Comorbid Disease and Perioperative Medicine
Cardiovascular
Understand the perioperative management of ischemic heart disease, heart failure, hypertension, and arrhythmias. Know that uncontrolled hypertension increases the risk of perioperative lability but that routine cancellation for mild hypertension is not indicated. Understand the management of patients with pacemakers and implantable defibrillators, including the use of a magnet and the need for reprogramming.
Respiratory
Know the management of asthma, COPD, and obstructive sleep apnea. Understand the importance of preoperative optimization of bronchospasm and the risk of postoperative pulmonary complications. Know the perioperative management of patients on home oxygen and the risk of pulmonary hypertension.
Endocrine and Renal
Understand the management of diabetes, thyroid disease, and adrenal insufficiency. Know that patients on chronic steroids may need stress-dose steroids. Understand the perioperative management of chronic kidney disease and dialysis timing.
Hematologic and Neurologic
Know the management of patients on anticoagulants, the risk of perioperative stroke, and the management of patients with epilepsy and neuromuscular disease.
Traps
Questions often test the need for stress-dose steroids, the timing of dialysis before surgery, and the management of a patient with a pacemaker. Another trap is the belief that all patients with a drug-eluting stent must wait 12 months; timing depends on the risk of bleeding versus stent thrombosis and requires cardiology input.
Worked Example
A patient on chronic prednisone for rheumatoid arthritis undergoing major surgery. Consider stress-dose hydrocortisone (e.g., 100 mg at induction and then tapering) because of the risk of adrenal insufficiency, especially with prolonged surgery.
Resuscitation and Crisis Management
Core Concepts
Know the ACLS algorithm: high-quality CPR, early defibrillation, and the reversible causes (the Hs and Ts). Understand the management of shockable rhythms (VF/pulseless VT) and non-shockable rhythms (asystole/PEA). Know the role of capnography as a marker of CPR quality and return of spontaneous circulation.
Perioperative Crises
Understand the management of malignant hyperthermia (dantrolene, stop triggering agents, cooling), anaphylaxis (epinephrine, fluids, airway), local anesthetic systemic toxicity (lipid emulsion), and massive hemorrhage. Know the presentation and management of venous air embolism, tension pneumothorax, and bronchospasm.
Team and Communication
Understand crisis resource management: leadership, role clarity, closed-loop communication, and the use of cognitive aids. Know the importance of debriefing after a crisis.
Traps
Questions often test the first drug in anaphylaxis (epinephrine, not antihistamines) and the dose of dantrolene in malignant hyperthermia (2.5 mg/kg IV). Another trap is the belief that a patient with PEA should be shocked; PEA is not shockable. Also know that capnography can confirm endotracheal tube placement and guide CPR.
Worked Example
During general anesthesia, the patient develops a rising end-tidal CO2, tachycardia, and hyperthermia with masseter spasm. Suspect malignant hyperthermia; stop volatile agents and succinylcholine, hyperventilate with 100% oxygen, and give dantrolene 2.5 mg/kg IV, then cool the patient.