The aim of this review is to provide practical clinical information on modern pain management options to guide the clinician on evidence-based practices, optimizing the treatment of pain and avoiding practices that may lead to potential abuse. Postoperative pain management is an essential component of any surgeon’s practice and has clear implications for surgical outcomes, patient satisfaction, and population health. Understanding options within a multimodal approach to pain management in the acute setting is a key determinant to improving outcomes for our patients. This review discusses multimodal analgesic options, including a variety of pain medications (opiates, antiinflammatory medications, and patient-controlled analgesia) and techniques (epidural catheter placement, regional nerve blocks) to be used in tandem. Lastly, best possible practices to avoid opiate abuse are discussed.

This review contains 4 figures, 5 tables, 1 video and 96 references.

Key words: antiinflammatories, epidural, narcotics, patient-controlled analgesia, postoperative pain, regional nerve block

In 2005, Terri Schiavo collapsed at home and was found by her husband without respirations or a pulse. She was resuscitated, but suffered severe anoxic brain injury and after 21/2 months was diagnosed as being in a persistent vegetative state. A court appointed her husband as her legal guardian as she did not have a written advance directive and had not specified a power of attorney for health care (POAHC), but heated court battles raged between her husband and her parents regarding who should be making decisions and what the appropriate decisions were. This case highlights the importance of writing down instructions for end-of-life care or designating someone to make decisions in their best interest in the event they could not make these decisions themselves. This review covers advance directives, do-not-resuscitate orders, and POAHC. Figures show an extended values history form, an example of a living will, the California’s Physician Orders for Life-Sustaining Treatment form, components of the CURVES mnemonic to assess decision-making capacity in critical/emergency situations, and activation and deactivation of power of attorney for health care. Tables list the most common types of advance directive and description of each, barriers to the use of advance directives, common themes in surgeons’ attitudes regarding advance directives, general requirements and exclusions for POAHC, and requirements for decision-making capacity in patients.

This review contains 5 figures, 9 tables, and 58 references

Keywords: Advance directives, power of attorney in health care, do not resuscitate order, decision-making, end-of-life, critical care

Critically ill patients often require surgical procedures and therapeutic interventions that produce significant pathophysiologic changes. Drug pharmacology can be greatly altered in this population wherein comorbid diseases, varied organ function, and polypharmacy can produce adverse drug reactions (ADRs). This review aims to describe basic pharmacokinetic principles (absorption, distribution, metabolism, elimination) and changes in these processes due to altered organ function in critically ill surgical patients. This knowledge is a key factor in reducing ADRs.

This review contains 10 figures, 2 tables, 101 references

Keywords: adverse drug reactions, drug interactions, obesity, pharmacodynamics, pharmacokinetics, plasma protein binding, therapeutic drug monitoring

The history and general principles of OR design are discussed, including physical layout and design standards, which encompass the layout and storage of devices and equipment. As both patient and staff safety are paramount, all of the risks that can be mitigated by good design are discussed: biologic, ergonomic, chemical, and physical. Environmental issues in the OR are listed and include temperature, humidity, and lighting. The proper use, storage, and risks of electronic and mechanical devices are discussed. Infection control is addressed and includes hand hygiene, gloves and protective barriers, antimicrobial prophylaxis and nonpharmacologic preventive measures. A housekeeping section discusses the benefits of segregating clean, clean-contaminated, and dirty cases. OR scheduling is noted. Tables outline International Commission on Radiological Protection–recommended radiation dose limits; key principles of the Joint Commission Universal Protocol; devices used in the operating room; standard equipment for endovascular operating rooms; benefits of voice activation technology in the laparoscopic operating room; criteria for defining a surgical site infection; factors that contribute to the development of surgical site infection (SSI); Centers for Disease Control and Prevention hand hygiene guidelines; distribution of pathogens isolated from surgical site infections: operating room cleaning schedules; classification of operations in relation to the epidemiology of SSIs; and basic principles of OR efficiency. Figures depict patient positioning and basic components of an ultrasound transducer,

This review contains 3 figures, 27 tables, and 216 references

Keywords: Operating room, patient positioning, safety, surgical site infection, equipment, protective barriers, antimicrobial prophylaxis

A clinical trial is a planned experiment designed to prospectively measure the efficacy or effectiveness of an intervention by comparing outcomes in a group of subjects treated with the test intervention with those observed in one or more comparable group(s) of subjects receiving another intervention.  Historically, the gold standard for a clinical trial has been a prospective, randomized, double-blind study, but it is sometimes impractical or unethical to conduct such in clinical medicine and surgery. Conventional outcomes have traditionally been clinical end points; with the rise of new technologies, however, they are increasingly being supplemented and/or replaced by surrogate end points, such as serum biomarkers. Because patients are involved, safety considerations and ethical principles must be incorporated into all phases of clinical trial design, conduct, data analysis, and presentation. This review covers the history of clinical trials, clinical trial phases, ethical issues, implementing the study, basic biostatistics for data analysis, and other resources. Figures show drug development and clinical trial process, and type I and II error. Tables list Food and Drug Administration new drug application types, and types of missing data in clinical trials.

This review contains 2 figures, 3 tables, and 38 references

Keywords: Clinical trial, study design, type I error, type II error, double-blind study, ethics

Descriptions of “evidence-based” approaches to medical care are now ubiquitous in both the popular press and medical journals. The term evidence-based medicine (EBM) was first coined in 1992, and over the last two decades, the field has experienced rapid growth, and its principles now permeate both graduate medical education and clinical practice. The field of EBM has been in constant evolution since its introduction and continues to undergo refinements as its principles are tested and applied in a wide variety of clinical circumstances. This review presents a brief history of EBM, EBM: fundamental tenets, a critical appraisal of a single study, reporting guidelines for single studies, a critical appraisal of a body of evidence, evidence-based surgery, and limitations in EBM. Tables list strength of evidence for treatment decisions (EBM working group), Oxford Centre for Evidence-Based Medicine revised levels of evidence for treatment benefits , “4S” approach to finding resources for EBM, critical appraisal of individual studies examining therapeutic decisions, reporting guidelines by study design, and key resources for evidence-based surgery.

This review contains 6 tables and 85 references

Enhanced recovery pathways (ERPs) are standardized coordinated, multidisciplinary perioperative care plans that incorporate evidence-based interventions to minimize surgical stress, improve physiologic and functional recovery, reduce complications, and thereby facilitate earlier discharge from the hospital. Several perioperative elements contribute to enhance surgical recovery. Preoperative elements include patient education, optimization of medical conditions and functional status, nutritional support, smoking cessation programs, minimization of preoperative fasting and preoperative carbohydrate drinks, avoidance of mechanical bowel preparation when not indicated, and avoidance of long-active sedatives as premedication. Intraoperative elements aim to attenuate the surgical stress response and include regional or local anesthesia; pharmacologic adjuvants, nonopioid analgesics, and maintaining normothermia; intravenous fluid management; and opting to favor small incisions when possible. Postoperative elements include considering multimodal analgesia (opioid-sparing strategies); encouraging early postoperative feeding; stressing the importance of early mobilization; restricting the unnecessary use of intravenous fluids, drains, and catheters; and instituting a discharge and follow-up plan for patients. Tables describe the evolution of intraoperative fluid management, organization of a multimodal perioperative care plan for a specific procedure or group of procedures; key elements to include in developing an ERP; sample multimodal perioperative care plans for elective colorectal resection, esophageal resection, and ambulatory laparoscopic cholecystectomy.

This review contains 1 figure, 6 tables, and 319 references.

Effective surgical treatments are available for a wide variety of diseases in the modern era; at the same time, surgical interventions have become increasingly complex and specialized. The contemporary surgeon must coordinate evaluation and management of patients with multiple medical diagnoses and shepherd these patients through an increasingly elaborate process of medical and surgical care. To provide effective care, the organ systems–oriented approach is key. This approach, demonstrated in the following review, guides the practitioner through each organ system in order and can be used to generate a differential diagnosis for each system and a comprehensive problem list for each patient. 

This review contains 20 tables, and 59 references.

Keywords: Postoperative period, perioperative period, cardiac complications, surgical site infection, incentive spirometry, postoperative delirium, postoperative renal failure

The pathogenesis of portal hypertension is described, as is the subsequent development of collateral circulation and varices. Methods for diagnosis of portal hypertension are discussed and can be suspected clinically in a patient with stigmata of chronic liver disease. The two most commonly used methods to assess the severity of liver disease are the Child-Turcotte-Pugh (CTP) class and the Model for End-stage Liver Disease (MELD) score. Upper gastrointestinal endoscopy is the most common method used to detect varices. The modalities for treating portal hypertension–related bleeding are given and may be pharmacologic or surgical. The surgical modality can involve shunts (portosystemic shunts) or nonshunt procedures (esophageal transection or devascularization). The management of specific causes of portal hypertension is given for esophageal varices; gastric varices; ectopic varices; portal hypertensive gastropathy and gastric vascular ectasia; ascites; and hepatic encephalopathy. 

This review contains 17 figures, 12 tables, and 27 references.

Keywords: liver decompensation, cirrhosis, portal hypertension, sinusoid, Budd-Chiari syndrome, ascites, varices, variceal bleeding, endoscopic bang ligation, portosystemic shunt, transjugular intrahepatic portosystemic shunt (TIPS)

The term jaundice refers to the yellowish-orange discoloration of skin, sclerae, and mucous membranes that results from excessive deposition of bilirubin in the tissues. A problem-based approach to the jaundiced patient that involves assessing the incremental information provided by successive clinical and laboratory investigations, as well as the information obtained by means of modern imaging techniques, is key. Current decision making in the approach to the jaundiced patient should include not only careful evaluation of anatomic issues but also close attention to patient morbidity and quality-of-life concerns, as well as a focus on a cost-effective diagnostic workup. For optimal treatment, an integrated approach that involves the surgeon, gastroenterologist, and radiologist is essential. This review covers terminology and epidemiology, clinical evaluation and investigative studies, workup and management of posthepatic jaundice, and postoperative jaundice. 

This review contains 5 figures, 13 tables, and 84 references. 

