Clinical conundrum in Perioperative Evaluation

Hospital Medicine Grand Rounds “The role of the peri-operative evaluation in safe patient outcomes: an initial patient dissatisfaction with a happy ending” Moises Auron MD FAAP Feb 11, 2009

Objectives ,[object Object],[object Object]

Objectives ,[object Object],[object Object],[object Object]

Case presentation ,[object Object],[object Object],[object Object],[object Object],[object Object]

PMH ,[object Object],[object Object],[object Object],[object Object],[object Object]

PSH ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Medications ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Social ,[object Object],[object Object],[object Object],[object Object]

Pre-operative assessment ,[object Object],[object Object],[object Object],[object Object],[object Object]

Circulation. 2007;116:1971-1996

Physical examination ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Signs of aortic insufficiency ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Babu AN, et al. Ann Intern Med. 138 (9): 736–42. Ashrafian H. Int J Cardiol. 2006 Mar 8;107(3):421-3.

Signs of aortic insufficiency ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Babu AN, et al. Ann Intern Med. 138 (9): 736–42. Ashrafian H. Int J Cardiol. 2006 Mar 8;107(3):421-3.

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Signs of aortic insufficiency

Pre-operative optimization ,[object Object],[object Object],[object Object]

Clinical risk factors: RCRI Lee, et al. Circulation. 1999; 100: 1043 – 1049.

Despite patient’s anger and yelling… ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Aortic regurgitation: Etiology ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Circulation 2008;118;e523-e661

Natural history of AR Circulation 2008;118;e523-e661

Natural history of chronic AR ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Circulation 2008;118;e523-e661

TTE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

LV Catheterization ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

http://www.med.yale.edu/intmed/cardio/echo_atlas/entities/aortic_regurgitation.html

Circulation 2008;118;e523-e661

Immediate Postoperative TEE ,[object Object],[object Object],[object Object]

Case presentation ,[object Object],[object Object],[object Object],[object Object]

ROS ,[object Object],[object Object],[object Object]

Under further questioning: ,[object Object],[object Object],[object Object]

HPI…. ,[object Object],[object Object]

HPI ,[object Object],[object Object],[object Object],[object Object]

PMH, FH and PSH ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Medications ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Preoperative assessment ,[object Object],[object Object],[object Object]

Physical exam ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Pre-operative assessment ,[object Object],[object Object],[object Object]

Despite angry complaints…. ,[object Object],[object Object],[object Object],[object Object],[object Object]

Perioperative implications of pleural effusion ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Gilmartin, et al. Thorax 1985; 40:60–65. Agusti, et al. Am J Respir Crit Care Med 1997; 156:1205–1209.

Pleural effusion and mechanical ventilation Graf J. Current Opinion in Critical Care 2009; 15:10–17.

[object Object],[object Object],[object Object],http://www.thoracicmedicine.org

Perioperative air safety ,[object Object],[object Object],[object Object],[object Object],Hickle R. Acta Anaesthesiol Scand Suppl. 1997;111:241-7.

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Perioperative air safety Hickle R. Acta Anaesthesiol Scand Suppl. 1997;111:241-7.

Perioperative air safety ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Neil J. AORN J. DEC 2008; 88 (6): 942-958

Perioperative air safety ,[object Object],[object Object],[object Object],Neil J. AORN J. DEC 2008; 88 (6): 942-958

Patient with active pulmonary TB ,[object Object],[object Object],[object Object],[object Object],[object Object],Neil J. AORN J. DEC 2008; 88 (6): 942-958

Pleural biopsy ,[object Object],[object Object],[object Object]

Light RW. NEJM. 2002; 346 (25): 1971-1977

Yataco JC, Dweik R. CCJM. 2005; 72(10): 854-872.

Ancillary testing ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Pleural rheumatoid factor ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Yataco JC, Dweik R. CCJM. 2005; 72(10): 854-872.

Rheumatology consult ,[object Object],[object Object],[object Object]

Preoperative lateral flexion-extension C-spine X-Rays ,[object Object],[object Object],[object Object],[object Object],Macarthur A, et al. Can J Anaesth. 1993; 40: 154-9. Crosby ET. Can J Anaesth. 1990; 37: 77-93.

[object Object],http://nyp.org/masc/colorectal.htm

Post-operative ,[object Object],[object Object],[object Object]

Clinical conundrum ,[object Object],[object Object]

Take home message ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Clinical conundrum in Perioperative Evaluation

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Clinical conundrum in Perioperative Evaluation