surgical, vascular, and other surgical patients, and
even the role of the anesthesiologist has evolved,
focusing on perioperative medicine outside the oper-
ating room setting as well. This chapter will discuss
principles of medical consultation and the role of the
perioperative medical consultant. Specifics regarding
risk assessment and management will be discussed in
subsequent chapters.
ROLE OF THE PERIOPERATIVE
MEDICAL CONSULTANT
The role of the perioperative medical consultant can
be described as having three main goals:
1. Preoperative risk stratification – to define and
evaluate the patient’s current medical conditions,
uncover previously unrecognized problems, and
estimate the patient’s surgical risk
2. Medical optimization – to recommend risk reduc-
tion strategies, perioperative medication manage-
ment, and any additional testing if indicated
3. Postoperative follow-up – to re evaluate medical
problems, ensure compliance with recommendations
ch01.indd 3
1
and medical therapy, provide advice, and anticipate,
recognize, and treat any postoperative medical
complications
GENERAL PRINCIPLES OF MEDICAL
CONSULTATION
In 1983 Goldman and colleagues1 published their
“Ten Commandments” for effective consultation
which were modified in 2007 by Salerno and col-
leagues2 (Table 1-1). These basic principles included:
1) Determine the question. 2) Establish urgency. 3)
Look for yourself. 4) Be as brief as appropriate. 5) Be
specific and concise. 6) Provide contingency plans. 7)
Honor thy turf. 8) Teach with tact. 9) Talk is cheap and
effective. 10) Follow-up. The basic meaning of these
concepts is noted in Table 1-1, and they will be high-
lighted throughout this discussion.
Types of Consultation
It is important to recognize different types of con-
sultation requests. The traditional or standard med-
ical consult is a formal request from the patient’s
attending physician/surgeon to evaluate the patient
and answer a specific question. In this role, the con-
sultant is expected to address the question and pro-
vide advice and recommendations, but not to write
orders, request additional consultants, or assume pri-
mary care of the patient. The consultant focuses on
29-01-2021 07:17:29
 4 Decision Making in Perioperative Medicine: Clinical Pearls

TABLE 1-1. Original and Modified Ten Commandments for Effective Consultations
1983 2006
COMMANDMENTS1 MODIFICATIONS2 MEANING AND MODIFICATION

1 Determine the Determine your customer. If the specific question is not obvious, call the
question. requesting physician – and ask if they want
comanagement.

2 Establish urgency. Establish urgency. Determine whether the consultation is emergent,

urgent, or elective.

3 Look for yourself. Look for yourself. Gather data independently to be most effective.

4 Be brief as Be brief as appropriate. No need to repeat in full detail the data that were
appropriate. already documented.

5 Be specific. Be specific, be thorough, Limit recommendations to improve likelihood

and descend from thy of compliance vs. leave as many specific
ivory tower to help when recommendations as needed but offer assistance in
requested. order writing if needed.

6 Provide contingency Provide contingency Anticipate potential problems, document therapeutic

plans. plans and discuss their options and contingency plans, and provide 24-hour
execution. contact information for help if needed.

7 Thou shalt not covet Thou may negotiate In most cases, consultants should play a subsidiary
thy neighbor’s turf. joint title to thy role; however, consultants can and should co manage
neighbor’s turf. any facet of patient care the requesting physician
desires (but clarify who is responsible for what).

8 Teach with tact. Teach with tact and Sharing your expertise is appreciated – although
pragmatism. decisions on leaving references should be tailored to the
requesting physician’s specialty, level of training, and
urgency of the consult.

9 Talk is cheap and Talk is essential. There is no substitute for direct personal contact with
effective. the primary physician.

10 Provide appropriate Follow-up daily. Recognize when to fade into a background role, but
follow-up. that time is almost never on the same day as the
consult. Daily written follow-up notes are desirable,
but when problems are no longer active, sign-off after
discussing with the requesting physician.

Data from Salerno et al. Arch Intern Med. 2007; 167:271-275 and Goldman et al. Arch Intern Med. 1983;143(9):1753-1755.

the specific problem rather than other medical issues,
follows-up briefly in the postoperative period, and
then signs off. More recently, many surgeons are
requesting the medical consultant to assume more of
a co management role taking a more global approach,
addressing all necessary medical issues, writing orders,
and providing daily follow-up. The responsibilities of
the consultant and the surgical team need to be clearly
defined in advance. Another type of consultation is
the so-called “curbside” or informal consult in which
the consultant is asked to provide an opinion or advice
without personally seeing the patient. These should be
discouraged from a medicolegal standpoint as there
is no formal doctor–patient relationship although at

ch01.indd 4 29-01-2021 07:17:29

 Chapter 1 ROLE OF THE PERIOPERATIVE MEDICAL CONSULTANT
times this has been challenged in court. Instead, the
consultant should offer to perform a formal consult,
but if any advice is given, it should be generic and sim-
ple. The “consultant” should also inform the request-
ing physician not to refer to him in the medical record.
Determining the Question
Although incumbent on the requesting physician
to clearly define the reason for the consultation
and provide relevant information, this is often not
the case. Many consult requests only state “med-
ical clearance” or “preoperative evaluation” with-
out mentioning the medical problems or even the
type of surgery planned. Therefore, it is impera-
tive for the consultant to determine what is being
requested to be able to respond appropriately.
The best way to clarify the question is by direct verbal
communication with the requesting physician.
TABLE 1-2. My Ten Commandments for how to Answer the Question
QUESTIONS TO BE ADDRESSED
1) What’s wrong?
2) How bad is it?
3) Is it adequately controlled?
4) Does it affect surgical risk?
5) Are additional tests indicated to improve risk
estimation or change management?
6) Are there treatments that will reduce risk?
7) How urgent is the surgery?
8) Should surgery be postponed for further workup
and treatment?
9) What do the surgeon and anesthesiologist think?
10) What do the patient and family want?
ch01.indd 5
5
Answering the Question
In order to decide whether the patient is medically
optimized for surgery, the consultant must identify
and address any specific medical problem mentioned
as well as any others that may impact surgical risk.
As noted above, there has been a shift from the tra-
ditional consult to more of a comanagement request,
and the consultant now tends to address more than
just the specific disease that was initially mentioned.
The basic approach on how to answer the question
is listed in Table 1-2. The consultant should also
avoid use of the phrase “cleared for surgery,” even
if that was the request, as it implies that the proce-
dure carries no risk for the particular patient when
all patients are potentially at some risk when they
undergo anesthesia and surgery. The consultant can-
not and should not guarantee a complication-free
outcome.
ANSWERS
List all the patient’s relevant medical conditions.
Describe the severity of the disease.
Ensure stability of the disease as well as appropriate
medical therapy.
Decide if this disease has an important impact on risk
and whether it requires treatment now.
Ascertain what other information, if any, will affect
clinical decision-making.
Determine what treatments are available that might
lower risk of perioperative complications without
potential for harm.
Decide if there if enough time to do something if
necessary.
Assess whether the patient is medically optimized or
would benefit in terms of lower risk by additional
workup or therapy now as opposed to after surgery.
Communicate with your colleagues and get their input.
Discuss risks/benefits with the patient/family to involve
them in decision-making.
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 6 Decision Making in Perioperative Medicine: Clinical Pearls

TABLE 1-3. “Checklist” for the Consultation Report

Demographics Patient information (name, DOB, MR#)
Reason for consult
Referring physician/service/contact info
Surgery: planned procedure/date
Anesthesia: type, if known

Pertinent medical problems Cardiopulmonary disease, HTN, DM, thyroid disease, bleeding disorder, stroke,
(positive or negative) seizures

Past surgical history Operations, type of anesthesia, date, complications

Social history Tobacco, alcohol, drug use – amount, duration, last use

Medications – Rx and OTC Name, dose, frequency, compliance

(home and hospital)

Allergies Description of allergic reaction

Pertinent family history Genetically related diseases: malignant hyperthermia, bleeding disorders

Review of systems (focused) Cardiopulmonary (chest pain, dyspnea, cough), exercise capacity/ADLs,
bleeding/bruising

Physical exam Vital signs, usual exam with focus on airway, dentition, murmur/gallop,
adventitious sounds, neurologic deficit, mental status/cognitive dysfunction

Lab tests Patient and surgery directed testing (pertinent basic blood tests, ECG) and any
specific results of relevant recent/past cardiac tests (stress test, echocardiogram,
coronary angiography, pacemaker interrogation), PFTs, head CT/MRI, carotid
dopplers, etc.

Impression Patient is/is not in his/her optimal medical condition (or is medically optimized)
for the planned procedure

Recommendations Current meds (continue, stop, change dose), new meds, prophylaxis (SSI, VTE, IE),
postop monitoring (ECG, troponin, telemetry, pulse oximetry)

Discussion Discuss specifics of pertinent problems (severity, stability, degree of control),

assess level of risk, and summarize; can include results of various risk calculators
(cardiac, OSA, pulmonary, frailty, delirium) in terms of increased risk rather than
quoting a percent

Consultant information Name, contact info (cellphone/beeper); date/time consult report was written

DOB-date of birth; MR-medical record; HTN-hypertension; DM-diabetes mellitus; Rx-prescription; OTC-over the counter; ADL-
activities of daily living; ECG-electrocardiogram; PFT-pulmonary function test; CT-computerized tomography; MRI-magnetic reso-
nance imaging; SSI-surgical site infection; VTE-venous thromboembolism; IE-infective endocarditis; OSA-obstructive sleep apnea

The Consultation Report

it is important to verify all data elements with the
Ideally a template can be created in the electronic patient to ensure that the information is accurate.
medical record that will import existing information Consultants have varying styles, but the bottom line
into required fields to streamline data entry. However, is that the report includes all pertinent information,

ch01.indd 6 29-01-2021 07:17:29

 Chapter 1 ROLE OF THE PERIOPERATIVE MEDICAL CONSULTANT
TABLE 1-4. Factors that Influence or Improve
Compliance with Consultant Recommendations
Prompt response (within 24 hours)
Limit number of recommendations (≤ 5)
Identify crucial or critical recommendations
(vs. routine)
Focus on central issues
Make specific relevant recommendations
Use definitive language
Specify drug dosage, route, frequency, duration
Frequent follow-up including progress notes
Direct verbal contact
Therapeutic (versus diagnostic) recommendations
Severity of illness
Reproduced with permission from: Cohn SL. Overview of
the principles of medical consultation and perioperative
­medicine. In: UpToDate, Post TW (Ed), UpToDate, Waltham,
MA. (Accessed on June 15, 2020.) Copyright © 2020 UpToDate,
Inc. For more information visit www.uptodate.com.
addresses the question being asked, assesses medical
optimization and surgical risk, and makes recommen-
dations for perioperative management. Table 1-3 is
a checklist for items to be included in the consultation
report.
IMPROVING COMPLIANCE WITH
RECOMMENDATIONS
Although the consultant evaluates the patient, renders
an opinion, and makes recommendations, it is import-
ant to understand that this advice may not be followed.
Studies have found various factors that are associated
with improving compliance (Table 1-4).3 In following
Goldman’s Ten Commandments, determining the
question and answering it in an appropriate manner
is paramount. Establish the urgency and respond in a
timely fashion. Elective consults should be answered
within 24 hours (ideally the same day) and sooner if
deemed urgent (within several hours) or emergent
ch01.indd 7
7
(immediate phone contact followed by in-person eval-
uation within 10–30 minutes or less). Be concise, prior-
itize crucial recommendations, and limit the number
of recommendations. The longer the list, the less
likely all recommendations will be addressed. The
more severely ill the patient, the more likely recom-
mendations will be implemented. Recommendations
regarding therapy are somewhat more likely to be
followed than those for diagnostic tests. Use defin-
itive language and be specific, particularly when
recommending medications. Specify the drug (not
class), dose, frequency, route of administration, and
duration of therapy as the surgeon may not be famil-
iar with the medication. Although some EMRs may
automatically notify the requesting physician when
a consult has been completed, and the current gen-
eration of clinicians tends to rely on text messaging
rather talking, direct verbal communication with the
surgeon is the most-effective means of discussing
your thoughts and recommendations. A preliminary
text can be sent, but it should be quickly followed by
a phone call to ensure that the message was received
and that there are no questions regarding patient man-
agement. Make appropriate follow-up visits to ensure
that recommendations were followed and reassess the
patient, and document your findings in a progress
note. Depending on the situation, follow-up may be
as short as a single postoperative visit, or in the case of
a severely ill patient or co management, may be daily
until improvement or discharge. When signing off,
document this in the medical record and inform the
surgical team. Also, indicate if the patient requires any
specific follow-up after discharge.
SUMMARY
Perioperative medical consultation is a combination
of art, science, and politics. The ideal medical con-
sultant is someone who will “render a report that
informs without patronizing, educates without lec-
turing, directs without ordering, and solves the prob-
lem without making the referring physician appear
to be stupid.”4 By following the principles outlined by
Goldman and colleagues, the medical consultant will
provide information and advice that will be helpful
to the requesting physician who will then implement
the recommendations with the goal being improved
patient outcomes.
29-01-2021 07:17:29
 8 Decision Making in Perioperative Medicine: Clinical Pearls
Clinical pearls
■■ A good consultant follows the three A’s of
medicine – availability, affability, and ability.
■■ Obey Goldman’s “Ten Commandments” –
understand the question, respond to it in a timely
fashion with appropriate recommendations, and
communicate with the requesting physician and
surgical team to ensure compliance.
REFERENCES
1. Goldman L, Lee T, Rudd P. Ten commandments for
effective consultations. Arch Intern Med. 1983;143(9):
1753-1755.
ch01.indd 8
2. Salerno SM, Hurst FP, Halvorson S, Mercado DL.
Principles of effective consultation: an update for
the 21st-century consultant. Arch Intern Med. 2007;
167(3):271-275.
3. Cohn SL. Overview of the principles of medical consul-
tation and perioperative medicine. UpToDate. Waltham,
MA: UpToDate Inc. Available at https://www.uptodate.
com. Accessed on June 15, 2020.
4. Bates R. The two sides of every successful consultation.
Med Econ. 1979;7:173-180.
29-01-2021 07:17:29