Keywords: Jaundice, biliary tree, biliary obstruction, cholangiocarcinoma, pancreatic cancer, endoscopic retrograde cholangiopancreatography, magnetic resonance cholangiopancreatography

Clinical evaluation and surgical decision making in patients with acute pancreatitis (AP) and chronic pancreatitis (CP) are two of the most complex conditions that a general surgeon faces. Each entity has unique laboratory and radiographic investigations, operations, and postoperative care. The clinical evaluation, history, and physical examination of AP is described. The clinical features necessary for diagnosis are listed, and contrast-enhanced computed tomography is described as the gold standard for diagnosis. This review uses definitions and terminology developed at the Atlanta symposium in 1992. The severity of an episode of AP is described in terms of established scoring systems (APACHE II [Acute Physiology and Chronic Health Evaluation II], Glasgow Coma Scale score, Ranson criteria). AP can range from mild to severe necrotizing, with each described. The clinical course is described in detail. For CP, the history, physical examination, and diagnosis via investigative and imaging studies are described. The anatomic and morphologic subtypes of chronic pancreatitis are listed and the operations directed at patients with CP are detailed, and can involve drainage or combined resection and drainage. 

This review contains 12 figures, 15 tables, and 55 references

Keywords: Acute pancreatitis, chronic pancreatitis, gallbladder disease, alcoholism, amylase, Whipple procedure

Laparoscopic splenectomy has become an established standard of care in the management of surgical diseases of the spleen, except in the hemodynamically unstable trauma patient requiring splenectomy. Although adoption of minimally invasive splenectomy has led to a gradual decrease in the indications for open splenectomy, both procedures are still essential components of spleen surgery. This review describes the indications and contraindications for procedure, preoperative preparation and consent, operative anatomy and technique, and long-term follow-up. Tables review the clinical indications for splenectomy, classification of splenectomy, a comparison of laparoscopic versus open postsplenectomy outcomes, indications and contraindications for partial splenectomy, and reported incidences of postoperative outcomes and complications after splenectomy. Figures depict splenomegaly, the American Society of Hematology 2011 evidence-based practice guidelines for management of primary idiopathic thrombocytopenic purpura in children and adults, a splenic mass, a splenic cyst, massive splenomegaly, laparoscopic splenectomy, the 2014 Centers for Disease Control and Prevention recommendations for adult and pediatric splenectomy vaccination, splenic artery embolization, various laparoscopic approaches to splenectomy, splenic vascularization, division of splenic artery branches, suspensory ligaments of the spleen, laparoscopic exposure and transection of splenic hilum, retrieval bags and related procedures, open splenectomy, stapling, and laparoscopic partial splenectomy. Videos demonstrate purely laparoscopic splenectomy and hand-assisted laparoscopic splenectomy.

This review contains 26 figures, 11 tables, 2 videos,  and 108 references.

Despite continued advances in therapeutic endoscopy and potent medications to suppress acid production, upper gastrointestinal bleeding (UGIB), defined as bleeding that occurs proximal to the ligament of Treitz, continues to be a common reason for surgical consultation. UGIB results in considerable use of hospital resources, and carries a 2 to 14% mortality. This review covers presentation and initial management, clinical evaluation, risk stratification, investigative tests, and discussion and management of specific sources of UGIB. Figures show an algorithm for management of bleeding from duodenal or gastric ulcers, a technique for duodenotomy and three-point ligation of a bleeding duodenal ulcer, anatomic locations of gastric ulcers according to the modified Johnson classification, and an algorithm for management of bleeding from esophageal  or gastric varices. Table list the Glasgow Blatchford prediction score for UGIB, the AIMS65 prediction score for UGIB, the Rockall prediction score for UGIB, and the Forrest classification for stigmata of recent hemorrhage used to evaluate bleeding ulcers and prevalence data for each class.

This review contains 5 figures, 7 tables, and 97 references

Keywords: Upper gastrointestinal bleeding, gastric ulcer, duodenal ulcer, variceal bleeding, endoscopy, vagal truncotomy, duodenotomy

Pancreatic neuroendocrine tumors (PNETs) comprise a diverse, heterogeneous group of tumours that range in presentation and biologic behavior, including small, asymptomatic, incidentally discovered, nonfunctional neoplasms, functional tumors (both localizable and unlocalizable) with associated clinical syndromes, and diffuse metastatic disease. Based on its functional status, the malignancy of a PNET can vary, from the benign (insulinoma) to that which is commonly malignant more than 50% of the time (gastrinoma, somatostatinoma). According to a recent study, PNETs appear to be increasing in incidence or at least in clinical detection; currently the disorder accounts for 1 to 2% of pancreatic tumors and with a reported clinical incidence of one to five cases per million persons annually in the United States. Nonfunctional PNETs make up the majority of cases, and comprise 2% of all pancreatic malignancies. Treatment has been primarily done through surgical management, particularly via resection. However, medical management has played a more increased role for patients where the disease is advanced, encompassing biotherapy, chemotherapy, and targeted therapies such as peptide receptor radionuclide therapy (PRRT). For nonfunctional PNETs—insulinomas, gastrinomas, glucagonomas, somatostatinomas, and VIPomas—the epidemiology, biology of disease, clinical presentation and diagnosis, localization of tumor, operative management considerations, surgical management of primary tumor, and prognosis and outcomes of each are discussed.

This review contains 6 figures, 18 tables, and 58 references

Keywords: Pancreas, neuroendocrine tumor, gastrinoma, somatostatinoma, VIPoma, insulinoma, incidentaloma, glucagonoma, enucleation

Adrenal tumors are most commonly identified incidentally during imaging for nonadrenal causes. Others may be identified after a patient presents with symptoms of adrenal hormone excess. Adrenal tumors are categorized as functional or nonfunctional, as well as by their malignant potential. It is important to understand the functionality of adrenal glands and properly diagnose potentially hormonally active adrenal tumors. This review outlines the anatomy and physiology of the adrenal glands and details the management of the diseases that result from adrenal hormone excess.

This review contains 8 figures, 7 tables, and 27 references.

Key words: Addison disease, adrenal, aldosterone, catecholamine, Conn syndrome, cortisol, Cushing syndrome, function, glucocorticoid, malignant, pheochromocytoma 

The peritoneum and retroperitoneum, once considered just spaces, are now recognized as primary locations for trauma, inflammation, infection, benign neoplasms, and malignancies. To understand the spread of disease in these locations, one must first understand their anatomy, physiology, and relationship. As both the peritoneum and retroperitoneum contain multiple organs, the relationships of the abdominal organs within these spaces are critical. This review defines both the peritoneum and retroperitoneum and then describes the most common disease states and spread of disease within these spaces. Spread of disease, in particular, spread of malignancy, within the peritoneum is complex but predictable and can be treated in certain instances with heated intra-abdominal chemotherapy intraoperatively.

This review contains 5 figures, 5 tables, and 37 references.

Key words: ascites, carcinomatosis, desmoid, hyperthermic intra-abdominal chemotherapy, peritoneum, peritonitis, retroperitoneal sarcoma, retroperitoneum

The peritoneum and retroperitoneum, once considered just spaces, are now recognized as primary locations for malignancies. Spread of disease, in particular, spread of malignancy, within the peritoneum is complex but predictable. This review covers the pathophysiology, diagnosis, and treatment of malignant peritoneal tumors such as peritoneal metastases and peritoneal carcinomatosis, pseudomyxoma peritonei, and mesothelioma, including a section on cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. In addition, primary malignant disease of the retroperitoneum is discussed, with particular emphasis on retroperitoneal sarcomas.

This review contains 9 figures, 3 tables, and 33 references.

Key words: hyperthermic intraperitoneal chemotherapy, peritoneal carcinomatosis, peritoneal malignancy, peritoneal mesothelioma, peritoneal metastasis, peritoneal tumors, pseudomyxoma peritonei, retroperitoneal malignancy, retroperitoneal sarcoma

Bowel obstruction (mechanical and functional) is a common cause of hospitalization for abdominal pain; patients with complaints of abdominal pain, nausea, vomiting, distention, and lack of flatus or bowel movement should be evaluated for obstruction. The surgeon must approach this diagnosis in a stepwise fashion to determine whether the patient has ischemia necessitating emergent operative intervention or whether initial nonoperative management is warranted. Mechanical obstruction in the small bowel is most commonly caused by adhesions from previous surgery, hernia, or mass, whereas mechanical obstruction in the colon is most often caused by volvulus, cancer, and diverticular stricture. Initial evaluation includes a detailed history, physical examination, and biochemical evaluation with initiation of resuscitative efforts as needed. CT with intravenous contrast is often most readily available and most helpful in diagnosing bowel obstruction type; specific CT findings can suggest the need for urgent operative intervention. Water-soluble contrast medium challenge has emerged as an important adjunct in evaluating the likelihood that a patient with nonischemic bowel obstruction will require operative intervention.  

This review contains 14 figures, 15 tables and 65 references

Keywords:Adhesive bowel obstruction, ileus, ischemic bowel obstruction, laparoscopic adhesiolysis, large bowel obstruction, postoperative bowel obstruction, small bowel obstruction, volvulus, water-soluble contrast medium

In assessing surgical risk, appropriate preoperative evaluation should systematically address a patient's pre-existing medical conditions and identifies unrecognized comorbidities, ideally leading to the anticipation and treatment of potential complications both pre- and postoperation. Thus, a thorough evaluation of the patient history and physical examination is essential. Various risk assessments discussed in this review are those for cardiac, pulmonary, renal, hepatic, and hematologic concerns. Cardiac risk assessment focuses on patient-related risk factors, including coronary artery disease, congestive heart failure, valvular heart disease, arrhythmias and conduction defects, implanted pacemakers and implantable cardiac defibrillators, cardiomyopathy, and hypertension. The pulmonary patient-related risk factors are explored and include age and general health status, smoking, chronic obstructive pulmonary disease, asthma, obstructive sleep apnea, obesity, pulmonary hypertension, and heart failure. Preoperative medication management is also explored.

This review contains 3 figures, 31 tables, and 75 references.

