Common neurodegenerative disorders in the perioperative setting: Recommendations for screening from the Society for Perioperative Assessment and Quality Improvement (SPAQI).

Aging is associated with normal and abnormal brain and cognitive changes. Due to the expected increase in older adults requiring surgery, perioperative clinicians will be increasingly encountering patients with neurodegenerative disease. To help perioperative clinicians understand signs of abnormal behaviors that may mark an undiagnosed neurodegenerative disorder and alert additional patient monitoring, The Society for Perioperative Assessment and Quality Improvement (SPAQI) worked with experts in dementia, neuropsychology, geriatric medicine, neurology, and anesthesiology to provide a summary of cognitive and behavioral considerations for patients with common neurodegenerative disorders being evaluated at preoperative centers. Patients with neurodegenerative disorders are at high risk for delirium due to known neurochemical disruptions, medication interactions, associated frailty, or vascular risk profiles presenting risk for repeat strokes. We provide basic information on the expected cognitive changes with aging, most common neurodegenerative disorders, a list of behavioral features and considerations to help differentiate neurodegenerative disorders. Finally, we propose screening recommendations intended for a multidisciplinary team in the perioperative setting.

Preoperative screening, evaluation, and optimization of the patient's medical status before outpatient surgery.

PURPOSE OF THE REVIEW: Preoperative evaluation and optimization of a patient's medical condition are important components of anesthesia practice. With ever increasing numbers of patients with serious comorbidities having complex procedures as outpatients, the task of gathering information and properly preparing for their care is challenging. Improvements in assessment and management can potentially reduce adverse events, improve patient and caregiver satisfaction, and reduce costs. RECENT FINDINGS: A growing body of literature and evidence-based practices and guidelines can assist clinicians who work in the expanding field of preoperative medicine. Care providers from various specialties in medicine are developing innovative methods, tools, and knowledge to advance science and processes. Data-driven practices are beginning to close the information gap that has plagued this field of medical practice. SUMMARY: Preparation of patients before surgery is a necessary and vital component of perioperative medicine. Practices are developing to guide effective interventions that benefit patients and healthcare systems. Outpatients present special challenges to preoperative assessment.

Gastrostomy tube placement is safe in advanced amyotrophic lateral sclerosis.

OBJECTIVES: To evaluate the safety and effect on survival of insertion of a gastrostomy tube (G-tube) in patients with amyotrophic lateral sclerosis (ALS) who have upright forced vital capacity (uFVC) ≤ 50% predicted. Current guidelines, which are based on higher rates of post-procedure complications in ALS patients with advanced respiratory dysfunction, have led to a recommendation to perform G-tube insertion before the FVC drops to <50% predicted, even when the patient has no significant dysphagia. METHODS: We assessed 41 ALS patients who received a G-tube, mostly by insertion of a percutaneous endoscopic gastrostomy (PEG) tube by a dedicated team that included a gastroenterologist and one of two anesthesiologists using Monitored Anesthesia Care with deep sedation, and 61 patients who did not receive a G-tube. uFVC was ≤50% predicted in 12 of 41 patients who received a G-tube and in 18 of 61 who did not. RESULTS: The procedure was safe regardless of FVC status, with low rates of post-operative complications in both low and high FVC groups. There was no survival benefit for patients who received a G-tube when compared with those who did not. DISCUSSION: PEG insertion is safe in ALS patients with significant respiratory muscle weakness when performed by a dedicated team, which suggests that the recommendation for G-tube placement should not be based on the patient's respiratory status.

Preoperative medical testing and preparation for ophthalmic surgery.

The prevention of complications during and after procedures is the most important goal of preoperative evaluation. Several studies have proven the utility of a patient history and physical examination when making a diagnosis. This article discusses preoperative testing and risk assessment as well as management for various conditions that pose challenges to anesthesia and or surgery.

CPAP adherence in patients with newly diagnosed obstructive sleep apnea prior to elective surgery.

BACKGROUND: Obstructive sleep apnea (OSA) is prevalent in the surgical population, and it has been suggested that preoperative patients should be screened and treated for OSA. However, it remains unclear whether patients diagnosed with OSA in the preoperative period adhere to prescribed CPAP therapy. OBJECTIVE: Our aim was to objectively quantify CPAP adherence, investigate predictors of poor CPAP adherence, and to establish an optimal CPAP setting in a cohort of presurgical patients diagnosed with OSA as part of the preoperative work-up. METHODS: In a retrospective observational study, we collected data on all adult presurgical patients seen by the Anesthesia Perioperative Medicine Clinic (APMC) who screened positive for OSA on the STOP-Bang questionnaire and underwent an in-laboratory diagnostic polysomnogram (PSG) before surgery. CPAP was offered to patients with moderate or severe OSA. Objective CPAP adherence was recorded during the perioperative period. Factors associated with reduced CPAP adherence were delineated. Patient characteristics were compared between those with STOP-Bang scores of 3-4 and those with higher scores (STOP-Bang score ≥ 5). RESULTS: During a 2-year period, 431 patients were referred and 211 patients completed a PSG. CPAP therapy was required in 65% of patients, and the optimal level was 9 ± 2 cm H(2)O. Objective CPAP adherence was available in 75% of patients who received CPAP therapy; median adherence was 2.5 h per night, without any significant difference between the STOP-Bang subgroups. African American race, male gender, and depressive symptomatology were independent predictors of reduced CPAP adherence. Severe OSA was significantly more prevalent in patients with a STOP-Bang score ≥ 5 than those whose score was 3-4 (55.1% versus 34.4%, p = 0.005). However, optimum CPAP pressure levels and adherence to therapy did not differ between the 2 STOP-Bang groups. CONCLUSIONS: Adherence to prescribed CPAP therapy during the perioperative period was extremely low. African American race, male gender, and depressive symptoms were independently associated with reduced CPAP usage. Further research is needed to identify and overcome barriers to CPAP acceptance and adherence in the perioperative setting.

Identification and evaluation of the patient with lung disease.

Preoperative pulmonary evaluation and optimization improves postoperative patient outcomes. Clinicians frequently evaluate patients with pulmonary disease before surgery who are at increased risk for pulmonary and nonpulmonary perioperative complications. Postoperative pulmonary complications are as common and costly as cardiac complications. In this article, the evaluation of patients with the most common conditions encountered in the preoperative setting, including unexplained dyspnea, asthma, chronic obstructive pulmonary disease, obstructive sleep apnea, and cigarette use, are discussed. Risk stratification for postoperative pulmonary complications and strategies to reduce them for high-risk patients are also discussed. From the available literature, high-risk patients and those patients for whom a multidisciplinary collaboration will be most helpful can be accurately identified.

Identification and evaluation of the patient with lung disease.

Preoperative pulmonary evaluation and optimization improves postoperative patient outcomes. Clinicians frequently evaluate patients with pulmonary disease before surgery who are at increased risk for pulmonary and nonpulmonary perioperative complications. Postoperative pulmonary complications are as common and costly as cardiac complications. In this article, the evaluation of patients with the most common conditions encountered in the preoperative setting, including unexplained dyspnea, asthma, chronic obstructive pulmonary disease, obstructive sleep apnea, and cigarette use, are discussed. Risk stratification for postoperative pulmonary complications and strategies to reduce them for high-risk patients are also discussed. From the available literature, high-risk patients and those patients for whom a multidisciplinary collaboration will be most helpful can be accurately identified.