Preoperative Testing
Steven L. Cohn, MD, MACP, SFHM and Gerald W. Smetana, MD, MACP
INTRODUCTION
Preoperative evaluation of apparently healthy patients
is a common activity for internists and other medi-
cal specialists. In general, the most important test is
a careful medical history to seek elements which may
increase perioperative risk above baseline. Individual
laboratory and other tests should be ordered selec-
tively based on patient and procedure-related charac-
teristics, and in general, should not be done routinely
without a clinical indication. Despite decades of evi-
dence arguing against routine testing, medical cul-
ture is such that some of this testing persists. General
rationales for ordering preoperative tests are to iden-
tify patients at higher risk for particular postoperative
complications, to guide anesthetic management, to
predict which patients require particular monitoring
after surgery, and for medicolegal reasons. In fact, in
most instances, testing for any of these indications
rarely achieves the desired goals. In this chapter, we
discuss the recommended selective indications for
testing.
If enough routine tests are ordered, it is likely that
one or more tests may be abnormal due to the typical
definition of normal as within 2 standard deviations
from the mean. This means, by definition, that in 5%
of patients without underlying disease, a test will be
abnormal. If tests are done routinely, an abnormal test
result may result in an unnecessary delay of surgery,
patient worry, and additional testing which may be
costly, and in some cases, carry risk for the patient.
ch02.indd 9
2
A selective approach to preoperative test ordering
avoids this trap.
Commonly, the results of preoperative testing do
not actually change perioperative care. Results are
more likely to be ignored or overlooked rather than
guide perioperative care. An optimal test would be one
that accurately identified patients at risk of postoper-
ative complications who would otherwise be charac-
terized as low-risk based on a history and physical, is
inexpensive, carries little risk, and has a high sensitivity
and specificity. Few tests have these qualities.
Increasingly, surgeons, anesthesiologists, and hos-
pital standards committees have recognized this fact
and are requiring fewer routine tests than had been
the case historically. For example, in the Choosing
Wisely guidelines, national societies were given the
chance to list five things that we should question or
not do. Many of the relevant surgery and anesthesi-
ology guidelines made a recommendation to avoid-
ing unnecessary preoperative testing.1 At least 13
different societies chose recommendations to limit
preoperative testing. Table 2-1 summarizes these
recommendations. In 2012, the American Society of
Anesthesiologists stated in a practice advisory that
“preoperative tests should not be ordered routinely…
tests may be ordered, required, or performed on a
selective basis for purposes of guiding or optimizing
perioperative management.”2
As an example of the unnecessary overuse of preop-
erative tests, in a study of patients undergoing low-risk
surgery (elective hernia repair), 34% of patients had
9
29-01-2021 07:22:28
 10 Decision Making in Perioperative Medicine: Clinical Pearls

TABLE 2-1. Choosing Wisely Campaign. Society Recommendations to Limit Preoperative Testing
SOCIETY RECOMMENDATION

American Society of Hematology- Don’t perform routine preoperative hemostatic testing (PT, aPTT) in
American Society of Pediatric an otherwise healthy child with no prior personal or family history of
Hematology/Oncology bleeding.

American Society of Anesthesiologists
Don’t obtain baseline laboratory studies in patients without significant
systemic disease (ASA I or II) undergoing low-risk surgery – specifically
complete blood count, basic or comprehensive metabolic panel,
coagulation studies when blood loss (or fluid shifts) is/are expected to
be minimal.

Society of General Internal Medicine Don’t perform routine preoperative testing before low-risk surgical
procedures.

American College of Surgeons Avoid admission or preoperative chest x-rays for ambulatory patients
with unremarkable history and physical exam.

American Academy of Ophthalmology Don’t perform preoperative medical tests for eye surgery unless there
are specific medical indications.

The Society of Thoracic Surgeons Prior to cardiac surgery, there is no need for pulmonary function testing
in the absence of respiratory symptoms.

The Society of Thoracic Surgeons Patients who have no cardiac history and good functional status do not
require preoperative stress testing prior to noncardiac thoracic surgery.

Society of Cardiovascular Computed Don’t order coronary artery calcium scoring for preoperative evaluation
Tomography for any surgery, irrespective of patient risk.

American Society for Clinical Avoid routine preoperative testing for low-risk surgeries without a
Pathology clinical indication.

American Society of Echocardiography Avoid echocardiograms for preoperative/perioperative assessment of

patients with no history or symptoms of heart disease.

American College of Radiology Avoid admission or preoperative chest x-rays for ambulatory patients
with unremarkable history and physical exam.

American College of Physicians Don’t obtain preoperative chest radiography in the absence of a clinical
suspicion for intrathoracic pathology.

Adapted with permission from: Meyer TE. Perioperative management of heart failure in patients undergoing noncardiac surgery.
In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on January 27, 2020.) Copyright © 2020 UpToDate, Inc. For more
information visit www.uptodate.com.

no comorbidities (according to NSQIP definitions), Routinely obtained preoperative testing without

and therefore no indication for preoperative testing.3
Yet 52% received a preoperative complete blood count
(or at least one component) and 15% received a coag-
ulation test. Neither the decision to order routine tests,
nor the test results, predicted rates of postoperative
complications.
a clinical indication is rarely abnormal. When it is
abnormal, the results often do not change preopera-
tive risk assessment or perioperative care. In an early
summary of the literature, preoperative testing only
modestly influenced the likelihood of postoperative
complications. Most patients who were at risk of specific

ch02.indd 10 29-01-2021 07:22:28

 Chapter 2 PREOPERATIVE TESTING 11

TABLE 2-2. The Incidence of Abnormal Preoperative Tests That Change Management and the Change in the
Likelihood of Postoperative Complications Based on the Test Results
TEST INCIDENCE OF ABNORMALITIES THAT LR + LR-
INFLUENCE MANAGEMENT (%)

Hemoglobin 0.1% 3.3 0.90

White blood cell count 0.0% 0.0 1.00

Platelet count 0.0% 0.0 1.00

Prothrombin time (PT) 0.0% 0.0 1.01

Partial thromboplastin time (PTT) 0.1% 1.7 0.86

Electrolytes 1.8% 4.3 0.80

Renal function 2.6% 3.3 0.81

Glucose 0.5% 1.6 0.85

Liver function tests 0.1%

Urinalysis 1.4% 1.7 0.97

Electrocardiogram 2.6% 1.6 0.96

Chest radiograph 3.0% 2.5 0.72

Adapted from: Smetana GW, Macpherson DS. The case against routine preoperative laboratory testing. Med Clin Am 2003;87:7-40
with permission from Elsevier.

complications could be identified through a careful his-
tory and physical examination. The incidence of abnor-
malities that changed management ranged from 0% to
3%, depending on the test (Table 2-2).
SPECIFIC TESTS
Complete Blood Count
For patients undergoing surgery with a large amount
of anticipated blood loss, it is reasonable to perform a
CBC, which includes measurement of hemoglobin and
hematocrit, before surgery. This will guide discussions
with the patient about a potential need for perioper-
ative transfusions. For low-risk surgery, or high-risk
surgery with little anticipated blood loss, a preoperative
CBC is not necessary. It is also reasonable for patients
over 65 years old who are undergoing major surgery.
While preoperative anemia confers a higher risk of
postoperative mortality than for patients with nor-
mal hemoglobin and hematocrit, it is unknown if the
anemia itself increases mortality, or if it is a marker for
underlying comorbidities (see Chapter 21) (Table 2-3).
In general, a platelet count adds little if there is no
clinical history of bleeding tendency. It is rare for clini-
cally significant thrombocytopenia (< 50,000) to exist
in the absence of a clinical history of bleeding ten-
dency or a chronic medical condition that can cause
thrombocytopenia. We suggest this test for patients
undergoing neuraxial anesthesia and those under-
going intracranial neurosurgery. A white blood cell
count does not predict infectious or other periopera-
tive complications. However, since both are elements
of a CBC, which is an inexpensive test, it is reasonable
to perform a full CBC if there is an indication for mea-
suring hemoglobin or hematocrit before surgery.
Measurement of Renal Function and Electrolytes
Perioperative chronic kidney disease may influence
anesthetic management and prompt more careful or
frequent monitoring of renal function after surgery.

ch02.indd 11 29-01-2021 07:22:28

 12 Decision Making in Perioperative Medicine: Clinical Pearls

TABLE 2-3. Indications for Commonly Ordered Preoperative chronic kidney disease (serum creatinine
Preoperative Tests > 2.0 mg/dl) is also one of six independent risk factors
for postoperative cardiac complications in the widely
TEST INDICATIONS*
used revised cardiac risk index (RCRI).4 Preoperative
Hemoglobin Symptoms of anemia, major blood measurement of renal function (primarily serum cre-
loss surgery atinine) should be performed selectively, rather than
in all patients undergoing surgery. Abnormalities are
WBC Infection, myeloproliferative uncommon in patients with no medical conditions
disease, myelotoxic meds
or medication use for which chronic kidney disease
Platelets Abnormal hemostasis, is possible. For example, it is appropriate to check
chemotherapy or renal function before major surgery in patients with
medications associated with diabetes, congestive heart failure, or known chronic
thrombocytopenia kidney disease. It is reasonable to measure in patients
over age 50 years old undergoing major surgery, as the
PT/INR History of bleeding diathesis, liver
disease, malnutrition, antibiotics, prevalence of chronic kidney disease increases with
warfarin age. Preoperative renal function testing is also recom-
mended for patients who are taking medications that
PTT History of bleeding diathesis may affect renal function. This would include ACE
Electrolytes CKD, HF, diarrhea, medications inhibitors, ARBs, diuretics, and NSAIDs.
that increase risk of electrolyte A theoretical reason for measuring electrolytes
abnormalities (ACEI/ARB, diuretic) would be to identify patients who may require potas-
sium supplementation after surgery or to predict the
BUN/ CKD, HTN, cardiac disease, elderly, potential for arrhythmia. The indication for measur-
creatinine meds ing preoperative electrolytes is like those noted above
Glucose DM (history or suspected); obesity, for measurement of renal function. In particular, pre-
steroids operative measurement of electrolytes is appropriate
for patients undergoing major surgery who are taking
LFTs Hepatitis (acute); cirrhosis one of the above medications. Neither preoperative
U/A GU instrumentation renal function nor electrolytes should be measured
routinely.
Pregnancy Woman of childbearing age,
test particularly if possibility of
pregnancy cannot be excluded Glucose
by history Hyperglycemia has been associated with an increase in
ECG Known/suspected cardiac disease, postoperative complications. While routine screening
intermediate-high risk surgery for all patients is not recommended, a serum glucose
is indicated for patients with known DM to assess cur-
CXR Active/suspected pulmonary rent control, and those with signs and symptoms sug-
disease gestive of DM for diagnostic purposes. Other potential
WBC-white blood cell; PT-prothrombin time; INR- indications include corticosteroid use and obesity,
International Normalized Ratio; PTT-partial thromboplastin both of which may be associated with hyperglycemia.
time; BUN-blood urea nitrogen; LFT-liver function tests; Although perioperative glucose levels correlate
U/A-urinalysis; ECG-electrocardiogram; CXR-chest x-ray; better than HbA1C levels for perioperative compli-
CKD-chronic kidney disease; HF-heart failure; ACEI/ARB-
angiotensin converting enzyme inhibitor/angiotensin
cations, the ADA recommends obtaining HbA1C in
receptor blocker; HTN-hypertension; DM-diabetes mellitus; hospitalized patients with DM and those with hyper-
GU-genitourinary glycemia (glucose >140 mg/dl) if not done in the past