Key words: surgical risk calculators, cardiac complications, coronary artery disease, hypertension, perioperative, cardiac risk assessment, preoperative evaluation

Management of the critically injured patient is optimized by a coordinated team effort in an organized trauma system that allows for rapid assessment and initiation of life-preserving therapies. This initial assessment must proceed systematically and be prioritized according to physiologic necessity for survival. Beginning in the prehospital setting, coordination, preparation, and appropriate triage of the injured are crucial to facilitating rapid resuscitation of the trauma patient. Next, active efforts to support airway, breathing, circulation, and disability are performed with simultaneous intervention to treat life-threatening injuries and restore hemodynamic stability in the primary survey. With ongoing evaluation and continued resuscitation, a secondary survey provides a head-to-toe assessment of the patient allowing for further diagnosis of injuries and triage to more definitive care.

This review contains 12 figures, 8 tables and 63 references

Key Words: advanced trauma life support, definitive airway, FAST/eFAST, field triage, Glasgow coma scale, primary survey, 1:1:1 resuscitation, secondary survey

The management of perioperative anticoagulation, antiplatelet therapy, and perioperative venous thromboembolism (VTE) prophylaxis is essentially a balancing act between patient risk factors for thrombosis and surgical risk factors for bleeding. The purpose of this review is to assist surgeons with the identification of patients at increased risk for thromboembolism when antithrombotic therapy is interrupted, patients for whom bridging anticoagulation should be considered, patients who require perioperative VTE prophylaxis, and patients at increased risk for bleeding complications and to briefly review the literature and major guidelines regarding perioperative antithrombotic therapy management and perioperative VTE prophylaxis. Figures show approaches to the management of perioperative anticoagulation, antiplatelet therapy, and VTE prophylaxis. 

This review contains 2 figures, 7 tables, and 61 references.

Keywords: Venous thromboembolism, pulmonary embolism, anticoagulation, surgery, perioperative period, prophylaxis

Patients with chronic lung disease, inflammatory bowel disease, rheumatoid arthritis, and solid-organ transplantations are often on steroid supplementation either intermittently or chronically. Endogenous steroid use results in decreased adrenocorticotropic hormone secretion by the pituitary gland through negative feedback mechanisms. Over several weeks, this can result in adrenal gland atrophy, eventually leading to secondary adrenal insufficiency. Appropriate management of perioperative glucocorticoid replacement therapy can be challenging, but appropriate replacement is essential to optimize patient outcomes. Insufficient dosing of glucocorticoids during the perioperative period can result in hypotension and even death. Excessive treatment with glucocorticoids decreases wound healing, increases the risk of hyperglycemia, and increases susceptibility to infection. This review covers the historical perspective, the hypothalamic-pituitary-adrenal (HPA) axis, when to suspect an impaired HPA axis, an argument against supraphysiologic glucocorticoid treatment in the perioperative period, the rationale for treating patients with impaired renal function, guidelines for dosing glucocorticoids in the perioperative period, and consulting a specialist. Figures show a clinical algorithm for evaluation and treatment of adrenal insufficiency in the perioperative period and the HPA axis. Tables list steroid conversions and perioperative glucocorticoid treatment recommendations.

This review contains 2 highly rendered figures, 2 tables, and 22 references.

The elderly population uses a significant portion of health care resources in the United States and poses an increasing challenge to perioperative care. Many reports point to both increasing age and frailty as important risk factors for short-term mortality; cardiovascular, pulmonary, and renal complications; and increased length of stay and hospital costs following operation. To provide the best care for the aging US population, it is important for the clinician to be familiar with the appropriate presurgical workup specific to the comorbidities prevalent to the elderly population. This review discusses the postoperative complications facing elderly surgical patients and the physiologic complications of aging, with a particular emphasis on the concept of frailty as a predictor of major morbidity and mortality. With age and comorbidities in mind, this review discusses the relevant preoperative cardiovascular, respiratory, and renal workup and includes important guidelines for appropriate risk assessment and reduction in the elderly surgical patient.

This review contains 1 figure, 5 tables, and 86 references.

Key words: aging, anesthesia, elderly, frailty, outcomes, preoperative workup, risk assessment

The most rapidly growing segment of the elderly population corresponds to persons age 85 and over. As of 2006, elderly patients accounted for 35.3% of the inpatient and 32.1% of the outpatient surgical procedures occurring in the United States. Because age-related changes occur in each organ system in all elderly individuals, this population merits special consideration when undergoing surgical procedures. Furthermore, there is a high probability that older adults will have multiple chronic medical problems, which may present a complex medication management challenge. This review covers the pharmacologic impact of physiologic changes associated with aging, preoperative assessment, preoperative medication management, delirium and the impact of perioperative medications in the elderly, anesthesia and related medications, and specific drug classes and their use in the elderly surgical patient. Figures show an overview of the management of the elderly surgical patient, and preoperative medication management. Tables list medications that should be avoided in older patients with reduced renal function, drugs that exhibit additive adverse effects, medications with high anticholinergic activity, medications that inhibit and induce the CYP450 system, herbal supplements, 2015 Beers Criteria summary of potentially inappropriate medication use in older adults, drugs associated with postoperative delirium, risk factors for postoperative delirium, and clinical pharmacology of commonly used anesthetic agents.

This review contains 2 highly rendered figures, 9 tables, and 61 references

Over the past few decades, the incidence of obesity has been steadily rising in the United States. The Centers for Disease Control and Prevention estimates greater than 40% of the US adult population is obese. Rising obesity rates are also increasing among children and adolescents as well, with nearly one in five children and adolescents considered obese. As a result, surgeons today face the challenge of caring for an increasing number of morbidly obese patients, and this trend is expected to worsen over time. This review covers preoperative evaluation, obesity-related comorbidities, respiratory insufficiency, anesthesia in patients with respiratory insufficiency, intraoperative management, postoperative management, complications of gastric surgery for obesity, diabetes mellitus, wound care, and other obesity-related diseases. Figures show impaired pulmonary function in the morbidly obese improved significantly after weight loss induced by bariatric surgery, significant improvement in mean pulmonary arterial pressure in 18 patients, 3 to 9 months after gastric surgery-induced weight loss of 42% ± 19% of excess weight, and a chronic venous stasis ulcer present for several years in a morbidly obese patient. The tables list evaluation and treatment of obstructive sleep apnea, and indications for extended postoperative chemoprophylaxis for venous thromboembolism in morbidly obese patients.

This review contains 3 highly rendered figures, 2 tables, and 46 references

Keywords: morbid obesity, obesity, metabolic surgery, venous thromboembolism chemoprophylaxis, Obstructive Sleep Apnea

Diabetes mellitus is the seventh leading cause of death in the United States; diabetic patients have a 50% chance of undergoing a surgical procedure during their lifetime, and operations in this patient population have been associated with a reported mortality of 4% to 13%. Careful planning of operative management and perioperative care must be taken into account when scheduling surgery for diabetic patients, especially patients taking insulin or oral hypoglycemic agents. Debate continues and inconsistencies remain regarding the management of both diabetes and hyperglycemia in the surgical setting. The review covers the evaluation of the diabetic patient, preoperative management, intraoperative management, postoperative management, total parenteral nutrition and blood glucose, cardiovascular and renal assessment, infection, and special populations. 

This review contains 2 figures, 5 tables, and 21 references

Keywords: Glucose, Hyperglycemia, perioperative period, surgery, diabetes mellitus, surgical site infection, preoperative management, postoperative management, wound healing

General surgeons are encountering an increasing number of cases involving immunosuppressed patients due to a number of factors, including the improvement in treatment for HIV, increased survival following solid-organ transplantation, and more aggressive chemotherapy. These groups of patients present unique challenges for the surgeon and often require more comprehensive preoperative assessment and perioperative monitoring. This review addresses the surgical management of these immunocompromised populations, with specific recommendations for each type of patient. Tables outline opportunistic infections and antibiotic prophylaxis; common immunosuppressive medications, posttransplantation drug levels, and side effects for renal transplant recipients; components of preoperative workup involving suspected infection in immunocompromised patients; and anesthetics and demonstrated impact on immune response and cancer recurrence. Graphs display the number of AIDS diagnoses and deaths and people living with AIDS and HIV in the United States over time, and compare percentages of death certificates reporting opportunistic infection versus chronic disease in the HIV-infected population. Management algorithms outline approaches to patients with defects in host defenses and candidates for transplantation to be deliberately immunosuppressed.

This review contains 2 graphs, 2 management algorithms, 4 tables, 157 references, and 5 annotated key references.

Large bodies of evidence link alcohol consumption and substance use disorders (SUDs) with motor vehicle collisions, as well as life-threatening intentional injury.  According to the substance use and mental health estimates from the 2013 National Survey on Drug Use and Health, 24.6 million individuals age 12 or older were current illicit drug users in 2013, including 2.2 million adolescents age 12 to 17, and 60.1 million individuals age 12 or older were binge drinkers in the past month.  Many people with SUDs become patients; therefore, the surgeon must be able to recognize and manage many of the related issues that can ensue. This review details the definition of SUDs, basic principles of toxicology, acute management of the patient with suspected substance use intoxication or withdrawal, managing life-threatening syndromes in patients with SUDs, overdose and withdrawal syndromes of opioids, stimulants, and depressants, surgical complications of SUDs, perioperative and postoperative considerations in patients with SUDs, and consultation and referral to a toxicologist and poison control center. Figures show first- and zero-order kinetics;  pupillary examination, laboratory and radiographic findings in SUDs; polymorphic ventricular tachycardia; consciousness as an interplay between arousal and awareness, an algorithm for the management of seizures, sine, mechanism of cocaine’s cardiac toxicity and hemorrhagic stroke in a cocaine abuser, necrotizing soft tissue infection, digit necrosis associated with intra-arterial injection of cocaine, scars from skin popping, nonocclusive thrombus in the left internal jugular vein, needle fracture with soft tissue dislodgment, oral contrast-enhanced computed tomographic scan showing rounded foreign bodies in the stomach, and fecal impaction associated with heroin. Tables list criteria for substance use disorders according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V), frequently misused drugs, causes of death in SUD, cardiac, neurologic, and metabolic signs and symptoms caused by commonly abused substances , anion and osmolar gap equations, life-threatening manifestations of cocaine toxicity, and alcohol-related disorders.

This review contains 15 figures, 8 tables, and 85 references.

