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By Robert N. Sladen, Douglas B. Coursin, Jonathan T. Ketzler, Hugh Playford

Anesthesia and Co-existing illnesses offers a well timed, quick assessment of universal and unusual co-morbidities which are encountered within the day by day perform of anesthesiology. It offers a advisor to the perioperative evaluation and anesthetic administration of sufferers with commonly established co-morbidities reminiscent of high blood pressure, diabetes, weight problems, myocardial ischemia, kidney and liver affliction. It concisely outlines priorities for sufferers with unique difficulties who're present process unrelated operative methods, akin to the obstetrical sufferer, the sufferer with past organ transplantation, the grownup sufferer with congenital middle illness, the spinal twine injured sufferer, the melanoma sufferer with past chemotherapy, the seriously unwell sufferer or the sufferer with a psychiatric affliction.

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Anesthesia and Co-Existing Disease

Anesthesia and Co-existing illnesses presents a well timed, swift review of universal and unusual co-morbidities which are encountered within the daily perform of anesthesiology. It presents a consultant to the perioperative evaluation and anesthetic administration of sufferers with commonly widely used co-morbidities corresponding to high blood pressure, diabetes, weight problems, myocardial ischemia, kidney and liver affliction.

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Cocaine is the only known naturally occurring local anesthetic. Consumption may be IV, intranasal or inhaled. First isolated in 1859, it was used in many products, including Coca-Cola, until banned in 1906 for nonprescription use. Most pts w/ a history of drug abuse deny it. Polysubstance abuse is common; consider toxicology screening. fluid and electrolytes ■ Rhabdomyolysis can lead to acute renal failure. cardiopulmonary ■ Myocardial ischemia/infarction: acute coronary syndrome is the most common cardiac pathology associated w/ cocaine 45 9:27 P1: SBT 0521759385p2-B 46 CUNY1088/Sladen 0 521 75938 5 May 28, 2007 Cocaine Toxicity ■ ■ ■ ■ ■ ■ ■ abuse.

1% population, 5–10% of these also have hepatic disease) r Decreased FEV1, modest decrease PaO2 (“pink puffer”), normal to decreased PaCO2 , decreased DLCO, normal Hct, mild cor pulmonale ■ Physiologic changes ➣ Permanent & minimally reversible obstruction to airflow during exhalation but w/ relatively preserved inspiratory flow ➣ Characterized by progressive expiratory airflow limitation w/ FEV1 <65% predicted, FEV1/FVC <80% ➣ Maximal inspiratory flow rate normal or near normal ➣ Increased RV, increased FRC, increased work of breathing ■ Symptoms & signs ➣ Symptoms may not be present until relatively late; cough, dyspnea (often limiting exercise), ankle swelling, hepatic congestion ➣ Slow & prolonged expiration, hyperinflation of thorax, distant breath sounds, may have wheeze, coarse early inspiratory crackles, use of accessory muscles of 39 9:27 P1: SBT 0521759385p2-B 40 CUNY1088/Sladen 0 521 75938 5 May 28, 2007 Chronic Obstructive Pulmonary Disease respiration, signs of pulmonary hypertension, right heart enlargement and/or failure ➣ With extremis, asterixis & cyanosis ■ Investigations ➣ Chest x-ray: hyperlucency, hyperinflation, bullae ➣ ABGs: hypoxemia w/ advanced disease, hypercapnia & compensatory metabolic alkalosis w/ advanced disease ➣ PFTs: as above ➣ ECG: right heart strain (right axis deviation, RBBB, p pulmonale) ➣ Flow volume loops: early changes: scooped-out lower part of expiratory limb (abnormal flow at low lung volumes); later changes: scooping at all lung volumes ■ Implications ➣ High risk acute-on-chronic respiratory failure (upper & lower respiratory tract infections, surgery) ■ Therapies ➣ Bronchodilators (beta-2 agonists, hypokalemia, cardiac arrhythmias, tremor), mucolytics, anticholinergics (mild AE, dry mouth), steroids (inhaled & systemic, cataracts, osteoporosis, secondary infection, diabetes), methylxanthines (eg, theophylline, nausea/diarrhea/headache/ seizures/cardiac arrhythmias), supplemental oxygen, intermittent antibiotics hematologic Polycythemia secondary to chronic hypoxemia metabolic-nutritional High work of breathing increases metabolic load, elevated resting energy expenditure.

15 8:52 P1: SBT 0521759385p2-A 16 CUNY1088/Sladen 0 521 75938 5 May 28, 2007 Anemia ■ ■ ■ ■ ■ Anemia is defined as a reduction below the normal limits of RBCs in the circulation. ➣ Iron deficiency is most common nutrient deficiency. ➣ Incidence of anemia increases w/ age. 5% of the population has a physiologic anemia. Determine etiology, degree of anemia, physiologic effect & need, if any, to treat immediately or treat during OR/ICU care. ➣ Signs & symptoms of anemia depend on the degree of anemia, speed with which the anemia developed & individual physiologic reserve.

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