ch02.indd 12 29-01-2021 07:22:28

 Chapter 2 PREOPERATIVE TESTING 13

3 months.5 Because the HbA1C level correlates with The ASA Task Force on Preanesthesia Evaluation
the average glucose during the past 3 months, serum Practice Advisory recommends against routine testing
fructosamine level may be a better measure of recent and suggests selective ordering of coagulation tests
glucose control as it reflects the average over the past based on history of bleeding disorders, renal dysfunc-
2–3 weeks. (See chapter on DM.) tion, liver dysfunction, type and invasiveness of pro-
cedure, and medications.2 The NICE guidelines also
Liver Function Tests recommend against routine preoperative hemostasis
tests but to consider them in people with chronic liver
In general, these tests should only be obtained in
disease undergoing intermediate, major, or complex
patients with suspected acute hepatitis (viral, alcoholic,
surgery or in those taking anticoagulants.7
or drug-induced), as elective surgery is contraindicated
in this setting, or as needed to evaluate patients with
Urinalysis
cirrhosis using the Child Pugh or MELD scores (albu-
min, bilirubin). Otherwise, liver function tests should The theory behind ordering a routine urinalysis before
not be performed preoperatively. (See chapter on liver surgery is to identify and treat asymptomatic bacteri-
disease.) uria (urinary tract infection or colonization), thereby
reducing the risk of perioperative infections. Most
Coagulation Tests studies on routine urinalyses have involved orthope-
dic patients undergoing total joint arthroplasty with
Standard coagulation tests such as the prothrombin
the objective being to prevent a prosthetic joint infec-
time/international normalized ratio (PT/INR) and
tion. However, the evidence has not shown a benefit
partial thromboplastin time (PTT) are frequently
for these patients. Although patients with asymptom-
obtained preoperatively to assess coagulopathy and
atic bacteriuria may have a higher incidence of pros-
guide therapy. However, the preponderance of evi-
thetic joint infection, there was no difference between
dence from multiple studies suggests that these
those treated with antibiotics and those who were
screening tests are not useful in predicting periopera-
not treated, suggesting that asymptomatic bacteriuria
tive bleeding in patients without known bleeding risk
may be a marker for risk of infection rather than the
factors. Furthermore, abnormal results often lead to
cause. Furthermore, the pathogens in the joint infec-
additional testing and possible delays in planned sur-
tions did not match those organisms isolated in the
gery. The PT/INR and PTT were designed to moni-
urine culture. The International Consensus Meeting
tor the anticoagulant effects of warfarin and heparin
on Periprosthetic Joint Infection recommended not
and to assess coagulation factor deficiencies – not to
to order routine urinalyses before total joint replace-
predict bleeding or guide hemostatic therapy.
ments although this is still a commonly encountered
Taking an accurate bleeding history, which inclu­
practice.8 In addition, guidelines from the Infectious
des medications that might affect hemostasis and the
Disease Society of America recommend against
patient’s personal and family bleeding history, will
screening for or treating asymptomatic bacteriuria in
detect most significant bleeding disorders and is more
patients undergoing elective nonurologic procedures
important than unselected blood testing (see chapter
(strong recommendation, low-quality evidence).9 On
on Coagulation Disorders). Most adult patients with
the other hand, in patients who will undergo endo-
hemophilia will have already been diagnosed, and
scopic urologic procedures associated with mucosal
patients with von Willebrand’s disease may also be
trauma, we recommend screening for and treating
more likely to be identified by history as PTT alone
asymptomatic bacteriuria prior to surgery (strong
will not necessarily be abnormal. Although bleeding
recommendation, moderate-quality evidence).
in certain situations like neurosurgery could be cata-
strophic, a large study in this patient population also
Urine Pregnancy Test
found that bleeding history was more predictive of
bleeding complications (need for transfusion, return Routine preoperative pregnancy testing is controver-
to the operating room, or 30-day mortality) than sial, although it is commonly required for all women
routine blood tests.6 of reproductive age before anesthesia. Pregnancy can

ch02.indd 13 29-01-2021 07:22:28

 14 Decision Making in Perioperative Medicine: Clinical Pearls
be excluded either by history, using a WHO check-
list,10 or by testing. The provider can be reasonably
certain that the woman is not pregnant (>99% nega-
tive predictive value) if she has no symptoms or signs
of pregnancy and meets any of the following criteria:
1) She has not had intercourse since last normal men-
ses. 2) She has been correctly and consistently using
a reliable method of contraception. 3) She is within
the first 7 days after normal menses. 4) She is within
4 weeks postpartum (for nonlactating women). 5) She
is within the first 7 days postabortion or miscarriage.
or 6) She is fully or nearly fully breastfeeding, amenor-
rhoeic, and less than six months postpartum.
The ASA guidelines recommend offering preg-
nancy testing to women in whom pregnancy is pos-
sible.2 In some institutions, rather than being a true
requirement, women have the option to refuse testing
after having a discussion regarding the risks associated
with anesthesia, surgery, and pregnancy. If she refuses,
it is important to document this process in the medi-
cal record. Although the incidence of a positive test is
low, it typically results in cancellation of surgery. Since
most preoperative testing is done days to weeks prior
to surgery, routine screening for pregnancy is typically
done on the day of surgery.
Electrocardiogram
Although electrocardiographic abnormalities are
often associated with postoperative cardiac complica-
tions, they typically do not provide additional infor-
mation beyond that obtained from the history and
physical exam. Multiple abnormalities identified to
have prognostic significance, although with poor con-
cordance across various studies, include arrhythmias,
pathological Q-waves, left ventricular hypertrophy,
ST depression, QTc prolongation, and bundle branch
blocks. Some of these are detectable on physical exam,
and most do not usually result in any change in man-
agement and almost never alter outcomes. The most
important ECG finding which is rarely encountered
would be evidence of a silent myocardial infarction
(pathological Q waves) that was not present on a pre-
vious ECG done in the past 2 months.
Electrocardiographic abnormalities increase with
age; therefore, this has often been used as a criterion to
obtain a baseline preoperative electrocardiogram. The
2014 ESC guidelines recommend an ECG for patients
ch02.indd 14
with risk factors scheduled for intermediate or high-
risk surgery. However, they also state to consider a pre-
operative ECG in patients with a risk factor undergoing
low-risk surgery or with no risk factors if above 65 years
of age and undergoing intermediate-risk surgery.11
The National Institute for Health and Care Excellence
(NICE) Guideline Development Group (GDG) also
said to consider a resting ECG in ASA 1 patients over
65 undergoing major or complex surgery if there were
no previous ECG results available from the past year.7
The 2007 ACC/AHA guidelines did not recommend a
preoperative ECG based on age alone, required at least
one clinical risk factor (except for vascular surgery),
and recommended against an ECG in asymptomatic
patients for low-risk surgeries.12 However, the 2014
ACC/AHA guidelines changed to a more liberal posi-
tion basically suggesting that an ECG could be obtained
in any asymptomatic patient even without heart disease
except for those undergoing low-risk surgery, but did
note that a standard age or risk factor cutoff for use of
preoperative testing has not been defined.13 The ASA
Task Force recognized that age alone may not be an
indication for an ECG and stated that cardiovascular
risk factors may be an indication for ECG.2
Another reason given for obtaining a preoperative
ECG is to have a baseline for comparison postoper-
atively if needed. However, this is not as helpful as
troponin in making the diagnosis of a postoperative
myocardial infarction.
We recommend obtaining a preoperative ECG if
the history suggests cardiac disease or if the patient is
undergoing vascular and possibly other high-risk sur-
gery. It is not indicated for patients undergoing low-
risk surgery or based purely on age.
Chest X-rays
Abnormal findings on a preoperative chest x-ray are
rarely unexpected. For example, x-ray findings of
COPD or CHF would not usually escape detection
by a careful history and physical examination. Studies
have suggested that approximately 1% of preoperative
chest x-rays yield results that are unexpected, and even
fewer change management. In addition, these findings
do not necessarily predict postoperative pulmonary
complication rates more accurately than clinical eval-
uation. So once again, this test should be performed
selectively.
29-01-2021 07:22:29