The field of minimally invasive surgery has evolved rapidly since the first laparoscopic appendectomies and cholecystectomies were performed nearly 30 years ago.1 Minimally invasive approaches are now widely used for gastrointestinal resection, hernia repair, antireflux surgery, bariatric surgery, and solid-organ surgery, such as hepatic, pancreatic, adrenal, and renal resections. Although the techniques and equipment needed to access, expose, and dissect vary according to the type of operation and surgeon’s preference, a basic set of equipment is essential for any laparoscopic or robotic procedure: endoscope, camera, light source, signal processing unit, video monitor, insufflator and gas supply, trocars, and surgical instruments. Understanding how to use and troubleshoot this equipment is critical for any surgeon who performs minimally invasive surgery. We review the essentials of basic laparoscopic equipment, including the mechanics of normally functioning equipment and the various types of laparoscopic trocars and instruments. We also discuss robotic equipment and the fundamental differences from laparoscopy. Minilaparoscopy and single-site equipment are briefly explained. Additionally, we discuss potential technical difficulties that surgeons may encounter while performing minimally invasive procedures and provide suggestions for troubleshooting these problems.

This review 13 figure, 2 tables, and 64 references.

Key Words: Laparoscopy, Robotic Surgery, Minimally Invasive Surgery, Laparoscopic Surgery, Trocars, Surgical Energy Devices, Insufflator, Laparoscopic Instrumentation, Ergonomics, Single Site Surgery

Nutritional optimization of the surgical patient remains a cornerstone of perioperative care. Significant effort and scrutiny are routinely directed to the field as it has the potential to improve outcomes, limit infectious complications, and decrease hospital length of stay and mortality. As such, previously identified cornerstones of care have been called into question. The timing, route, and intensity of nutritional supplementation remain the subject of controversy in an ever-evolving field. Previous methods of nutritional assessment, such as albumin and transthyretin, have proved unreliable, and their use is no longer recommended. In their place, new scoring systems are available to risk assess patients for malnutrition. We review the most pressing changes and assess the landscape of the field today.

Key words: critical illness, enteral, glutamine, malnutrition, nutrition, outcomes, parenteral, protein

Laparoscopic surgery has gained popularity in recent time. An essential aspect of this technique is production of a pneumoperitoneum with insufflation for adequate visualization and manipulation of abdominal contents. Various techniques have been developed over the years for optimal access with minimization of complications. Some of these complications include vascular injury, visceral injury, and incisional hernia. Furthermore, considerations with regards to the patient’s physical morphology, and the cardiovascular/respiratory effects of increased abdominal pressure and anesthesia must be accounted for. The guidelines to optimize patient care in these regards are discussed in this review.

This review contains 2 videos, 5 figures, 2 tables, and 79 references.

Keywords:  trocar insertion, port site hernia, Veress needle, optical trocar, trocar related injuries, Hassan cannula, pneumoperitoneum, air embolism, pneumoperitoneum physiology

Infections are common complications treated in surgical and trauma intensive care units. Identification of infections in surgical patients is rarely incidental; it is sought most often in response to clinical signs. The presence of surgical infectious disease is usually determined clinically and confirmed microbiologically. Precision in terminology is vital; though similar in connotation, infection is not interchangeable with similar terms like sepsis and bacteremia. This chapter describes the signs and symptoms of infection, including the key signs of inflammation, pain, vital sign changes, and confusion. The approach to diagnosing infections is provided and includes an evaluation for the presence of infection, a history and physical examination, and various diagnostic tests, including hematologic and biochemical tests, microbiologic studies, and radiology. The various surgical/trauma infections are described and include the diagnostic approach to specific surgical infection like appendicitis, diverticulitis, and skin and soft tissue infections; postoperative infections referred to as surgical site infections; and nosocomial infections such as urinary tract infection, vascular catheter infection, septic shock, pulmonary infection, and Clostridium difficile infection. Figures show the interrelationships among infection, sepsis, and the systemic inflammatory response syndrome, and the percentage of critically ill trauma patients with fever or leukocytosis in the first week after admission, and the cardinal signs of localized inflammation. A table shows the fundamental approach to diagnosis of infection. Algorithms include diagnosis of superficial surgical site infection, Diagnosis of catheter-associated urinary tract infection, and diagnosis of central line–associated and catheter-related bloodstream infections.

This review contains 8 figures, 4 diagnostic algorithms, 5 tables, and 58 references.

Surgical site infection remains a preeminent focus of perioperative care given its huge potential to impact outcomes, length of stay, and mortality. Numerous governmental and regulatory bodies have developed recommendations to limit the incidence of surgical site infection. These recommendations continue to evolve at a rapid pace, with all aspects of perioperative care sharing ongoing scrutiny. Implementation of these strategies should remain the focus of all providers to limit the incidence of postoperative infections and optimize outcomes.

This review contains 4 figures, 14 tables, and 109 references.

Key words: antibiotic, complication, infection, preoperative, preparation, postoperative, scrub, surgical site infection

Sepsis accounts for approximately one in three hospital deaths, and is associated with very high health care costs due to prolonged lengths of stay in the intensive care unit and hospital. Sepsis is essentially an immunologic response to infection that is propagated systemically, leading to diffuse cellular and microcirculatory dysfunction, vasodilation, vital organ hypoperfusion, and eventual failure. This review covers the pathophysiology, stabilization/assessment, diagnosis, treatment, and disposition and outcomes of sepsis. Figures show the inflammatory and thrombotic response to infection, the action of nitric oxide on vascular smooth muscle cells, accelerated glycolysis and increased lactate production as a result of the catecholamine surge seen in septic shock, sepsis mortality associated with number of organ failures identified in the emergency department (ED), and protocolized therapy for septic shock. Tables list definitions of sepsis syndromes; frequently cited scoring systems for mortality prediction in emergency department patients with sepsis; Sequential Organ Failure Assessment (SOFA) score; current recommendations regarding treatment bundles at 3 and 6 hours of resuscitation; antibiotic recommendations based on suspected source; and vasopressors used in septic shock with recommended dosing, mechanism of action, and indications.

This review contains 5 figures, 7 tables, and 57 references.

Keywords: Sepsis; Surviving Sepsis Campaign guidelines, definitions, SEP-1 sepsis quality measure, time-to-antibiotics, volume resuscitation, lactated ringers

Health care–associated infections (HAIs) are those that are acquired while patients are being treated for another condition in the health care setting. HAIs are associated with substantial morbidity and mortality, with 75,000 deaths attributable to HAIs each year. This review outlines the evolution of HAI as a quality metric and introduces key governmental and professional organization stakeholders. The role of the local infection control program is also discussed. Using the example of surgical site infection, we detail the multitude of factors that contribute to the occurrence of an HAI, evidence-based preventive strategies, and systems-based programs to reduce preventable infections. Specific diagnostic criteria and preventive strategies are also introduced for catheter-associated urinary tract infection, central line–associated bloodstream infection, ventilator-associated pneumonia, Clostridium difficile infection, and various multidrug-resistant organisms.

This review contains 3 figures, 11 tables, and 76 references

Keywords: catheter-associated urinary tract infection, central line–associated bloodstream infection, Clostridium difficile, hospital-acquired infection, infection, quality, surgical site infection, ventilator-associated pneumonia 

Nosocomial infections are a threat to all hospitalized patients. They can increase morbidity, mortality, length of stay, and costs and occur in almost every body site. This review features an algorithmic approach to the risk, detection, and treatment of nosocomial infections. Respiratory infections include pneumonia, tracheitis or tracheobronchitis, paranasal sinusitis, and otitis media. Operative site or injury-related infections include those occurring in wounds, the intra-abdominal space, methicillin-resistant Staphylococcus aureus (MRSA), empyema, posttraumatic meningitis, osteomyelitis, and sternal and mediastinal infection. A review of intravascular device--associated infection focuses on catheter-related bacteremia and its management. Catheter-associated urinary tract infections (UTIs) and enteric infections are also considered. Enteric infections and transfusion-associated infections are covered in depth, reviewing the most important recent advances and studies. A discussion of postoperative fever addresses the magnitude and incidence of hospital infections, UTIs, and catheter duration and pathogens typically involved and considers the associated costs and the risks of acquiring a nosocomial infection.

This review contains 5 figures, 13 tables and 292 references

Keywords: Nosocomial infection, hospital-acquired infection, MRSA, empyema, meningitis, osteomyelitis, urinary tract infection, peritonitis, postoperative fever, surgical site infection

The goal of this review is to discuss basic principles for the appropriate use of antibiotics in the surgical patient, largely focusing on the treatment of intra-abdominal infections. Limited pharmacologic data on common antibiotics are provided. Current reference sources and institutional guidelines should be used for specifics on dosing and administration. This review covers general principles, including treatment of surgical infections, laboratory tests, pharmacokinetics and pharmacodynamics, adverse reactions, antimicrobial resistance, and antibiotic prophylaxis in surgical patients. In addition,  specific considerations of appropriate antimicrobial therapy, such as acute cholecystitis/cholangitis, pancreatitis, appendicitis, diverticulitis, Clostridium difficile, and skin and soft tissue infections are presented. Tables list high-risk factors in intra-abdominal infections, empirical antibiotic based on risk stratification for the treatment of community-acquired intra-abdominal infections, dose adjustments for obese patients, most common isolated pathogens from intra-abdominal infections, 2005–2010, with resistance trends, adaptation of Tokyo guidelines on severity scoring and recommended antimicrobial therapy,  and recommended antibiotics for necrotizing soft tissue infections.

This review contains 9 tables and 59 references

Soft tissue infections are a diverse group of diseases that involve the skin and underlying subcutaneous tissue, fascia, or muscle. The authors review the diagnosis and management of the main soft tissue infections seen by surgeons, including both superficial infections and necrotizing infections. When the characteristic clinical features of necrotizing soft tissue infection are absent, diagnosis may be difficult. In this setting, laboratory and imaging studies become important. Studies emphasizes that computed tomography should continue to be used judiciously as an adjunct to clinical judgment. The delay between hospital admission and initial débridement is the most critical factor influencing morbidity and mortality. Once the diagnosis of necrotizing soft tissue infection is established, patient survival and soft tissue preservation are best achieved by means of prompt operation. Bacterial infections of the dermis and epidermis are covered in depth, along with animal and human bites. Methicillin-resistant Staphylococcus aureus (MRSA) accounts for up to 70% of all S. aureus infections acquired in the community and is the most common organism identified in patients presenting to the emergency department with a skin or soft tissue infection. The more classic findings associated with deep necrotizing infections—skin discoloration, the formation of bullae, and intense erythema—occur much later in the process. It is important to understand this point so that an early diagnosis can be made and appropriate treatment promptly instituted. The review’s discussion covers in depth the etiology and classification of soft tissue infection, pathogenesis of soft tissue infections, toxic shock syndrome, and reports on mortality from necrotizing soft tissue infection.

