Preoperative Chest Radiography in Elective Surgery: Review and Update.

INTRODUCTION: The preoperative evaluation is designed to identify factors that may predispose a patient to perioperative complications in an effort to ensure patient safety. The use of chest radiography in the preoperative evaluation has progressed from routine testing to a more selective approach based on evidence that routine testing is low yield. However, preoperative chest radiography (POCR) may still be utilized more frequently than necessary as guidelines provide varying recommendations and providers continue to order the test by convention. The literature is reviewed to update providers on the indications for POCR and encourage more selective use. METHODS: Articles related to POCR were retrieved via PubMed search and subsequent cited reference search. Effort was made to analyze primarily meta-analysis, systematic reviews and current guidelines and secondarily larger observational studies. No randomized controlled trials related to use of POCR were identified. FINDINGS: POCR frequently detects abnormalities; however, a majority of abnormalities detected are in patients with a history of cardiopulmonary disease or signs and symptoms indicative of cardiopulmonary disease. The frequency with which detected abnormalities influence perioperative management is low and evidence suggests that the clinical examination alone provides sufficient information to dictate any necessary changes in management in a majority of cases. Current evidence does not support the ability of POCR to reliably predict postoperative pulmonary complications. CONCLUSIONS: Selective use of POCR is recommended. Emphasis on a thorough preoperative clinical examination is usually sufficient to make decisions on perioperative management as POCR rarely provides significant additional information. POCR is generally indicated in patients with signs or symptoms of acute or unstable cardiopulmonary disease. The relationship between POCR and patient outcomes, morbidity and mortality is not known.

Association of Mild Cognitive Impairment With Exposure to General Anesthesia for Surgical and Nonsurgical Procedures: A Population-Based Study.

OBJECTIVE: To examine whether exposure to general anesthesia for operations and procedures after the age of 40 years is associated with incident mild cognitive impairment (MCI) in elderly patients. PATIENTS AND METHODS: A population-based, prospective cohort of Olmsted County, Minnesota, residents aged 70 to 89 years at enrollment, underwent baseline and 15-month interval evaluations that included the Clinical Dementia Rating scale, a neurologic evaluation, and neuropsychological testing. Anesthesia records after the age of 40 years until last evaluation for MCI were abstracted. Proportional hazards regression, adjusting for other known MCI risk factors, was used to assess whether exposure to surgical general anesthesia after the age of 40 years is associated with the incidence of MCI. RESULTS: Of 1731 participants (mean age, 79 years), 536 (31.0%) developed MCI during a median follow-up of 4.8 years. Anesthesia exposure was not associated with MCI when analyzed as a dichotomous variable (any vs none; adjusted hazard ratio [HR], 1.07; 95% CI, 0.83-1.37; P=.61), the number of exposures (adjusted HR, 1.05; 95% CI, 0.78-1.42; adjusted HR, 1.12; 95% CI, 0.86-1.47; and adjusted HR, 1.02; 95% CI, 0.76-1.34, for 1, 2-3, and ≥4 exposures compared with no exposure as the reference; P=.73), or the total cumulative duration of exposure (adjusted HR, 1.00; 95% CI, 0.98-1.01, per 60-minute increase; P=.83). In secondary sensitivity analyses, anesthesia after 60 years of age was associated with incident MCI (adjusted HR, 1.25; 95% CI, 1.02-1.55; P=.04), as was exposure in the previous 20 and 10 years. CONCLUSION: We found no significant association between cumulative exposure to surgical anesthesia after 40 years of age and MCI. However, these data do not exclude the possibility that anesthetic exposures occurring later in life may be associated with an increase in the rate of incident MCI.

Perioperative considerations in patients with Gitelman syndrome: a case series.

STUDY OBJECTIVE: To determine the perioperative considerations for low-risk and high-risk surgery in patients with Gitelman syndrome. DESIGN: Retrospective chart review. SETTING: University-affiliated medical center. PATIENTS: 42 patients with Gitelman syndrome. MEASUREMENTS: Of the 42 patients with Gitelman syndrome, 5 underwent procedures requiring anesthesia: mastectomy, spinal fusion, thyroidectomy, tonsillectomy, and bronchoscopy. The anesthesia record and all associated laboratory tests and clinical notes associated with those procedures were recorded. MAIN RESULTS: No acute electrolyte abnormalities or postoperative complications occurred with these procedures in patients with Gitelman syndrome. CONCLUSION: Gitelman syndrome is a mild disorder when appropriately managed.