Certain incidental findings may occasionally
prompt further elective outpatient evaluation, such
as a solitary nodule. However, the recommendations
for screening for such conditions do not differ in the
perioperative period. Another rationale is to provide
a baseline in the event that a postoperative chest x-ray
is required for a clinical indication. However, poten-
tial findings of pneumonia or CHF can easily be diag-
nosed without the benefit of a preoperative baseline.
The American College of Physicians recommended
a preoperative chest x-ray for patients over 50 years
old undergoing major surgery, and those with under-
lying cardiopulmonary disease.14 This is largely expert
opinion as opposed to strongly evidence-based and
is now somewhat outdated. The American Society
of Anesthesiologists observes similar risk factors but
does not feel that these are unequivocal indications for
a preoperative chest x-ray.2 These risk factors include
smoking, recent upper respiratory tract infection,
COPD, cardiac disease, and advanced age.
Clinical pearls
■■ Preoperative testing is NOT indicated when
used as screening/routine testing or for mini-
mally invasive surgeries or procedures.
■■ Do not repeat tests when recent studies were
done within the past 6 months, and results are
unlikely to have changed.
■■ Preoperative testing IS indicated when done
selectively based on a targeted history and phys-
ical or for higher-risk surgical procedures in
higher-risk patients.
■■ Age alone should not be criteria to order a test.
■■ Do NOT order preoperative tests IF the results
will NOT influence management.
REFERENCES
1. Choosing Wisely Campaign. “Search on: preoperative.”
Available at https://www.choosingwisely.org/. Accessed
January 27, 2020.
2. Committee on Standards and Practice Parameters,
Apfelbaum JL, Connis RT, et al. Practice advisory for
preanesthesia evaluation: an updated report by the
American Society of Anesthesiologists Task Force on
Preanesthesia Evaluation. Anesthesiology. 2012;116(3):
522‐538.
ch02.indd 15
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3. Benarroch-Gumpel J, Sheffield KM, Duncan CB, et al.
Preoperative laboratory testing in patients undergo-
ing low-risk ambulatory surgery. Ann Surg. 2012;256:
518-522.
4. Lee TH, Marcantonio E, Mangione CM, et al. Derivation
and prospective validation of a simple index for pre-
diction of cardiac risk of major noncardiac surgery.
Circulation. 1999;100:1043-1049.
5. American Diabetes A. 15. Diabetes Care in the Hospital:
Standards of Medical Care in Diabetes-2020. Diabetes
Care. 2020;43(suppl 1):S193-S202.
6. Seicean A, Schiltz NK, Seicean S, Alan N, Neuhauser
D, Weil RJ. Use and utility of preoperative hemostatic
screening and patient history in adult neurosurgical
patients. J Neurosurg. 2012;116:1097‐1105.
7. O’Neill F, Carter E, Pink N, Smith I. Routine preopera-
tive tests for elective surgery: summary of updated NICE
guidance. BMJ. 2016;354:i3292. Available at https://www.
nice.org.uk/guidance/ng45/chapter/Recommendations.
8. Proceedings of the International Consensus Meeting
on Periprosthetic Joint Infection. Gehrke T, Parvizi J.
2013. Available at https://rothmanortho.com/stories/
blog/rothman-jefferson-philadelphia-internation-
al-joint-consensus. Accessed June 4, 2020.
9. Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice
Guideline for the Management of Asymptomatic
Bacteriuria: 2019 Update by the Infectious Diseases
Society of America. Clinical Infectious Diseases.
2019;68:e83e110. Available at https://doi.org/10.1093/
cid/ciy1121.
10. World Health Organization. Selected Practice
Recommendations for Contraceptive Use. 3rd ed. World
Health Organization; 2016. Available at https://apps.
who.int/iris/handle/10665/252267.
11. Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/
ESA Guidelines on non-cardiac surgery: cardiovascu-
lar assessment and management: The Joint Task Force
on non-cardiac surgery: cardiovascular assessment and
management of the European Society of Cardiology
(ESC) and the European Society of Anaesthesiology
(ESA). Eur Heart J. 2014;35(35):2383‐2431.
12. Fleisher LA, Beckman JA, Brown KA, et al. ACC/
AHA 2007 guidelines on perioperative cardiovascular
evaluation and care for noncardiac surgery: a report
of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines
(Writing Committee to Revise the 2002 Guidelines
on Perioperative Cardiovascular Evaluation for
Noncardiac Surgery) developed in collaboration with
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Society of Nuclear Cardiology, Heart Rhythm Society,
Society of Cardiovascular Anesthesiologists, Society
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 16 Decision Making in Perioperative Medicine: Clinical Pearls
for Cardiovascular Angiography and Interventions,
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for Vascular Surgery. J Am Coll Cardiol. 2007;50(17):
e159‐e241.
13. Fleisher LA, Fleischmann KE, Auerbach AD, et al.
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cular evaluation and management of patients under-
going noncardiac surgery: a report of the American
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29-01-2021 07:22:29
 Anesthesia for
Nonanesthesiologists
Jeffrey B. Dobyns, DO, MSHA, MSHQS, FASA and Jeffrey W. Simmons, MD, MSHQS, FASA
INTRODUCTION: BEYOND
PHARMACOLOGY AND PHYSIOLOGY
Anesthesia is an interplay between pharmacology
and physiology. Medications used during anesthesia
provide a specific function of a balanced anesthetic
technique comprised of amnesia, analgesia, akinesia,
hypnosis, and control of autonomic responses. The
anesthesiologist directs this biological interaction
while also playing a vital leadership role in the periop-
erative team. This physician leads a team of nurse
anesthetists, anesthesia assistants, or residents, engages
with hospital consults to develop a safe anesthetic plan,
communicates risks and plans with the surgery team,
and directs intraoperative and perioperative care. Most
importantly, the anesthesiologist will explain the anes-
thesia-related risks, benefits, and alternatives with the
patient with the goal of shared decision-making.
PREOPERATIVE EVALUATION
The overall goal of preoperative evaluation for anes-
thesiologists is threefold. One, identify modifiable
risks that are amenable to optimization before surgery
and create a plan of action to address or improve the
comorbidity in an attempt to improve overall patient
outcomes. Two, risk stratify the patient based on a
thorough assessment to determine the need for addi-
tional cardiopulmonary testing, delay in the procedure,
or move to an appropriate surgical location. Ideally, the
CH03.indd 17
3
first two goals are accomplished in the weeks before
surgery to allow for intervention. Optimization for
surgery includes patient education on the risks, bene-
fits, and alternatives to surgery and anesthetic options.
Three, develop a patient-specific anesthetic plan based
on the type of surgery and comorbidities. The day of
surgery anesthesia care team determines the final anes-
thetic plan, including drug choice and dosing sequence,
level of sedation required, definitive airway manage-
ment, and communication with the surgery team.
The anesthesia and surgical teams often solicit
input from primary care or specialty medicine ser-
vices, such as cardiology or pulmonology, to aid in
preoperative risk stratification. The purpose of this
consultation is to assess the opportunity for optimiza-
tion of chronic medical conditions that have a direct
bearing on surgical and anesthetic outcomes.
Surgical clearance is an older term that implies a
degree of certainty of outcome. It does not address
perioperative care, risk factor modification, or coordi-
nation of care issues, and is not focused on longitudi-
nal health improvement and management. Clearance
often leaves patients feeling as though there is “zero
risk” to them from their anesthetic and surgical pro-
cedure. Writing “cleared for surgery” has no meaning
to the surgery and anesthesia teams as there is no indi-
cation of the basis of the clearance. Equally less useful
are the common recommendations to “avoid hypoxia,
hypotension, and hypothermia,” since avoidance of
these factors is fundamental to all anesthetics.
17
29-01-2021 07:25:05
 18 Decision Making in Perioperative Medicine: Clinical Pearls

All surgical procedures carry an element of risk, Airway Evaluation

where total risk is the sum of intrinsic and modifi-
Airway management is a critical skill for anesthesia
able factors.1 Optimization focuses on the preemptive
providers and is a primary focus of the preoperative
reduction of elements of modifiable risk, such as pre-
evaluation. Numerous factors on the preanesthesia
operative smoking cessation. Optimization purposely
assessment suggest difficulties in airway manage-
does not imply outcome certainty and sets the stage
ment (Table 3-3). Numerous scoring systems predict
for coordinated perioperative care among a multi-
difficult intubation. The Mallampati Score identifies
tude of providers, such as primary and specialty care,
patients with poorly visualized pharyngeal structures
physical and occupational therapy, and social work-
and is the most widely used (Figure 3-1). No scoring
ers, to name a few. Furthermore, optimization focuses
system is perfectly predictive, and anesthesia provid-
on longitudinal healthcare improvement. High-qual-
ers must anticipate the unexpected difficult airway.
ity, risk-factor-modifying recommendations, such as
Proper utilization of airway scoring systems coupled
increasing preoperative exercise tolerance, nutrition,
with a physical examination is essential to executing a
smoking cessation, and anemia management, sig-
safe anesthetic and minimizing unexpected difficulty.
nificantly improve anesthetic and surgical outcomes
Equally crucial to assessing for difficult intubation
(Table 3-1).
is anticipating and planning for airway difficulty at
ASA Scoring extubation.

The American Society of Anesthesiologists patient ANESTHESIA MEDICATIONS

severity scoring scale groups patients into one of six
different categories based on comorbidities and func- General anesthesia is a medication-induced state of
tional impairment (Table 3-2). Interrater reliability unconsciousness resulting in amnesia and analgesia
is paramount when using the ASA patient severity with or without reversible skeletal muscle paralysis.
scoring system and can be improved when specific The concept of “balanced anesthesia” refers to the use
examples are provided related to each score. The ASA of two or more medications to produce a comparable
scoring system demonstrates excellent risk prediction effect as that of a larger dose of a single medication
in multiple studies and is often a component of com- (Table 3-4). Balanced anesthesia minimizes patient
bined risk scoring systems. risk and maximizes patient comfort and safety. The
objectives are to relieve patient anxiety, minimize pain,
and reduce the potential for adverse effects inherent in
TABLE 3-1. Surgical Clearance Versus Optimization
larger doses of analgesic and anesthetic medications.
CLEARANCE OPTIMIZATION
Common Induction Agents
• Implies a degree of • Purposefully does
certainty of outcome not imply certainty of Etomidate. Etomidate is an induction medication
• Usually does not outcome selected for its hemodynamic stability. While etomi-
address coordination • Recommends date does provide hemodynamic stability, it is asso-
of care issues perioperative ciated with considerably higher rates of nausea and
• Does not usually management vomiting when compared with propofol. Induction
address perioperative • Integrates care of doses are associated with transient adrenal sup-
care specifically medical issues with
pression, the clinical significance of which remains
• Not focused on other involved care
debated.
longitudinal providers
healthcare • Establishes ownership Propofol. Propofol is the most commonly used
improvement and for patient care induction agent due to its rapid onset and recovery.
management initiatives It has beneficial antiemetic properties and relatively
• Focuses on longitudinal
benign side effects. In addition to antiemetic prop-
healthcare improvement
erties, propofol has antipruritic and bronchodilatory
and management
properties.

CH03.indd 18 29-01-2021 07:25:05

 Chapter 3 ANESTHESIA FOR NONANESTHESIOLOGISTS 19

TABLE 3-2. American Society of Anesthesiologists Patient Classifications

ASA PS
CLASSIFICATION DEFINITION EXAMPLES, INCLUDING, BUT NOT LIMITED TO:

ASA I A normal healthy Healthy, nonsmoking, no or minimal alcohol use

patient

ASA II A patient with mild Mild diseases only without substantive functional limitations.
systemic disease Examples include (but not limited to): current smoker, social
alcohol drinker, pregnancy, obesity (30 < BMI < 40), well-
controlled DM/HTN, mild lung disease

ASA III A patient with severe Substantive functional limitations; one or more moderate to severe
systemic disease diseases. Examples include (but not limited to): poorly controlled
DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis,
alcohol dependence or abuse, implanted pacemaker, moderate
reduction of ejection fraction, ESRD undergoing regularly
scheduled dialysis, premature infant PCA < 60 weeks, history
(>3 months) of MI, CVA, TIA, or CAD/stents.

ASA IV A patient with severe Examples include (but not limited to): recent ( < 3 months) MI,
systemic disease that CVA, TIA, or CAD/stents, ongoing cardiac ischemia or severe valve
is a constant threat dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD
to life or ESRD not undergoing regularly scheduled dialysis

ASA V A moribund patient Examples include (but not limited to): ruptured abdominal/thoracic
who is not expected aneurysm, massive trauma, intracranial bleed with mass effect,
to survive without the ischemic bowel in the face of significant cardiac pathology or
operation multiple organs/system dysfunction

ASA VI A declared brain-dead *The addition of “E” denotes Emergency surgery: (An emergency is
patient whose organs defined as existing when delay in treatment of the patient would lead
are being removed for to a significant increase in the threat to life or body part)
donor purposes

Ketamine. Ketamine is a rapidly acting anesthetic
agent administered intravenously or intramuscularly.
In addition to its hypnotic and analgesic effects, ket-
amine has minimal cardiovascular depressant effects.
In-situ, ketamine may increase heart rate and cardiac
output, making it an ideal medication in trauma anes-
thesia and has been used as a battlefield anesthetic
by the military for many years. Ketamine’s hypnotic
action works through blocking NMDA receptors,
while its analgesic actions may have cholinergic, ami-
nergic, and opioid system properties.
Analgesia
Opioid medications such as fentanyl, hydromorphone, or
morphine are often used as part of a balanced anesthetic
plan and generally have minimal hemodynamic effects.
Opioid administration is associated with postoperative
and postdischarge nausea and vomiting. Opioid-sparing
techniques of pain management, standard in enhanced
recovery pathways, employ regional techniques (nerve
blockade), or multimodal adjuncts (acetaminophen,
NSAIDs, GABA inhibitors) instead of opioids.
Amnesia
Amnesia in anesthesiology is a medication-induced
short-term loss of memory surrounding the surgical
experience. Depending on medication selection, amne-
sia can be anterograde or retrograde. Benzodiazepine
medications and volatile anesthetic agents reliably
produce amnesia. Benzodiazepines administered in

CH03.indd 19 29-01-2021 07:25:05

 20 Decision Making in Perioperative Medicine: Clinical Pearls

low doses (midazolam 1–2 mg IV or diazepam 5–10 agents such as succinylcholine activate the motor end-
mg orally) have minimal respiratory depressant effects plate on skeletal muscle causing visual fasciculations
and are used in preprocedural sedation for regional followed by a period of flaccid paralysis lasting 6-12
nerve blocks or to reduce patient anxiety. minutes. Nondepolarizing medications (NDMR) such
as rocuronium or vecuronium are used during the
Neuromuscular Blocking induction of anesthesia or for maintenance muscle
There are two classes of neuromuscular blocking relaxation during surgery. Acetylcholinesterase inhib-
agents: depolarizing or nondepolarizing. Depolarizing itors, such as neostigmine, or binding agents such as
sugammadex, reverse the effects of NDMRs. Volatile
gases administered during anesthesia provide some
TABLE 3-3. Factors Predictive of (but not limited to) muscle relaxation, but also cause significant systemic
Difficult Airway Management
vascular vasodilation. Intravenous NDMR is hemody-
Small or receded Small mouth opening namically stable and allows for a reduction in volatile
mandible or maxilla gas concentration (balanced anesthetic approach).
(midface hypoplasia)
Large overbite History of difficult Vasopressors
intubation and/or mask
The use of vasopressor medications is common during
ventilation
anesthesia to reverse the vasodilatory and myocardial
Obesity Prominent maxillary teeth depressant effects of anesthetic agents. Phenylephrine
Short, thick neck Limited neck extension;
and ephedrine are commonly used for their vasocon-
prior neck fusion/fixation strictive and contractility augmenting effects, respec-
tively. Temporary use of vasopressors during periods
Poor dentition Head and neck tumors of surgical bleeding or restoration of intravascular
Facial trauma Maxillomandibular fixation volume is standard practice.