This review 8 figures, 22 tables, and 58 references

Keywords: Erysipelas, cellulitis, soft tissue infection, necrotizing fasciitis, myonecrosis, toxic shock syndrome

Postoperative pneumonia is currently the third most common complication seen in surgical patients and is associated with an increase in both patient morbidity and hospital costs. The incidence of postoperative pneumonia varies among the different surgical subspecialties. A number of evidence-based strategies exist regarding the prevention and management of pneumonia. However, the majority of studies on ventilator-associated pneumonia (VAP) do not specifically focus on surgical patients but rather are based on mixed medical-surgical ICU patients. The aim of this review is to define the incidence, pathogenesis, and risk factors of both postoperative and VAP; determine what pathogens are commonly encountered; discuss treatment methods; and introduce measures that can be implemented in both the surgical wards and the ICU aimed at preventing this complication.

This review contains 5 figures, 7 tables, and 64 references. 

Key Words: antimicrobial therapy, disease prevention, postoperative pneumonia, surgical critical care; ventilator associated pneumonia, culture, prevention, management, bundles, diagnosis

The basic principles of rapid diagnosis, timely physiologic support, and definitive intervention for intra-abdominal infections have remained unchanged over the past century; however, specific management of these conditions has been transformed as a result of numerous advances in technology. This review covers clinical evaluation, investigative studies, options for intervention, early source control and duration of antimicrobial therapy, infections of the upper abdomen, infections of the lower abdomen, other abdominal infections, and special cases.Figures show an algorithm outlining the approach to a suspected upper abdominal infection, abnormal abdominal ultrasounds showing calculi in the gallbladder and confirming the diagnosis of acute acalculous cholecystitis, endoscopic retrograde cholangiopancreatographies showing a distal common bile duct stone in acute pancreatitis, extrinsic compression of the common hepatic duct by a stone in the Hartmann pouch, and endoscopic sphincterotomy for acute biliary decompression in acute obstructive cholangitis, air outlining the gallbladder and bile ducts in emphysematous cholecystitis, abdominal and pelvic CT scans showing pancreatic findings graded by Ranson into five categories, a splenic abscess, an inflamed and thickened appendix with surrounding fat stranding, appendiceal perforation and abscess formation, diverticulitis with a small amount of extraluminal air, left lower quadrant fluid collection consistent with peridiverticular abscess, diffuse inflammation and right upper quadrant extraluminal air, and thickening of the colonic wall with both intramural and extramural air, an algorithm outlining the approach to the patient with a suspected lower abdominal infection, upright chest x-ray and abdominal CT scans of patients with sudden-onset diffuse abdominal pain, and an omental (Graham) patch. Tables list diagnostic indicators of upper abdominal pain and fever, comparison of acute cholecystitis and emphysematous cholecystitis, Hinchey system for classification of perforated diverticulitis, Centers for Disease Control and Prevention (CDC) guidelines for diagnosis of pelvic inflammatory disease, and CDC guidelines for antibiotic treatment of pelvic inflammatory disease.

This review contains 16 highly rendered figures, 5 tables, and 238 references

Nosocomial infections are a threat to all hospitalized patients. They can increase morbidity, mortality, length of stay, and costs and occur in almost every body site. This review features an algorithmic approach to the risk, detection, and treatment of nosocomial infections. Respiratory infections include pneumonia, tracheitis or tracheobronchitis, paranasal sinusitis, and otitis media. Operative site or injury-related infections include those occurring in wounds, the intra-abdominal space, methicillin-resistant Staphylococcus aureus (MRSA), empyema, posttraumatic meningitis, osteomyelitis, and sternal and mediastinal infection. A review of intravascular device--associated infection focuses on catheter-related bacteremia and its management. Catheter-associated urinary tract infections (UTIs) and enteric infections are also considered. Enteric infections and transfusion-associated infections are covered in depth, reviewing the most important recent advances and studies. A discussion of postoperative fever addresses the magnitude and incidence of hospital infections, UTIs, and catheter duration and pathogens typically involved and considers the associated costs and the risks of acquiring a nosocomial infection.

This review contains 5 figures, 13 tables and 292 references

Keywords: Nosocomial infection, hospital-acquired infection, MRSA, empyema, meningitis, osteomyelitis, urinary tract infection, peritonitis, postoperative fever, surgical site infection

Acute respiratory failure (ARF) is the most common reason for patients to be admitted to a critical care setting, and occurs when oxygenation and/or ventilation begin to fail. Improved use of advanced therapies to optimize care such as supplemental oxygen, noninvasive positive pressure ventilation, and mechanical ventilation have shown a decline in ARF-related mortality. This review covers pathophysiology, stabilization and assessment, diagnosis and treatment, sedation, analgesia, and neuromuscular blockade, and disposition and outcomes. Figures show an oxygen-hemoglobin dissociation curve demonstrating the relationship between oxygen saturation and partial pressure of oxygen, low-flow nasal cannula, nonrebreather face mask with a one-way exhalation valve and bag reservoir, high-flow nasal cannula including air-oxygen blender setup, Venturi mask with various color adapters, bag-valve-mask apparatus with oxygen reservoir, one-way inspiratory valve, and self-inflating bag, extrapolated desaturation time for different clinical scenarios, lung ultrasonograms demonstrating a normal appearing lung versus a diagnosis of interstitial edema, an apical four-chamber view of the heart showing a significantly enlarged right ventricle, and mortality for various conditions causing respiratory failure. 

This review contains 11 figures, 31 tables, and 47 references. 

Keywords: Acute respiratory failure, ventilation, positive end-expiratory pressure, oxygenation, pulse oximetry, consolidation, pulmonary edema, pneumonia, ventilation-perfusion matching

Sudden cardiac death, whether in the hospital or out of the hospital, is a leading cause of death. Early recognition and activation of an emergency response, following the “chain of survival”, is critical. High quality Cardiopulmonary Resuscitation (CPR) should be initiated as soon as possible. Rescue breaths can be added when a qualified medical professional is available. Once emergency medical services personnel arrive for an out of hospital cardiac arrest or the “code team” arrives for an in hospital cardiac arrest, the Advanced Cardiovascular Life Support (ACLS) algorithm should be followed. For patients with pulseless ventricular tachycardia or ventricular fibrillation, early defibrillation improves the chances for restoration of spontaneous circulation and survival. The use of vasopressors and anti-arrhythmics are part of the protocol, though the benefits are unclear. Once trained airway providers are available, placement of an advanced airway, either supraglottic or endotracheal, can be considered after several minutes of CPR-ACLS, though optimal timing and clear benefit have not been established. For patients who remain comatose after resuscitation, initiation of Targeted Temperature Management can improve outcomes. Neuroprognostication is complex and should be delayed for at least 3-5 days after resuscitation and should be based upon multiple sources of information.

This review contains 1 figure, 5 tables, and 44 references.

Keywords: Cardiac arrest, cardiopulmonary resuscitation, anti-arrhythmics, airway management, targeted temperature management, prognostication 

There are four main categories of shock: hypovolemic, distributive, cardiogenic, and obstructive. Although the main end point (i.e., inadequate delivery of oxygenated blood to the body’s tissues and organs) of each of these categories of shock is the same, the pathophysiologic mechanisms differ. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes for patients with shock. Figures show the Frank-Starling relationship illustrating changes in distributive and cardiogenic shock, the FAST examination, lung ultrasonography in pulmonary edema, pericardial effusion, apical four-chamber view of the heart with right ventricular enlargement, and a parasternal short-axis view of the heart. 

This review contains 6 figures, 25 tables, and 30 references.

Keywords: Hemorrhagic shock, volume loss, third spacing, anaphylactic shock, cardiogenic shock, obstructive shock, septic shock, sepsis, resuscitation

Anaphylaxis, a serious allergic reaction, is rapid in onset and marked by flushing, urticaria, angioedema, pruritus, bronchospasm, and abdominal cramping with nausea, vomiting, and diarrhea. It is not uncommon; approximate lifetime prevalence of anaphylaxis was estimated to be 0.5 to 2% or possibly higher due to the common academic belief that the incidence of anaphylactic reactions is underreported. Rarely, anaphylaxis may cause death, most commonly from drugs, foods, and insect stings. This review covers the epidemiology, etiology, pathogenesis, diagnosis, clinical manifestations, treatment, and prognosis. Figures show inflammatory pathways in allergic inflammation and mast cell degranulation and pathways of activation. 

This review contains 2 figures, 5 tables, and 72 references. 

Keywords: Anaphylaxis, allergy, shock, auto-injector epinephrine, inflammation, mast cell, venom

When a patient presents with altered mental status, it is critical to assess the patient in a systematic manner to diagnose and treat the underlying cause. A careful history, a rapid and focused neurologic examination, laboratory testing, and radiologic imaging all aid in achieving a diagnosis. Once initial stabilization of the patient has been achieved, management of coma is determined by the specific underlying etiology, precipitating condition, or acute event. It is critical to accomplish rapid assessment of coma, especially identifying reversible causes, which are in an effort to improve outcome. This review is intended to be an introductory overview of disorders of consciousness that also provides a practical and streamlined approach to the diagnosis and management of coma and seizures. 

This review contains 2 figures, 12 tables, and 24 references.

Keywords: Coma, consciousness, electroencephalogram, basilar artery occlusion, reflex, pupillary response, neurology

Encephalopathy can range from the acute confusional state to frank coma, and is broadly defined as a constellation of symptoms and signs reflecting diffuse cerebral dysfunction.  The potential causes of encephalopathy are vast requiring a thorough initial assessment and systematic diagnostic approach.  Obtaining a comprehensive history may be challenging and ancillary sources of information are often helpful in narrowing the differential diagnosis.  The general examination may provide hints as to the cause of encephalopathy and the neurologic examination can guide both acute management and focus the diagnostic investigations on specific etiologies which fit the clinical presentation.  The systemic manifestations of infection and toxic exposures are common causes of encephalopathy.  In sepsis, not only is brain perfusion compromised, multi system dysfunction is common and additional factors related to the specific infection such as hypoxia in pneumonia or secondary CNS involvement can complicate management.  An understanding of the common physical examination findings of toxic exposures can aid in the diagnosis and rapid treatment of reversible toxic encephalopathies such as narcotics, benzodiazepines or environmental toxins.  Cardiopulmonary dysfunction can lead to hypoxic-ischemic encephalopathy and advances in critical care, and particularly targeted temperature management following cardiac arrest, have improved the neurologic outcome in these patients.  