Hard cervical collar or Unstable neck or

Halo traction atlantoaxial instability Antiemetics
Macroglossia Burns to head and neck Volatile anesthetic medications are known risk fac-
tors for postoperative nausea and vomiting (PONV).
Certain disease Other risk factors include being female, receiving
processes: rheumatoid
concomitant opioids, being a nonsmoker, and hav-
arthritis, Ludwig’s
Angina
ing a history of PONV. The incidence of PONV can
be reduced by administering at least two antiemetics

Class I Class II Class III Class IV

FIGURE 3-1. Mallampati Diagram. Reproduced with permission from Thomas J. Nuckton, David V. Glidden, Warren S. Browner, David
M. Claman. Physical Examination: Mallampati Score as an Independent Predictor of Obstructive Sleep Apnea. Sleep. 2006;29(7):903–908.
Oxford University Press.

CH03.indd 20 29-01-2021 07:25:05

 Chapter 3 ANESTHESIA FOR NONANESTHESIOLOGISTS 21

TABLE 3-4. Hemodynamic Changes with Common Anesthetic Medications

AGENT CLASS DOSE CO SVR CBF/ CMRO2 SIDE EFFECTS

Propofol Hypnotic/ Induction 1–2 mg/kg ↓↓ ↓ ↓↓/↓ Hypotension/

injection pain

Etomidate Hypnotic/ Induction 0.2–0.4 mg/kg ↔ ↔ ↓/↓ Myoclonus, nausea,

adrenal suppression

Ketamine Hypnotic/ Induction 1–3 mg/kg ↑ ↔ ↑/↓ Psychotropic

effects/
hypertension

Midazolam Hypnotic/ Induction 0.05–0.1 mg/kg ↔ ↔ ↓/↓ Ventilatory

depression

Fentanyl Analgesic 0.5–1.5 mcg/kg ↔ ↔ ↔ Ventilatory

depression

Morphine Analgesic 0.05–0.1 mg/kg ↔ ↓ ↔ Ventilatory

depression

Lidocaine Analgesic/ 0.5–1 mg/kg ↔ ↔ ↔ Tinnitus

Anti- Inflammatory

Rocuronium Muscle Relaxant 0.5–1.2 mg/kg ↔ ↔ ↔ Histamine release

Succinylcholine Muscle Relaxant 1–2 mg/kg ↔ ↔ ↔ Myoclonus and

myalgias

Volatile Gases Hypnotic/ Varies by Gas ↓ ↓↓ ↓↓/↓ Nausea

Analgesic/ Muscle
Relaxant

from different classes. In modern anesthesia, this
is commonly accomplished with 5-HT3 antagonist
(ondansetron) and glucocorticoids (dexamethasone).
Other agents, such as transdermal scopolamine,
should be placed the night before surgery or a mini-
mum of 3 hours before the procedure. Newer agents,
such as Aprepitant, have very high success rates to
reduce PONV but may be cost-prohibitive.
INDUCTION OF ANESTHESIA
The induction of anesthesia is the process of admin-
istering medications to produce unconsciousness.
Preparation for induction of general anesthesia
requires optimal patient positioning for intubation as
well as placement of monitors such as pulse oximetry,
blood pressure cuff, EKG electrodes, end-tidal carbon
dioxide monitor, and temperature probe. Once opti-
mally positioned, the patient breathes 100% oxygen for
several tidal volume breaths to denitrogenate the lungs
(often referred to as preoxygenation). Preoxygenation
is a critical step in the induction of anesthesia as a
patient will become apneic after anesthetic medica-
tion administration and may rapidly desaturate and
become hypoxic. After preoxygenation, medication
administration occurs in either a “rapid sequence”
fashion or “normal/routine sequence.” Rapid sequence
intubation describes administering medications to
produce unconsciousness and muscle relaxation and
then immediately placing an endotracheal tube (with-
out proving the ability to mask ventilate). Selection of
rapid sequence intubation occurs when a patient is
having an urgent procedure and has been NPO for less
than 6 hours, or where mask ventilation may increase

CH03.indd 21 29-01-2021 07:25:05

 22 Decision Making in Perioperative Medicine: Clinical Pearls

the chance of aspiration of stomach contents. A rou-
tine intubation sequence occurs with mask ventilation
following the administration of anesthetic medica-
tions and loss of consciousness. A combination of
anesthetic medications is given depending on the level
of anesthesia required. Once the endotracheal tube
is confirmed by auscultating the lungs for bilateral
breath sounds, verifying equal chest rise, and visualiz-
ing persistent end-tidal CO2 on the monitor, the oper-
ating room nursing staff begins skin preparation and
final positioning for surgery.
Hemodynamic Concerns
Following induction and intubation, patients display
hemodynamic changes consistent with the medica-
tions delivered and airway management. Patients often
manifest a period of hypertension and tachycardia fol-
lowing intubation and tracheal stimulation, followed
by a period of hypotension as they are “prepped and
draped,” during which minimal stimulation occurs.
The induction of anesthesia is a tumultuous period of
the anesthetic experience and requires the vigilance
and finesse of the anesthesia team. Seasoned and vigi-
lant anesthesia providers predict these hemodynamic
changes based on the comorbidities of the patient and
alter the amounts of medications given on induction
or have the proper medications available to counter-
act periods of low stimulation. The overall goal of
induction is to safely and efficiently produce a state of
unconsciousness and analgesia sufficient for the pro-
cedure while maintaining the patient’s hemodynamics
comparable to their baseline values.
MAINTENANCE OF ANESTHESIA
The maintenance phase of anesthesia maintains a
level of patient unresponsiveness and relaxation that
allows the performance of the surgical procedure
(Table 3-5). Maintenance involves the use of volatile
inhalational anesthetic gases and intravenous narcotic
medications.
Monitoring
Patient monitoring during the maintenance of general
anesthesia includes standard monitors recommended
by the American Society of Anesthesiologists and neu-
romuscular blockade monitoring (Table 3-6). Selective
employment of anesthetic depth and invasive cardio-
vascular monitors, such as Bispectral Index, arterial
lines, central venous catheters, and transesophageal

TABLE 3-5. Stages of Anesthesia

STAGE OF
ANESTHESIA DESCRIPTION EFFECTS

1 Analgesia Analgesia without amnesia; disorientation; consciousness maintained

2 Excitation Excitation and delirium with struggling; coughing and vomiting possible;
rapid, irregular respirations; rapid eye movements; pupillary dilation;
divergent pupils; amnesia

3 Surgical Loss of consciousness; loss of touch sensation; amnesia; divided into four
anesthesia planes of increasing depth:

• Plane 1: decreased eye movement and pupillary constriction

• Plane 2: loss of corneal reflex; increased tearing
• Plane 3: loss of laryngeal reflexes, pupillary dilation; loss of light reflex
• Plane 4: progressive loss of breathing and muscle tone

4 Medullary Apnea; cardiovascular instability; necessitate cardiac and respiratory support;

depression amnesia

CH03.indd 22 29-01-2021 07:25:05

 Chapter 3 ANESTHESIA FOR NONANESTHESIOLOGISTS
TABLE 3-6. ASA Standard Monitors
Oxygenation: inspired oxygen-gas concentrations,
including a low oxygen concentration alarm
Continuous end-tidal carbon dioxide
Noninvasive blood pressure at least every 5 minutes
Continuous electrocardiogram
Body temperature
Pulse oximetry
Breathing circuit disconnection alarm in cases
involving mechanical ventilation
echocardiography, are based on patient and proce-
dural risk assessment.
Mechanical Ventilation
Lung protective ventilation strategies are individual-
ized mechanical ventilation plans that advocate for
lower tidal volumes, a reduced fraction of inspired
oxygen, and the use of positive end-expiratory pres-
sure (PEEP). Mechanical ventilation begins with tidal
volumes of 6–8 ml/kg IBW and 4–5 cmH2O PEEP
and individualized adjustments after that. When
compared with patients receiving large-tidal-volume
ventilation, lung-protective ventilation improves out-
comes by reducing the incidence of supraventricular
cardiac arrhythmias, atelectasis, ventilator-induced
lung inflammation, and postoperative pulmonary
complications, as well as reducing hospital length-of-
stay and healthcare resource utilization.2
Fluid Management
Excessive fluid administration increases the poten-
tial for acute lung injury and contributes to the high
incidence of postoperative pulmonary complications.
Goal-directed fluid management guided by noninva-
sive cardiac output monitors results in reduced hos-
pital length-of-stay, decreased postoperative nausea
and vomiting, and earlier return of gastrointestinal
function.3 Liberal fluid management using crystal-
loid infusion volumes up to 20–30 mL/kg/h reduces
postoperative dizziness, drowsiness, pain, nausea and
vomiting, and length-of-stay in the ambulatory surgery
CH03.indd 23
23
setting. Liberal fluid management is associated with
worsened outcomes in more complex patients and
procedures, such as colon resection. Restrictive or
zero-balance fluid management seeks to replace only
fluid loss during surgery as well as a maintenance crys-
talloid infusion of 1-3 mL/kg/h to replace sensible and
insensible fluid loss. Restrictive fluid management has
a higher association with postoperative acute kidney
injury than liberal or goal-directed strategies.3
TYPES AND LOCATIONS
OF ANESTHESIA
The prescription of general versus regional anesthesia
is a balance of multiple factors weighed by the anes-
thesia team on the day of surgery, particularly focus-
ing on provision of the safest anesthetic for the patient.
There are two theoretical reasons why regional anes-
thesia should be safer than general anesthesia: a total
regional technique may provide less cardiovascular
stress, which is significant since most perioperative
complications and adverse outcomes result from the
stress response to surgery, particularly in patients with
chronic disease, and a regional anesthetic provides
preemptive analgesia.4 Medical consultants should
refrain from recommending a certain anesthetic tech-
nique but should discuss with an anesthesia provider
when concerns exist.
The debate between superiority of regional ver-
sus general anesthesia is timeless. Each modality has
advantages and disadvantages. While general anes-
thesia is the most commonly prescribed anesthetic
technique, it is increasingly common to see both
general and regional anesthesia used adjunctively.
Enhanced Recovery Protocols rely on general and
regional anesthetic techniques. The use of the two
together improves postoperative pain management,
reduces postoperative and postdischarge nausea and
vomiting, opioid consumption, blood transfusions,
­
complications, healthcare costs, and length of stay, and
improves patient satisfaction across multiple surgical
specialties.5–7 Regardless of the technique or combina-
tion chosen, the anesthetic plan is individually formu-
lated after a detailed assessment of patient risks and
benefits in conjunction with the patient and surgical
care teams. The selected anesthetic plan maximizes
quality, safety, and satisfaction while reducing the risk
of adverse outcomes.
29-01-2021 07:25:05
 24 Decision Making in Perioperative Medicine: Clinical Pearls

TABLE 3-7. Regional Nerve Blocks

TECHNIQUE BLOCK AREA MOTOR/SENSORY

Interscalene Upper extremity +/+

Supraclavicular

Infraclavicular

Axillary

PECS/serratus Breast -/+

Quadratus lumborum Unilateral or bilateral truncal -/+

Transversus abdominis plane

Erector spinae Unilateral or bilateral truncal +/+

Paravertebral

Rectus sheath Front of abdomen -/+

Ilioinguinal and iliohypogastric Groin and genitals +/+

Femoral Anterior lower extremity +/+

Adductor canal Anterior lower extremity -/+

Sciatic Posterior lower extremity +/+

Popliteal Posteriorlower extremity +/+

Ankle Posterior lower extremity -/+

Spinal Below T6 +/+

Epidural

Combined spinal epidural

Monitored Anesthesia Care Regional Anesthesia and Neuraxial Anesthesia

Monitored anesthesia care (MAC) is a type of anesthe-
sia service where an anesthesia provider continuously
monitors the patient’s hemodynamics and vital signs
while providing a level of sedation appropriate for the
procedure (light to heavy sedation) with conversion to
general anesthesia if needed. MAC does not describe
a level of anesthesia. It denotes the presence of an
anesthesia provider capable of performing all levels of
anesthesia. MAC is often provided for lower intensity
procedures such as endoscopy or superficial skin pro-
cedures. MAC Anesthesia accounts for 30–35% of all
cases performed in the ambulatory setting.8
Regional and neuraxial anesthesia may be appropriate
for many surgical procedures as the sole anesthetic or
combined with intravenous sedation (Table 3-7). The
potential for regional or neuraxial anesthetic failure
necessitates preoperative optimization in the same
way as a general anesthesia patient.
Nonoperating Room Anesthesia (NORA)
Nonoperating room anesthesia refers to anesthesia
services performed outside of the typical theater of the
operating room. Service lines requesting NORA are

CH03.indd 24 29-01-2021 07:25:05

Another random document with
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the seat of visible lesions. There may be pallor, œdema and swelling,
but not unfrequently there are blood extravasations varying in size
from a pin’s head upward and giving a dark red aspect to the affected
tissues. Under the microscope the affected fibres are seen to have
lost their transverse striation and to have assumed a more or less
granular or hyaline appearance. Next to the gluteal muscles, these
changes are frequently found, in the muscles of the thigh (especially
the rectus femoris, and triceps extensor cruris), and in those of the
loins (psoas, ilio-spinalis, and longissimus dorsi). Exceptionally the
pectoral muscles are involved or even the abdominal muscles. A
considerable straw-colored œdema may be found in the
intermuscular connective tissue.
The red bone marrow primarily of the large bones of the limbs
(femur, tibia, humerus, radius,) and less frequently of other bones,
even of the vertebræ, is often the seat of intense vascular congestion
and even of hemorrhage. The medullary matter is of a deep red or
black color, and there is an abnormal accumulation of red globules in
various conditions of growth and destruction (red nucleated
corpuscles, fragments of corpuscles, colored granules). Dieckerhoff
considers the condition one of osteomyelitis, but it seems to be
rather a sudden, extraordinary exaggeration of the processes of blood
metamorphosis. Neumann found that when the blood regeneration
process is very active even the yellow marrow may be changed into
red, and this throughout all the bones of the extremities.
The kidneys are usually the seat of congestion, and black spots of
infarction, when the disease has lasted for twenty-four hours. In
rapidly fatal cases they may appear normal. There may be
enlargement of the kidneys with softening and granular degeneration
of the renal epithelium in cases that survive for some days.
The bladder contains dark brown or red glairy urine of a high
density and loaded with urea, hæmoglobin, etc.
The terminal portion of the spinal cord and the lumbo-sacral
plexus, or some of its branches, are sometimes blood stained, or the
seat of an exudate or surrounded by one.
Symptoms. In the regular type of hæmoglobinæmia in the horse
the history of the attack is highly significant. The subject is in good
working condition, he may be fat, or lean, but in either case the
muscles are firm and well developed, diet has been liberal,
embracing a large proportion of albuminoids, work has been
constant up to within a day or two preceding the attack, when the
animal has been left absolutely idle in the stall without any reduction
of feed. Then finally it has been suddenly subjected to active exertion
which demands vigorous muscular movement, and above all activity
of the respiratory muscles and the heart. This exertion usually
consists in riding under the saddle or going in harness, but may
attend on casting in the stall, lounging in a ring, or in a playful run
when suddenly set at liberty.
Severe Cases. The attack comes on early in the course of such
exercise. The patient may not have gone more than one hundred
yards from the stable or he may have traveled for half an hour or an
hour, but the disease rarely shows itself after a longer period of work.
The horse which left the stable full of life and spirit, suddenly flags
and hangs on the bit, the ears or head may drop, and one or more
limbs usually the hind ones, are moved stiffly and awkwardly, or
even stagger. He knuckles over at the fetlocks, drags the toes on the
ground, flexes the joints imperfectly, the muscles appearing to be
rigid and uncontrollable, or he crouches, the joints remaining
semiflexed the animal in vain attempting to extend them. The patient
trembles violently, sweats profusely, breathes deeply and rapidly and
assumes a pinched, anxious, agonized expression of countenance.
The heart beats tumultuously, the pulse (in 84 per cent. Friedberger
and Fröhner) is accelerated to a variable degree, and the temperature
is still normal (in 80 per cent. Friedberger and Fröhner), or rarely
exceeds 101.5°F. There is often tenderness on percussion and
sometimes even on manipulation over the loins, short ribs, and the
croup, and pinching of the loins may cause wincing. The affected
muscle or muscles (lumbar, gluteal, crural) are usually firm, hard
and tender, they may be the seat of spasm or of œdema and paresis.
These parts may, however, have their sensitiveness lessened and
even punctures or electric currents may have little effect on them.
Soon the increasing muscular weakness is incompatible with the
maintenance of the standing position, the bending of the limbs and
crouching become extreme, the animal makes vain efforts to control
the muscles and extend the joints, and helplessly drops to the
ground. When down he moves his legs convulsively, but is unable to
coördinate the muscular movements and all efforts to rise are
unavailing.
The spasms and paresis may attack other parts of the body such as
the pectoral region the shoulders and even the abdomen, but the
earliest and most persistent disorder is usually in the divisions of the
lumbo-sacral plexus affecting the supra or sublumbar muscles, the
gluteals, the patellar (triceps,) the adductors and the abductors. The
caudal muscles are exceptionally involved. In a series of ten cases
Bouley noticed that the left hind limb was always the first paralyzed
(evidently a simple coincidence).
Urine may be passed freely or the bladder may be paretic so that it
must be emptied with the catheter. In severe cases the urine is of a
high density and of a dirty brownish gray, red or almost black color.
It contains no blood clots, nor blood globules, but granular
hæmoglobin, tyrosin and other waste products contribute to produce
the reddish color. In some instances there is an abundant
metalbumen which renders the liquid glairy, causing it to fall in fine
threads or films. Urea is usually present in great excess. Hippuric
and even uric acid are usually present but not in excess. When the
disease has advanced to nephritis the albuminuria is complicated by
the presence of casts of the uriniferous tubes, renal epithelium, white
and even red blood globules.
During the violence of the attack there is no disposition nor leisure
to eat, but when the more violent symptoms abate appetite is usually
manifested. There may be more or less paresis of both bowels and
bladder, so that neither fæces nor urine is passed yet in other cases
both are discharged spontaneously.
The senses are preserved, excepting in the case of the affected
muscles and the integument which covers them. There may,
however, be more or less dullness and stupor in certain cases from
poisoning of the cerebral centres by the poisons circulating in the
blood.
Mild Cases. In the mildest cases there is stiffness and lameness
in one, or less frequently in both hind limbs, coming on when put to
work after a period of idleness, and not associated with any
appreciable lesion of the limb in question. There may or may not be
hardness and swelling of the gluteal or other muscles of the quarter
or loins. This has the appearance of rigidity or spasm but may be
primarily due to œdema or exudation into the substance of the
muscle. In some instances the muscles of the breast, shoulder, or
forearm are the seat of the trouble. Muscular trembling and
perspiration may be present and if the urine is examined, it is often
found to be glairy, or charged with urea, and allied nitrogenous
products. These cases are not benefited by local applications, but
they recover (temporarily) under rest and above all under active
eliminating treatment. Under gentle and progressive exercise too
they improve and get well. They recur, however, with great readiness
under a rich nitrogenous diet and a temporary rest followed by
sudden exertion.
Between the mildest and gravest cases there are infinite gradations
of severity, one-third to one-half of the worst cases usually
terminating fatally, whereas the mildest are always amenable to
treatment.
Progress. The course of the disease depends on the severity of the
attack but also, in no small degree, on the good judgment of the
driver. Cases that develop with great suddenness, and apparently
with extreme severity may subside spontaneously if the animal is
placed in a condition of absolute rest. If, however, we can secure rest
of the muscles of progression only, while the breathing remains rapid
and labored, improvement is unlikely, as the system continues to
receive large accessions of the toxic products. When the patient is
down and unable to rise, the enforced rest may be beneficial, but too
commonly, the greater effort with which breathing is carried on in
the recumbent position, and the frequent ineffectual struggles of the
limbs prevent the requisite muscular quietude.
In some cases, and especially in the mildest, recovery may seem to
have been effected in a few hours, and in others it will be seen in
twenty-four or forty-eight hours, while in still others the paresis and
helplessness may continue for a week and yet be followed by
recovery. In these cases appetite may be retained in greater or less
degree, but the intestinal peristalsis is usually weak and imperfect,
the fæces small in quantity and dry, and the bladder atonic so that
the urine may have to be drawn off with the catheter. It usually
retains the deep red color, or improvement may be heralded by a
change to a dirty grayish hue. If, however, it shows an excess of
albumen, cylindroid casts entangling renal epithelium and white or
red globules it will indicate the access of diffuse nephritis and a
prolonged or even a fatal illness.
When control of the limbs is not restored at the end of a week, the
paretic muscles usually undergo marked and rapid wasting, which