This review contains 2 figures, 3 tables, and 25 references.

Key words: encephalopathy, delirium, ascending reticular activating system, acute confusional state, subclinical seizures, Glasgow Coma Scale, Full Outline of Unresponsiveness (FOUR) Score , hypoxic-ischemic encephalopathy, neuroleptic malignant syndrome, serum neuron-specific enolase

Acute renal failure definitions have changed dramatically over the last 5 to 10 years as a result of criteria established through the following consensus statements/organizations: RIFLE (Risk, Injury, Failure, Loss of function, End stage renal disease), AKIN (Acute Kidney Injury Network), and KDIGO (Kidney Disease: Improving Global Outcomes). In 2002, the Acute Dialysis Quality Initiative was tasked with the goal of establishing a consensus statement for acute kidney injury (AKI). The first order of business was to provide a standard definition of AKI. Up to this point, literature comparison was challenging as studies lacked uniformity in renal injury definitions. Implementing results into evidence-based clinical practice was difficult. The panel coined the term “acute kidney injury,” encompassing previous terms, such as renal failure and acute tubular necrosis. This new terminology represented a broad range of renal insults, from dehydration to those requiring renal replacement therapy (RRT). This review provides an algorithmic approach to the epidemiology, pathophysiology, diagnosis, prevention, and management of AKI. Also discussed are special circumstances, including rhabdomyolysis, contrast-induced nephropathy, and hepatorenal syndrome. Tables outline the AKIN criteria, most current KDIGO consensus guidelines for definition of AKI, differential diagnosis of AKI, agents capable of causing AKI, treatment for specific complications associated with AKI, and options for continuous RRT. Figures show the RIFLE classification scheme and KDIGO staging with prevention strategies.

This review contains 1 management algorithm, 2 figures, 6 tables, and 85 references.

Keywords: Kidney, renal, KDIGO, azotemia, critical, urine, oliguria, creatinine, dialysis

The concept of and approach to multiple organ dysfunction syndrome (MODS), also known as progressive systems failure, multiple organ failure, and multiple system organ failure, have evolved over the last decade. Characterized by progressive but potentially reversible tissue damage and dysfunction of two or more organ systems that arise after a significant physiologic insult and its subsequent management, MODS evolves in the wake of a profound disruption of systemic homeostasis. Pre-existing illness, nutritional status, hospital course, and genetic variation all lead to the development of organ dysfunction in patients exposed to these risk factors. The ultimate outcome from MODS is influenced not only by a patient’s genetic and biological predisposition but also by specific management principles practiced by intensivists. This review details the clinical definitions, quantification, prevention, evaluation, support, and outcomes of organ dysfunction. A figure shows the increasing severity of organ dysfunction correlated with increasing intensive care unit mortality, and an algorithm details the approach to MODS. Tables list risk factors and prognosis for MODS, the multiple organ dysfunction (MOD) score, the sequential organ failure assessment (SOFA) score, intensive care unit interventions that reduce mortality or attenuate organ dysfunction along with unproven or disproven ICU interventions, and the temporal evolution of MODS.

This review contains 1 figure, 7 tables, and 159 references.

The stress system receives and integrates a diversity of cognitive, emotional, neurosensory, and peripheral somatic signals that arrive through distinct pathways. Activation of the stress system leads to behavioral and physical changes that are remarkably consistent in their qualitative presentation. The stress response is mediated largely by the hypothalamic-pituitary-adrenal (HPA) axis and the sympathoadrenal system, which includes the sympathetic nervous system and the adrenal medulla. The stress response is normally adaptive and time limited and improves the chances of the individual for survival. The time-limited nature of this process renders its accompanying antigrowth, antireproductive, catabolic, and immunosuppressive effects temporarily beneficial and/or of no adverse consequence to the individual. However, chronic activation of the stress system as occurs in critically ill patients may lead to a number of disorders, including stress hyperglycemia, dysfunction of the HPA and hypothalamic-pituitary-thyroid (HPT) axes, and hypothalamic-pituitary growth hormone (GH) dysfunction. These disorders are reviewed in this chapter. Diagnosis of adrenal insufficiency/critical illness–related corticosteroid insufficiency and who to treat with steroids are also covered in depth. The author emphasizes the controversial management of these deregulated hormonal axes with only limited data supporting an improvement in outcome with hormonal replacement therapy.

This review contains 3 Figures, 1 Table, 39 References, 5 Board-Styled MCQs, and a Teaching Slide Set for teaching and reference purposes.

The human body is programmed to maintain constant homeostasis of all body systems through a complex neuroendocrine and autonomic network. Through a variety of exaggerated autonomic and cytokine responses, illness and injury alter this homeostasis. Mechanisms that are impaired include glucose cellular transport and peripheral and hepatic insulin uptake. Over the past several decades, numerous reports have described the deleterious effects of glucose variability and hyperglycemia. In a randomized prospective study of critically ill patients, Van den Berghe first reported that intensive glucose control (≤ 110 mg/dL) significantly decreased morbidity and mortality. This study was a catalyst for a multitude of subsequent reports evaluating the effects of glycemic control in other patient populations. 

This review contains 1 figures, 5 tables, and 90 references.

Keywords: Hyperglycemia, critical illness, intensive care unit, tight glycemic control, stroke, myocardial infarction, postoperative period, sepsis

Cardiac arrhythmias and events, such as acute coronary syndrome and acute decompensated heart failure, are becoming increasingly common with an aging population. Much is written regarding the evaluation and management of these conditions in the cardiac and vascular patient populations; however, there is less literature to discuss the management strategies in the critically ill noncardiac postoperative and polytrauma patients. Factors such as physiologic stress, electrolyte imbalances, neurologic derangement, infection, and massive fluid shifts create an environment that promotes cardiopulmonary instability. Appropriate recognition of cardiac arrhythmias, acute coronary syndromes, and heart failure coupled with accurate and timely intervention can reduce morbidity and mortality in these patients. This review discusses the assessment and management of cardiac tachy- and brady-arrhythmias, acute coronary syndromes, and acute decompensated heart failure in the surgical patient.

This review contains 5 figures, 8 tables and 48 references

Keywords: acute coronary syndrome, angina, arrhythmia, bradycardia, cardiac ischemia, dieresis, fluid overload, heart failure, infarction, tachycardia

Brain failure consists of a wide spectrum of central nervous system pathologies with many different neurologic manifestations. The causes of brain failure include several disease processes that result in decreased supply of blood and oxygen to the brain or metabolic derangements that affect the central nervous system. Brain failure usually results in some altered level of consciousness. Brain failure and brain death result in several pathophysiologic changes. The definition of brain death is controversial and evolving. However, clear guidelines to determine brain death have been established. These guidelines state that three cardinal findings be present to establish brain death: (1) coma or unresponsiveness, (2) absence of brainstem reflexes, and (3) apnea. Several clinical parameters must be met when these findings are made. Adjunctive studies such as four-vessel cerebral angiography, electroencephalography, and nuclear brain scintigraphy can help make a diagnosis of brain death. When brain death is established, suitability for organ transplantation should be evaluated. After obtaining consent, potential organ donation should be optimized for possible donation.

This review contains 2 figures, 6 tables, and 71 references

Keywords: brain failure, brain death, consciousness, coma, death, delirium, organ donation

Continued hepatic injury by genetic or environmental factors results in a state of chronic inflammation, fibrosis, and progressive hepatocyte dysfunction that can progress to cirrhosis and end stage liver disease (ESLD). Cirrhosis is the eighth leading cause of mortality in the United States, while the burden of disease is even greater in regions with endemic viral hepatitis. Common risk factors include a history of hepatitis; alcohol or IV drug abuse; use of certain medications; and other risk factors associated with transmission of viral hepatitis, including tattoos, sexual promiscuity, and incarceration. Although many patients with cirrhosis are asymptomatic and remain undiagnosed, many will eventually develop secondary complications from chronic liver failure, which can be difficult to manage and are associated with significant morbidity, including: portal hypertension, variceal bleeding, coagulopathy, hepatic encephalopathy, and renal failure. In addition, hepatocellular carcinoma (HCC) is estimated to be 30 times more common among patients with cirrhosis, which can be an aggressive malignancy with 5-year overall survival of less than 15%. In this chapter, we provide a comprehensive overview of chronic liver failure, including the epidemiology of cirrhosis, pathophysiology of liver injury, and assessment and management of cirrhosis and associated downstream complications. Finally, we discuss the role of liver transplantation for both ESLD and HCC.

This review contains 6 figures, 9 tables, and 53 references.

Key Words: chronic liver failure, cirrhosis, coagulopathy, end stage liver disease, hepatic encephalopathy, hepatocellular carcinoma, hepatorenal syndrome, liver transplantation, portal hypertension, varices

Normal neurologic function requires a constantly balanced environment of electrolytes.  Normal hepatic and renal function is critical in maintaining this balance while removing toxins, maintaining a physiologic pH and regulating the excretion of electrolytes.  Nutritional intake provides essential nutrients but deficiencies can lead to characteristic syndromes such as Wernicke's encephalopathy and pellagra and exposure to neurotoxic substances such as heavy metals can lead to encephalopathy.  Thyroid and adrenal dysfunction are common endocrine causes of encephalopathy and symptoms can often improve rapidly with treatment.  A subset of idiopathic encephalopathy is increasingly being recognized as having an autoimmune basis, often presenting as a paraneoplastic process, and having a constellation of symptoms which can aide in the diagnosis.  Timely recognition and treatment of the autoantibodies which target neural structures, with immunosuppressive therapy, can improve outcome in these patients.  

This review contains 4 figures, 3 tables, and 42 references.

Key words: osmotic demyelination syndrome,hepatic encephalopathy, renal failure, triphasic waves, dialysis disequilibrium syndrome, Wernicke encephalopathy, Korsakoff syndrome, myxedema coma, Hashimoto encephalopathy

An estimated 92.1 million Americans have at least one type of cardiovascular disease (CAD).¹  Even though death rates due to CAD have declined, at least 2200 Americans die each day of CAD. ² In the U.S. at least 50 million operations occur every year and up to 4% are associated with adverse cardiac events. ³There are many identifiable risk factors for cardiac disease such as diabetes, hypertension, obesity, smoking, and high cholesterol. 1In addition, there are non-modifiable risks for cardiac disease; these include age, gender, family history, and homocysteine levels. ⁴ Hypotension and tachycardia are the most common causes of ischemic cardiac events in the intra-operative phase. The failure to detect myocardial injury early on may contribute to complications as long as 30 days post-operatively. Typically, ischemic findings on electrocardiography and elevated troponin measurements have been used as potential indicators of ischemia or myocardial injury after non-cardiac surgery in the peri-operative setting. In the treatment of ischemic cardiac events, intensified medical therapy (antiplatelet, beta-blocker, ACE inhibitor, or a statin) in patients who suffered from a troponin elevation in the postoperative period reduces the risk of having a major cardiac event within a year. 

This review contains 1 figure, 2 tables, and 74 references. 

Keywords: Myocardial Injury after Non Cardiac Surgery (MINS), Perioperative ischemia, Troponin assay, VISION study, Coronary artery disease

This review is a summary of the acid-base physiology that is essential to understanding acid-base pathophysiology. An acid is defined as a proton donor; a base is defined as a proton acceptor. The body fluids are composed of acids and bases, which are tightly regulated by our organ systems, specifically the respiratory system and kidneys. Derangements in the body’s acid-base homeostatic mechanisms or overloading the capacity of the body’s ability to respond can lead to acid-base disorders. These include acidosis and alkalosis, which can be further classified into respiratory, metabolic, or mixed disorders. The approach to these disorders is to stabilize the patient, focusing on respiratory and circulatory status and treating the underlying cause of the acid-base derangement.

This review contains 4 figures, 6 tables, and 30 references

Keywords: acid-base disorders, acid-base homeostasis, acid-base physiology, acidemia, alkalemia, metabolic acidosis, metabolic alkalosis, mixed acid-base disorders, respiratory acidosis, respiratory alkalosis 

Cell function and thus life depend on the preservation of several electrochemical gradients. Evolutionary pressures have developed several regulatory mechanisms, the penultimate goal of which is to maintain total body and distribution of each electrolyte within the intracellular and extracellular compartments at concentrations compatible with life. Ultimately, patient survival depends on this balance despite the continual changes imposed by both internal physiologic processes and external stressors. During periods of critical illness, however, these mechanisms can be overwhelmed, necessitating additional support. Indeed, disorders of electrolyte homeostasis are highly prevalent among intensive care unit patients, and severe disturbances are associated with elevated mortality. As has been previously learned, merely normalizing laboratory abnormalities without addressing the underlying pathophysiology does little to improve outcome. Thus, for those providing this care, an in-depth understanding of the biochemistry and physiology of electrolyte disorders and a systematic approach to diagnosis and therapy are complementary components essential for patient survival. This chapter discusses the major electrolytes—sodium, potassium, calcium and phosphate, and magnesium—and covers the hyper- and hypodeficiencies and disturbances for each electrolyte.

This review contains 7 Figures, 6 Tables, 5 Etiologic Algorithms, and 106 References.

This review highlights important age-related changes at the physiologic level and their clinical consequences. Latest societal guidelines and consensus expert opinions on pre- and perioperative management of elderly surgical patients are discussed. Age-related postoperative complications, including precipitating factors and appropriate management, are summarized. The latest advancements in the management of important surgical problems in geriatric populations are outlined.

This review contains 4 figures, 8 tables, and 103 references.

Key words: aging, elderly patient, immunosenescence

This review describes the approaches taken for patient with massive hemorrhage, a derangement of hemostasis, and anemia. For hemorrhage, control of the source of bleeding, restoration of the blood volume, and management of the coagulopathy is presented. Exclusion of technical causes of bleeding, an initial assessment of potential coagulopathy, and an interpretation of coagulation parameters is described for derangements of hemostasis. For anemia, acute coronary artery ischemic syndromes and neurologic conditions are described. Additionally, bleeding disorders are presented. Figures depict various algorithms related to decision-making and treatment. Tables show the management of the patient with an increased International Normalized Ratio, coagulopathy scores, classification and management of Von Willebrand disease, and tests of platelet function.

This review contains 5 figures, 16 tables and 83 references

Keywords: Bleeding, intraoperative hemorrhage, coagulopathy, packed red blood cells, hemostasis, fresh frozen plasma, hemophilia, bleeding disorders

Characteristically, several fluid and electrolyte disorders have dysfunction of the central nervous system (CNS) as a major complication. The brain, within a closed space, cannot respond quickly or effectively to prevent the acute stresses of osmotic swelling or contraction of extracellular and/or intracellular spaces. Disorders of many other ions and neutral molecules can lead to pathology, including cognitive abnormalities, encephalopathy, falls, and seizures. This chapter looks at osmolar change and brain volume regulation and the importance of sodium (Na), potassium, phosphate, and magnesium. The section on sodium looks at its importance to serum osmolality and discusses hyponatremia and hypernatremia, syndrome of inappropriate antidiuretic hormone (SIADH) and cerebral salt wasting, dialysis disequilibrium syndrome, and the CNS effects of elevated ammonia and altered glucose levels. The section on potassium discusses the ratio between the intracellular and extracellular potassium concentrations and looks at hypokalemia and hyperkalemia. Phosphate plays a vital role in energy metabolism, and this section explores hypercalcemia and hypocalcemia. Magnesium’s role in cell proliferation and energy metabolism is discussed, with subsections on hypomagnesemia and hypermagnesemia. Tables list symptoms of electrolyte disorders, ways to distinguish between SIADH and cerebral salt wasting, risk factors for osmotic demyelination, and expansion and contraction syndromes. Figures include a graph showing serum Na against urine osmolality in a patient with symptomatic hyponatremia, and a chart of a woman with hyperammonemia and severe metabolic acidosis. This chapter contains 2 highly rendered figures, 4 tables, 65 references, 5 MCQs.

There are multiple congenital and acquired disorders of coagulation that may result in unplanned bleeding or clotting. These disorders can result in an increase in morbidity and mortality to surgical patients. Unexpected bleeding during and after surgery can be prevented by having an adequate understandings of these entities and by being aware of the available treatment options. In addition to awareness of bleeding disorders, it is important to recognize the risks associated with disorders predisposing patients to clotting, or thrombophilias. This review discusses the major inherited disorders of the coagulation cascade resulting in bleeding or clotting tendencies in relation to surgical patients. von Willebrand Disease (vWD), hemophilia A, hemophilia B, hemophilia C, acute coagulopathy of trauma, disseminated intravascular coagulation (DIC), uremic bleeding, bleeding in cirrhosis, clotting disorders, and acquired thrombophilias are covered. 

This review 4 figures, 25 tables, and 47 references.

Keywords: Thrombosis, bleeding, coagulation, disseminated intravascular coagulation, factor deficiency, factor V Leiden, von Willebrand disease, thrombophilia, clotting, hemophilia

Exsanguination occurs rapidly after trauma (median 2 to 3 hours after admission) and is the leading cause of preventable trauma deaths. The modern treatment for traumatic hemorrhagic shock is simultaneous mechanical hemorrhage control and damage control resuscitation (DCR), which emphasizes using plasma as the primary means for volume expansion. Other core DCR principles include minimization of crystalloid, permissive hypotension, and balanced blood product resuscitation. The treatment of traumatic hemorrhage is complicated by trauma-induced coagulopathy (TIC); DCR is thought to address TIC directly despite incomplete understanding of the underlying mechanisms. Recent data point to a 1:1:1 ratio of plasma and platelets to red blood cells as the optimal blood product ratio for acute traumatic hemorrhage. However, this paradigm may soon be supplanted by a transition back to whole blood. Although it is intuitive to apply these same protocols and algorithms to patients with nontraumatic hemorrhage, the scientific evidence is lacking.

This review contains 5 figures, 8 tables and 76 references

Keywords: massive transfusion, hemorrhage, endotheliopathy, trauma-induced coagulopathy

Disorders of water and sodium balance are common in clinical practice. To better assess them, we must have a clear understanding of water-electrolyte homeostasis and renal function. The following review goes over practical equations necessary for electrolyte balance analysis as well as the foundations of renal physiology. Emphasis is placed on the understanding of sodium transport and its physiologic and pharmacologic regulation. In addition, we explore the most common electrolyte imbalance affecting up to 28% of hospitalized patients: hyponatremia (ie, low sodium concentration). Hyponatremia has been found in several acute and chronic clinical scenarios including postoperative, drug-induced, and exercise-associated hyponatremia. However, it is not uncommon to find this disorder coexisting with other diseases such as syndrome of inappropriate secretion of antidiuretic hormone (SIADH), acquired immunodeficiency syndrome (AIDS), cancer, and in rare cases, hypothyroidism. To better understand this disorder, the etiology, diagnosis with clinical manifestations and laboratory values, and treatment options are explored.

This review contains 9 figures, 9 tables, and 53 references

Keywords: aldosterone, antidiuretic hormone, body fluids, electrolyte balance, hyponatremia, hypovolemia, osmolality, sodium transport, vasopressin

Hypernatremia is an electrolyte disorder most prevalent in the elderly and the critically ill, with over 60% of cases developing over the course of an inpatient stay. Characterized by elevated serum sodium concentrations, this disorder is manifested either by pure-water loss without replacement, or excessive sodium intake without appropriate water balance. Left untreated it may lead to seizures and coma. General treatment in the case of severe hypernatremia is infusion of isotonic saline followed by pure-water after the patient is stabilized. Further treatment of the underlying cause may involve diuretics, thiazides, and a variety of other medications in conjunction with dietary and lifestyle modifications. This review offers an overview of various disorders of water balance: diabetes insipidus, nephrotic syndrome, cirrhosis, idiopathic edema, and volume depletion, as well as their clinical presentations, lab tests, and management.