may last for months or years. This is especially common in the case
of the patellar muscles (muscle of the fascia lata, triceps extensor
cruris) in which the atrophy may become so extreme that the skin
covering the inner and outer sides of the thigh may be brought
virtually in contact in front of the femur. This entails an almost
complete inability to sustain the body on the hind limbs. When
atrophy is less extreme, there is only a weakness, stiffness, or
swaying or staggering on the hind limbs in progression.
In fatal cases death may occur early in connection with the violent
struggles, the excited breathing, pulmonary hypostasis and
congestion, a cyanotic hue of the visible mucous membranes and a
gradual increase of stupor. Though delayed for several days, there is
a continuation of the muscular struggles, and the labored breathing;
the red or glairy character of the urine persists or is exaggerated; the
nervous irritability increases, with muscular trembling; and cyanosis,
or stupor increases until death.
The mortality is always high in the severe forms of the disease, the
deaths ranging from 20 per cent. upward.
After a first attack there is a strong predisposition to a second
under similar exciting conditions.
Diagnosis. The peculiar symptoms of this disease and the
circumstances attending its onset, are usually sufficient to
distinguish it from all others. There may be danger of confounding
certain cases with thrombosis of the posterior aorta, or of the iliac
arteries or their branches, but the absence, in such cases, of the
special history of the attack and of the morbid state of the urine, and
the absence of pulsation in the arteries distal to the thrombosis will
serve to prevent confusion. Spinal myelitis will be distinguished by
the gradual nature of the onset, by the absence of the conditions
attending on the attack of hæmoglobinæmia, and usually by the
absence of hæmoglobin, urea and other nitrogenous products in
excess in the urine.
 Prevention. The hard worked or systematically exercised horse,
which is at the same time heavily fed must not be left in a state of
absolute rest in his stall for twenty-four hours. A fair amount of
exercise must be given on every day in the week, and at the same
time, the food should be restricted in ratio with the restriction of
exercise. Turning for an hour or two daily into a yard may be a
sufficient precaution. When from any cause, rest is imperative, the
diet must be materially reduced and given in part in a laxative form
(bran, roots), or a slight laxative (Glauber salts) or diuretic
(saltpeter) may be added. Cleanliness and a free ventilation of the
stable, are also of value in obviating at once auto-intoxication and
the admission of poison through the lungs. In the same way a free
allowance of drinking water is beneficial as favoring a general
elimination from the various emunctories, and a dilution of the
plethoric blood.
These precautionary measures are especially important in the case
of horses which have passed through a first attack and which are in
consequence strongly predisposed to a second. Horses fed liberally
on highly nitrogenous food (oats, beans, peas, cotton seed meal), will
also require specially careful oversight when at rest for a day or two
only.
Treatment. The first and perhaps the most important
consideration is absolute rest. If the subject is stopped instantly on
the appearance of the first symptoms, the disease may be often
aborted. It is better to avoid the exercise of walking to a stable until
such time as the severity of the attack has somewhat moderated and
then to move the subject only in the slowest and quietest possible
way. If the patient is already down and unable to rise, he may be
carried to the nearest stable in an ambulance or on a stone-boat, and
there helped to his feet and supported in slings. Though he may be
unable to continue in the standing position without the sling, yet if
he can use his limbs at all for support, and is prevented from lying
down, the breathing will be rendered so much more free and quiet,
that it may greatly lessen the transfer of the poisonous elements into
the general circulation and materially contribute to recovery. If,
however, he cannot stand on his limbs at all, but must settle in the
slings, the compression of the chest will so excite the breathing that
it will induce dyspnœa, pulmonary congestion and a rapidly fatal
result. In such a case a good bed must be provided and the patient
made as comfortable as possible in the recumbent position.
In some cases in the earliest stages a full dose of sweet spirits of
nitre or even half a pint of whiskey has seemed to assist in aborting
the disease though the urine was already of a deep red color. It
probably acted by supporting the already oppressed heart, and
securing a prompt elimination by the kidneys.
Friedberger and Fröhner strongly recommend bleeding in all cases
of dyspnœa and excited heart action, and considering the plethoric
condition of the animal it would equally commend itself in other
cases as well. This is the most prompt sedative of the nervous and
vascular excitement, and the most speedy and certain means of
removing much of the poisons accumulated in the blood, and of
diluting what remains by reason of the absorption of liquids from
every available source. This will more than counterbalance any
temporary increase of poisons drawn from the portal system to fill up
the vacuum in the systemic veins caused by the emission of blood.
When the thick tarry condition of the blood seriously hinders a
speedy abstraction both jugulars may be opened at once.
In some cases of great nervous excitement bromides may be useful
in moderating circulatory and respiratory movement, but on the
whole the advantage is greater from an immediate resort to
eliminating agents.
One of the most effective agents is water. If the patient is thirsty he
should have all he will drink, and if not, it may even be given from a
bottle, or thrown into the rectum. A still more effective resort would
be to introduce water intravenously in the form of a normal saline
solution, or even to pass it into the trachea through a small cannula
or large hypodermic needle. This serves to dilute the over dense
blood, to stimulate the kidneys and other emunctories to active
secretion, and to retain in solution the hæmoglobin, urea and other
products which would otherwise cause greater irritation. This would
be especially applicable after the blood tension had been diminished
by phlebotomy.
Warm fomentations to the loins or croup are not without their
influence. They tend to soothe the irritated parts and to solicit the
action of the kidneys more particularly. The old resort of a fresh
sheep skin, with the fleshy side in, may be used as a substitute.
 Perhaps the most important indication is to secure depletion from
the overloaded portal system and liver. Where nothing better offers,
a pint or quart of castor oil, or a pound of Glauber salts, or a half
drachm of podophyllin and four drachms of aloes may be given. If
available 1 to 1½ grains of eserine, or 7 grains of barium chloride
may be given hypodermically in distilled water or that which has
been raised to the boiling point. This may be supplemented by
frequent injections of hot soap suds or even of laxative saline
solutions. If the bowels can be roused to free secretion the removal of
toxic matters from the portal blood and the delay in the progress of
similar matters through the liver will go far toward securing a
favorable result. When free purgation has been secured recovery can
usually be counted on.
The action on the bowels must be followed up by diuretics to
eliminate the offensive matters from the general system. Colchicum
has been recommended because of its action in increasing the solids
of the urine, and this may be combined with saltpeter or other
diuretic, or the latter may be used alone and repeated twice a day. If,
however, the patient can, by the free use of common salt or
otherwise, be induced to drink freely of water, the elimination
through the kidneys will be sufficiently secured.
The muscular weakness and paralysis that remain after the acute
symptoms have subsided must be met by stimulating liniments and
even blisters to the loins or affected muscles, by the internal use of
strychnia (2 grs. twice daily) until the jerking of the muscles
indicates that its physiological action has been secured, and by an
electric current daily for ten minutes at a time through the affected
nerves and muscles. Animals that have been helpless for weeks have,
in our hands, recovered under such treatment, and even cases of
several months’ standing, with the most extensive atrophy of the
triceps, and in which the animal could barely stand, have made a
satisfactory recovery.
Any remaining nephritis must be treated according to its
indications.
During recovery and in the convalescent animal the diet should be
laxative and non-stimulating. Bran mashes, turnips, beets, carrots,
green fodder, ensilage and scalded hay may be allowed. Oats, corn,
beans, peas, vetches, etc., must be carefully avoided. If the food fails
to maintain the bowels in a gently relaxed condition one, two or
more ounces of sulphate of soda may be added daily.
In the mild cases a good dose of purgative medicine succeeded by a
course of diuretics will serve a good purpose.
In all cases alike work must be resumed very gradually. At first the
animal may be walked a few hundred yards, and the pace or load and
duration of exercise may be increased day by day until full work can
be safely endured. In an animal that has once suffered the same
gradual inuring to labor should be followed, after any short period of
rest on a fairly good ration.
 JAUNDICE, ICTERUS, THE YELLOWS.
Symptomatic. Causes: Mechanical obstruction of bile duct, gall-stones, hydatids,
distomata, extraneous bodies, inflammation, stricture, obliteration, absence,
ulceration, spasm, tumor, enlarged lymph glands, gastric tumors, pancreatic,
kidney or omental tumor, aneurism, fæcal accumulation, pregnancy, ovarian
tumor: Without mechanical obstruction, ptomaines and toxins, animal venoms,
mineral poisons, hepatic atrophy, fear, other emotions, cerebral concussion,
imperfect oxidation, excess of bile, hepatic inflammation, constipation and
reabsorption of bile, experimental jaundice, balance of tension in gall ducts and
blood vessels, duodenitis, compression of aorta, hæmatoidin and bilirubin,
destruction of blood globules by hydroæmia, taurocholate of soda, chloroform,
ether, freezing, heat, electricity, alkalies, nitrites. Hæmoglobin: Its solubility in
horse. Bile acids and blood pigment. Summary of causes. Gravity of icterus.
Symptoms: Coloration, yellow, orange, brown, of tissues and secretions: Tests,
staining white paper, Gmelin’s test, nitric and sulphuric acids, rainbow hues:
Pettenkofer’s test for bile acids, syrup and sulphuric acid, dark violet: Stranburg’s
test syrupy paper and sulphuric acid, dark violet; clay colored fœtid stools; gravity.
The terms icterus and jaundice are applied to a yellowness of the
mucosæ, urine, skin and tissues caused by the presence in them of
the coloring matters of bile. The condition is a symptom of many
different affections rather than a disease per se, yet the phenomenon
is so characteristic that it has been hitherto accorded a special place
and article in systematic works.
Jaundice is either associated with mechanical obstruction of the
bile duct or ducts, or it is independent of such obstruction. The
following enumeration of its causes slightly modified from
Murchison, is equally applicable to the lower animals as to man:
A. Jaundice From Mechanical Obstruction of the Bile Duct.
I. Obstruction by foreign bodies within the duct:

1. Gall stones and inspissated bile.

2. Hydatids and distomata.
3. Foreign bodies from the intestines.
II. Obstruction by inflammatory tumefaction of the duodenum or
of the lining membrane of the bile duct with exudation into its
interior.
III. Obstruction by stricture or obliteration of the duct.

1. Congenital deficiency of the duct.

2. Stricture from perihepatitis.
3. Closure of the orifice of the duct in consequence of ulcer of the
duodenum.
4. Stricture from cicatrization of ulcers in the bile duct.
5. Spasmodic stricture.
IV. Obstruction by tumors closing the orifice of the duct or
growing in its interior.
V. Obstruction by pressure on the duct from within, by:

1. Tumors projecting from the liver itself.

2. Enlarged glands in the fissure of the liver.
3. Tumor of the stomach.
4. Tumor of the pancreas.
5. Tumor of the kidney.
6. Post peritoneal or omental tumor.
7. An abdominal aneurism.
8. Accumulation of fæces in the bowels.
9. A pregnant uterus.
10. Ovarian and uterine tumors.
B. Jaundice Independent of Mechanical Obstruction of the Bile
Ducts.
I. Poisons in the blood interfering with the normal
metamorphosis of bile.
1. The poisons of the various specific fevers (Anthrax, Texas fever, Hog cholera,
Swineplague, Petechial fever, Pyæmia, Septicæmia, etc.).
2. Animal poisons: snake poison.
3. Mineral poisons: phosphorus, mercury, copper, antimony, etc.
 4. Chloroform, ether, etc.
5. Acute atrophy of the liver.
II. Impaired or deranged innervation interfering with the normal
metamorphosis of bile.
1. Severe mental emotions: fright, anxiety, etc.
2. Concussion of the brain.
III. Deficient oxygenation of blood interfering with the normal
metamorphosis of bile.
IV. Excessive secretion of bile, more of which is absorbed than can
undergo the normal metamorphosis.
Congestion of the liver: a. Mechanical, b. Active, c. Passive.
V. Undue absorption of bile into the blood from habitual or
protracted constipation.
Mechanical obstruction, by tying the bile ducts in a dog, caused in
two hours yellow coloration of the contents of the hepatic lymphatics
and thoracic duct, and also of the blood in the hepatic veins
(Saunders). That this jaundice is due to reabsorption and not to
suppressed secretion of bile, already present in the blood, may be
fairly inferred, from the complete absence of icterus, where, from
general disease of the liver, the secretion of bile has been entirely
suspended, and in which the gall ducts and bladder contain only a
little gray mucus (Haspell, Frerichs, Budd, Murchison), also from the
fact that after complete extirpation of the liver in frogs not a trace of
biliary acids nor pigment can be detected in the blood, urine, or
muscular tissue (Müller, Runde, Lehmann, Moleschott). Bile acids
and bile pigment are formed in the liver by disintegration of blood
globules, and when present in excess in the blood it is by virtue of
reabsorption.
This reabsorption will take place under the slightest favoring
influence. The obstructions in the bile duct, above referred to, cause
the tension in these ducts to exceed that of the blood in the
capillaries of the liver and at once osmosis of bile into the blood
vessels sets in. This may occur from so slight a cause as the
congestion and swelling of the duodenal mucosa around the opening
of the bile duct. Again reabsorption of bile may be determined by a
lessening of the normal fullness and tension of the hepatic capillaries
as when the aorta is mechanically compressed by abscess, neoplasm,
ingesta, or otherwise, just behind the diaphragm (Heidenham,
Brunton). The cause is the same in both cases, namely, the want of
balance between the fullness and tension of the bile ducts, and the
hepatic blood vessels. There is increased fullness of the hepatic
biliary ducts, or decreased plenitude of the hepatic capillaries and
lymphatics.
It must be added, however, that the coloring matter of the bile is
apparently produced, in the liver, from that of the blood, and that the
pigment (hæmatoidin), found in old extravasations of blood, is
probably identical with bilirubin, and that any agent or condition
which causes liberation of the coloring matter of the red blood
globules, will cause a staining of the tissues, like that of jaundice. The
following agents are known to have this effect on the blood globules:
water, in hydroæmic states of the blood (Hermann); taurocholate of
soda from absorption of bile (Frerichs, Kuhne, Feltz, Ritter);
chloroform (Chaumont); ether (Burdon-Sanderson); freezing
(Rollet); a high temperature +60° C. (Schultze); frictional and
induction currents of electricity (Burdon-Sanderson); the alkalies
(ammonia, potash and soda) and nitrites when present in excess.
The injection of hæmoglobin into the veins of dogs has been
followed by the appearance of bile pigment in the urine, but
Naumyn, Wolff, Legg and Brunton failed to obtain the same result in
rabbits.
It is noticeable that the hæmoglobin of horses’ blood is very
soluble at all temperatures and that of dogs very slightly so (Burdon-
Sanderson). This may serve to explain the great prevalence among
solipeds of diseases, associated with dusky brown or yellow
discoloration of the mucosæ, with petechiæ, and with the passage of
blood pigments in the urine. It may further explain the usually
benignant course of jaundice in the horse and its extreme gravity in
the dog.
There is further reason to believe that the bile acids, when in
excess, may be transformed into bile pigment in certain conditions of
the blood, as occurs under the action of sulphuric acid out of the
body (Stœdler, Meukomen, Folwarcyny, Röhrig). Moreover, in the
healthy state, the greater part of the bile secreted, including acids
and pigment, is re-absorbed from the intestinal canal, but is oxidized
and decomposed in the blood so that it cannot be detected, in blood
or urine. But let the transformation be interrupted, as in certain
diseases of the lungs, with imperfect oxidation, and the bile
circulates in the blood, stains tissues and urine, and in short causes
jaundice.
To sum up: it may be said that icterus is probably never due to
simple inactivity of the liver: it may, however, be caused by excessive
secretion of bile which is re-absorbed from obstructed bile ducts or
bowels:—it may result from imperfect transformation, in the blood,
of the bile which is normally re-absorbed from the intestine: or it
may possibly be caused by the formation of pigments in the blood
from the abnormal transformation of bile acids, or by solution of the
hæmoglobin of the blood corpuscles.
The gravity of jaundice varies as much as its causes. It is well
known that the system may be saturated with bile, and the tissues
and urine deeply stained without much constitutional disorder. The
pigment alone is not an active poison. But there may be much
attendant suffering from obstructed biliary ducts or bowels, from
diseases of the lungs, or from disintegration of the blood globules
and imperfect nutrition, or there may be profound nervous
prostration and disorder from uræmia, or from the presence in the
blood of an excess of effete and partially oxidized albuminoids (See
Azotæmia). According to our present knowledge, constitutional
disorder, prostration and suffering in cases of jaundice, are mainly
due to the presence in the circulation of these albuminoids, and of
taurocholic acid which latter has a most destructive effect on the
blood corpuscles.
The symptoms, therefore, are not characteristic apart from the
yellow coloration of the tissues and urine and the chemical reactions
of the bile acids and bile pigments furnished by the latter.
The coloration of the tissues may be a simple tinge of yellow
especially noticeable in the eye (conjunctiva), or it may amount to
the darkest shades of orange and brown. It may or may not be
complicated by the presence of spots or patches of blood-staining
(ecchymosis) on the visible mucous membranes but especially in
cases complicated by poisoning with taurocholic acid or effete
nitrogenous products.
The urine may be similarly colored in all shades of yellow or
orange brown, and may leave a correspondingly deep stain on white
paper.
The test for bile pigments (Gmelin’s) is simple and beautiful. Pour
a little nitric acid into a test tube held obliquely and then add a few
drops of sulphuric acid, and finally a little urine, so slowly, that it will
remain on the surface. Soon at the point of junction appear in
succession the various colors of the rainbow: yellow, green, blue,
violet, red and lastly a dirty yellow. It is open to this objection that
the characteristic play of colors may be produced by alcohol in the
absence of bile pigments. Indican also will produce the green and
yellow with blue between but never the violet nor red, nor all in their
regular order.
A second mode of applying this test is by spreading a few drops of
the urine on a white plate and letting fall a drop of nitric acid in the
centre. The play of colors is very characteristic.
The test for bile acids (Pettenkofer’s) is to place a portion of the
urine in a test tube, and after adding a drop of syrup, to add
cautiously, drop by drop, two-thirds of the amount of sulphuric acid.
Shake the mixture and set aside for some minutes. If sufficient heat
is not produced by the mixing of the acid and urine warm slightly.
The mixture becomes of a dark violet color which is destroyed by a
temperature a little above 140° Fah.
A convenient application of this test (Stranburg) is to add a little
cane sugar to the urine, dip a piece of filtering paper in the mixture,
dry it thoroughly, pour a drop of sulphuric acid on the paper and
allow it to run partially off. In a quarter of a minute a beautiful violet
color is produced, best seen by holding up the paper to the light and
looking through it (Brunton).
In cases due to obstruction of the bile ducts the dung is destitute of
bile, whitish, often clayey and fœtid, while in cases due to
reabsorption without obstruction the fæces have their natural color
and odor.
It is needless to enumerate all the concomitant symptoms of
jaundice which will be better noticed under the different disorders
which determine it, for a list of which see the causes.
The gravity of the affection will depend on the dangerous nature of
these concurrent diseases, and the destructive changes in the liver
and blood rather than on the depth of color in the textures.
 CATARRHAL ICTERUS (JAUNDICE) OF
SOLIPEDS.
Causes: infection from duodenum through biliary duct. Suppression of bile
favors. Musty, heated, mow burnt fodder, over feeding, irregular feeding, or
watering, over work, worms, fatigue, damp stables, duodenal congestion, gall-
stones, concretions, pancreatic tumor, ascaris in bile ducts, distoma, infection
through portal vein, toxins. Symptoms: of duodenal catarrh, icterus, yellow,
viscous, odorous urine, dullness, weakness, somnolence, tardy pulse and
breathing, costiveness, or diarrhœa, pale, fœtid stools. Duration: 2 to 3 weeks or
longer. Lesions: duodenitis, distended biliary and pancreatic ducts, calculi,
enlarged softened liver and kidneys. Diagnosis: icteric symptoms in absence of
fever. Prognosis: usually favorable. Treatment: laxative diet, pasture, soiling,
ensilage, roots, fruits, water freely, exercise, antisepsis, elimination, laxatives,
cholagogues, diuretics, calomel, salines, nitro-muriatic acid, podophyllin, castor
oil, aloes, tartar emetic, bitters, sodium bicarbonate.
Causes. This may be said to be an extension of infection from the
duodenum through the bile ducts. The microbes of the intestinal
canal become acclimatized by living in the bile-charged contents of
the duodenum until they acquired the power of survival and
multiplication in the biliary ducts themselves. The well known
antiseptic qualities of the bile, constitute a powerful barrier to this,
yet the power of adaptation on the part of certain germs is greater
than the defensive action of the bile. The attack is however mostly in
connection with indigestion or muco-enteritis, and a more or less
perfect suspension of biliary secretion, so that this defensive action is
reduced to its minimum and the germs can ascend the bile ducts in
the mucous secretion as a culture medium, and by interference with
the resumption of a free hepatic secretion, they succeed in safely
colonizing themselves in the mucosa and hepatic parenchyma.
Whatever, therefore, interferes with the integrity of the duodenal
functions directly contributes to the extension of infection from
bowel to liver. Old, heated, musty, cryptogamic, dusty fodder, grains
that have been badly harvested in wet seasons, feed that has been
damp and fermented, overloading of the stomach, irregular feeding
and watering, giving drink after a feed of grain, underfeeding,
overwork, worms, excessive fatigue, damp, dark stables, etc., tend to
induce indigestions and to lay the bile ducts open to infection.
Blocking of the bile duct and stasis of its contents may be a sufficient
cause. The swollen mucosa around the orifice of the duct not only
blocks the passage but favors the formation of a mucous plug as
recorded by Benjamin of an equine patient. Wolff found obstruction
of the duodenum in the horse by a mass of ingesta, and blocking of
the gall duct, with jaundice.
Gall stones and concretions are very direct causes of biliary
obstruction and jaundice. Though less common in horses than cattle,
these are not unknown in idle, pampered animals when on dry
winter feeding.
Tumors of the pancreas or adjacent organs pressing on the gall
duct are recognized as causes of equine icterus, (Megnin, Nocard).
With any obstruction to the bile a disturbance of balance of
pressure between the bile ducts and the hepatic veins is brought
about by respiratory movements. On the one hand the aspiratory
power of the chest empties the hepatic veins, lessening blood
pressure, and in expiration the contraction of diaphragm and
abdominal muscles compresses the gall ducts increasing their
tension and favoring absorption of bile.
The entrance into the bile duct of the ascaris megalocephala is at
once a cause of obstruction and of the transference of duodenal
microbes, and the presence of trematodes (fasciola hepatica, or
distoma lanceolatum) will also favor obstruction. Other parasites,
like the echinococcus or actinomycosis, may press on the biliary
ducts and determine jaundice.
Another mode of infection is by way of the portal vein, the
microbes entering from the intestine and becoming arrested and
colonized in the liver (Dieckerhoff).
Whether from the presence of the microbes or from the absorption
of ptomaines and toxins from the intestines, the radical biliary ducts
become inflamed, swollen, and even blocked, and the hepatic cells
degenerated or even completely devitalized, so that they fail to take
an aniline stain. In such cases the remaining sound hepatic cells go
on producing bile, but as this cannot any longer escape through the
partially obstructed interlobular biliary radicles, it is largely
absorbed and produces icterus. Cadeac mentions a case of this kind
in a mare in which the toxic matters had not only led to hepatic
disease, but also to structural changes in the eliminating organ (the
kidney).
Symptoms. In the horse the disease is mostly attendant on
subacute duodenitis, and even when this is associated with infective
catarrh of the biliary passages the kidneys remain mostly sound and
active, and eliminate alike the bile pigments and the more toxic
matters so that the disease is not often grave. Beside the essential
feature of yellow mucosæ, and urine, the latter viscous and smelling
strongly, there is profound depression, sluggishness, weakness and
somnolence. Imperfect muscular control and even slight paresis may
be present. Tardy pulse and breathing are at times noticeable. At
others these, like the temperature, are normal. The mouth is hot and
dry. The urine may be slightly albuminous. The bowels incline to
costiveness from lack of their customary stimulus, yet this in turn
may give rise to diarrhœa. In either case, as the disease advances, the
defecations lose the healthy yellowish brown color, becoming pale
and fœtid.
Duration. The attack may last one, two or three weeks, and
generally ends in recovery. With irremediable structural lesions, it is
of course permanent and even fatal.
Lesions. The most common feature is duodenitis with thickening
around the orifice of the common bile and pancreatic duct. The
biliary ducts may be distended and their contents more than usually
viscid and glairy from the presence of pus. Their mucosa may show
ramified redness, or concretions as casts or calculi. The liver is
enlarged, soft and friable giving way readily under the pressure of the
finger. Enlargement of the kidneys is usually present, the cortical
substance having a brownish red and the medullary portion a
yellowish pink hue.
Diagnosis. The absence of hyperthermia in jaundice, serves to
distinguish it from the acute febrile affections (pneumonia,
influenza, contagious pneumonia, petechial fever, etc.,) which are
marked by yellowness of the mucosæ and skin.
Prognosis. The merely functional forms of icterus in solipeds
usually end in recovery.
 Treatment. The first consideration is a laxative diet. A run at
pasture will usually meet every indication. Fresh cut grass, ensilage,
turnips, carrots, potatoes, beet, apples, or other succulent diet may
be given as substitute. Bran mashes and hay cut and moistened may
be allowed in the absence of the above. Abundance of water and
especially cool water will stimulate bowels, liver and kidneys, favor
the elimination of the bile by contraction of the biliary ducts, and
hasten the expulsion of the poisons through the kidneys. Regular
exercise an hour after meals stimulates both bowels and liver to
action.
Medicinal treatment is largely directed to antisepsis of the bowels
and the arrest of the production of injurious toxins; elimination from
the bowels and incidental depletion from the portal vein and liver;
antisepsis and stimulation of the liver; and stimulation of the urinary
secretion.
The preparations of mercury fill several of these indications.
Calomel 2 drs., or blue mass 1½ dr., is not only a soothing laxative
and antiseptic, but seems to operate as a calmative and antiseptic to
the liver as well. It may be continued in 5 to 10 grain doses two or
three times a day, according to the size of the animal and the
condition of the bowels, and associated with ½ dr. belladonna
extract to each dose together with a bitter (quassia, gentian, nux
vomica). Or 4 or 5 ozs. sulphate of soda may be given three times a
day, with 2 drs. salicylate of soda as an antiseptic. Or, to increase the
hepatic action, nitro-muriatic acid largely diluted may be given in
sixty drop doses thrice a day in the drinking water. These are
especially valuable for their antiseptic action, cutting off at once the
source of nervous irritation from the attendant indigestions, and
duodenal congestion, and arresting the flow of the irritant toxins and
other products through the portal system. Podophyllin, castor oil,
aloes, rhubarb, often act well by depletion from the portal vein, and
expulsion of indigestible and irritant matters from the intestines, but
there is more danger of resulting swelling of the duodenal mucosa
than with the mercurials or aqua regia. Goubaux recommends 2½
drs. of tartar emetic.
Siedamgrotzky has had good results from an electric current sent
through the region of the liver, but in the horse this is rarely
demanded.
 A course of bitters, with bicarbonate of soda in small doses, may be
demanded to re-establish the healthy tone of the stomach and
intestines, and a run at pasture, or at least an open air life, exercise,
and a laxative diet with abundance of good water should be secured.
Any undue costiveness should be counteracted at once by a saline
laxative.