This review contains 1 figure, 5 tables, and 26 references

Keywords: Hypernatremia, Edematous States , Diabetes insipidus, Volume Depletion, Cirrhosis, Diuretics

Dysphagia may be oropharyngeal or esophageal. Evaluation is described, including a thorough dysphagia history of associated painful swallowing, location, solids versus liquids, intermittent versus progressive, acute versus gradual onset, and associated symptoms such as weight loss. Physical examination and key diagnostic tests are also reviewed. The evidence-based management of various etiologies of esophageal dysphagia are summarized. Motor disorders described include achalasia, the other primary esophageal motility disorders, and the most common secondary esophageal motility disorders. Esophageal diverticulae are also reviewed in this section. Mechanical esophageal obstruction is presented, including discussions of esophageal webs, rings, peptic stricture, and cancer. Important inflammatory and infectious causes of dysphagia are described, including caustic ingestion, eosinophilic esophagitis, and esophageal infections. The oral phases of liquid and solid swallowing are presented, as are the pharyngeal and esophageal phases of swallowing. Figures show the results of several diagnostic tests and other conditions, including pharyngeoesophageal diverticulum, giant epiphrenic diverticulum, Schatzki ring, and midesophageal squamous cell carcinoma. A flowchart outlines evaluation and management of dysphagia. 

This review contains 13 figures, 12 tables, and 68 references. 

Keyword: Esophageal cancer, Achalasia, Diffuse esophageal spasm, Esophageal ring, Peptic esophagitis, Eosinophilic esophagitis, Scleroderma, Esophageal stricture, Chagas disease, Stroke

Pleural effusions can occur in a wide variety of clinical situations. The most important test for the initial diagnosis and evaluation of a pleural effusion is the chest radiograph. Further investigation, such as imaging, pleural fluid analysis, pleural biopsy, and thoracoscopy, may be required to determine the etiology of the pleural effusion. This review covers the clinical evaluation, investigative studies, and management of pleural effusion, as well as basic facts of the pleura. An algorithm shows the approach to the patient with a pleural effusion. Figures show chest radiographs of patients with pleural effusion; six computed tomographic scans (showing right-side empyema showing a loculated effusion; a free-flowing, sickle-shaped, right-side effusion; parapneumonic effusion [PPE] at diagnosis, after initial chest tube placement, and after fibrinolytics; and left-side chylothorax secondary to lymphoma); an algorithm to manage known malignant pleural effusions; and a photograph of a PleurX catheter after placement and subcutaneous tunneling. Tables list the pathophysiologic mechanisms of pleural effusion, differential diagnosis for pleural effusions, relationship between pleural fluid appearance and causes, pleural fluid tests for causative assessment, practical guidelines for definitive management of malignant pleural effusion, and categorization of PPE by risk of poor outcome. Techniques for bedside thoracentesis and tube thoracostomy as well as for bedside fibrinolytic use are also presented.

This review contains 9 figures, 13 tables, and 95 references.

Keywords: Pleural effusions, empyema, parapneumonic effusion, PleurX, thoracentesis, thoracostomy, loculated effusion

Our body encounters a multitude of microorganisms in our daily lives. Due to surveillance of our robust immune system, these microbial encounters remain largely benign and only become pathologic at times. The majority of these pathogens are cleared rapidly by our innate immune system. The innate immune system is our body’s first line of defense that mounts a nonspecific response against pathogens. In this review, a contemporary summary of this complex system and its relevance to disease processes that are commonly seen in the surgical setting are presented, including components and activation of innate immunity, and relevant clinical scenarios. 

This review contains 10 figures, 11 tables, and 32 references.

Keywords: Innate immunity, humoral immunity, phagocytosis, neutrophils, macrophages, pathogen-associated molecular pattern, damage-associated molecular pattern, wound healing, sepsis, SIRS, deep vein thrombosis, solid-organ rejection

Engraftment of a transplanted organ into an allogeneic host triggers a cascade of immunologic responses in the host that are designed to facilitate graft rejection. Modern donor-to-host matching techniques and immunosuppression protocols have successfully tempered this natural immune response so that graft survival has dramatically improved. However, optimizing graft survival by precisely downregulating the host response to graft rejection while preserving host immune defenses against pathologic and infectious agents remains poorly understood and elusive in current clinical practice. This review discusses transplant immunology with respect to host versus graft and the basis of allorecognition, as well as clinical management of the transplanted allograft. Figures show human leukocyte antigen (HLA), direct allorecognition, T cell receptor and CD3, T cell–associated second messenger signaling pathway, CD8 molecules directly ligating class I HLAs and CD4 molecules directly binding HLA class II, detection of alloantibodies by enzyme-linked immunosorbent assay or flow cytometry, recipient-donor crossmatch, histopathology of kidney allograft with antibody-mediated rejection, and an algorithm for assessment and management of renal allograft rejection. 

This review contains 9 figures, 6 tables and 61 references.

Keywords: Transplantation, immunology, human leukocyte antigen, crossmatch, donor, acute rejection, chronic rejection

This review presents normal wound healing as a complex process that is generally carried out in three overlapping stages: an inflammatory phase, a proliferative phrase (made up of fibroplasia, contraction, neovascularization, and granulation), and a remodeling phase. In addition, wound healing occurs under the influence of multiple cytokines, growth factors, and extracellular matrix signals. Figures show the layers of the skin and the cycles of wound healing. 

This review contains 6 highly rendered figures, 8 tables, and 47 references

Keywords: wound, wound care, healing, epithelialization, migration, granulation

Acute wounds are the result of local trauma and may be associated with severe life-threatening injuries. All patients with acute wounds should be assessed for comorbidities such as malnutrition, diabetes, peripheral vascular disease, neuropathy, obesity, immune deficiency, autoimmune disorders, connective tissue diseases, coagulopathy, hepatic dysfunction, malignancy, smoking practices, medication use that could interfere with healing, and allergies. The authors address the key considerations in management of the acute wound, including anesthesia, location of wound repair (e.g., operating room or emergency department), hemostasis, irrigation, débridement, closure materials, timing and methods of closure, adjunctive treatment (e.g., tetanus and rabies prophylaxis, antibiotics, and nutritional supplementation), appropriate closure methods for specific wound types, dressings, postoperative wound care, and potential disturbances of wound healing. 

This review contains 11 figures, 31 tables, and 92 references.

Keywords: Wound, wound infection, burns, suture, staple, wound closure, wound healing, dehiscence, skin grafting

Chronic wounds are challenging for both the practitioner and the patient. These wounds often cause pain and lead to unemployment, social activity disruption, and quality of life issues for the patient. As the world population advances in age and increases in body mass index, there has been an increase in diabetes and venous insufficiency, ultimately resulting in a rise in the number of patients with chronic wounds. This review covers disease definition, wound-healing necessities, treatment options for management of chronic wounds, special wound care considerations, and investigational therapies. Figures show distribution of chronic wound etiologies, vacuum-assisted closure treatment of chronic wounds, chronic arterial ulcer of the medial foot, a step-wise application of a multilayer compression dressing, and four stages of pressure ulcers. Tables list known causes of tissue hypoxia, types of débridement, common dressings used in chronic wounds, and stages of a pressure ulcer.

This review contains 5 figures, 10 tables and 110 references

Keywords: Chronic wound, wound care, venous insufficiency, diabetes, pressure ulcer, diabetic ulcer, venous insufficiency, stem cell, biofilm

Wounds are a major source of complications in surgery, but many can be avoided by using a sound, evidence-based approach to wound care. Preoperative considerations are discussed and include smoking cessation, glycemic control, weight loss, and adequate nutritional intake. Intraoperative considerations are presented and include proper classification of surgical wounds, hyperoxia and warming, and fascia closure techniques. Postoperative considerations that are presented include recognizing both early and late fascia complications, understanding skin closure techniques, and using adjuncts to postoperative wound management. 

This review contains 7 figures, 24 tables, and 67 references.

Keywords: Surgical site infection, infection, closure, suture, negative pressure wound therapy, open abdomen, mesh, surgery, granulation tissue

Plastic surgery does not claim a specific region of the body, a tissue type, a disease process, or a technique. Instead, plastic surgery holds central to its core the concepts of tissue perfusion and tissue rearrangement to restore function and appearance. Rather than being at the fringes of medicine and surgery, mastery of these issues allows the plastic surgeon to become a generalist and consultant to all of the surgical disciplines. Reconstructive surgery, wound healing, tissue perfusion, and vascularity are the general themes first discussed by the authors. Plastic surgery considerations for surgery of the abdomen, the breast, and the soft tissues are then covered in order, with all relevant procedures described. The authors discuss scar revisions and the principles of wound closure that favorably impact the final appearance in their conclusion. 

This review contains 5 figures, 9 tables and 15 references

Keywords: Plastic surgery, reconstructive surgery, tissue perfusion, wound healing, panniculectomy, mammaplasty, omental flap, scar revision

Principles of initial wound management include adequate debridement, bacterial contamination assessment, nutritional optimization, and moist wound healing versus the use of negative-pressure wound therapy. The main goals of coverage procedures are to achieve a healed wound and avoid infection. Aside from allowing to heal by secondary intention, options for wound closure include primary closure, skin grafting, local flaps, and free flaps. Each wound should be evaluated on an individual basis to determine which method of coverage is most appropriate.

This review contains 13 figures, 2 tables, and 22 references.

Key Words: free tissue transfer, pedicle flaps, soft-tissue coverage, wound closure, wound healing, wound management, wound reconstruction, tissue flaps

Wound management and soft-tissue repair can vary depending on the location. The head and neck, chest and back, arm and forearm, hand, abdomen, gluteal area and perineum, thigh, knee, lower leg, and foot all have different local options and preferred free flaps to use for reconstruction. Secondary reconstruction requires a detailed analysis of all aspects of the wound including any scars, soft tissue and/or skin deficits, functional defects, contour defects, complex or composite defects, and/or unstable previous wound coverage. Careful monitoring of both the patient and reconstruction is necessary in the postoperative period to ensure long-term success.

This review contains 2 figures and 17 references.

Key Words: free tissue transfer, pedicle flaps, soft-tissue coverage, wound closure, wound healing, wound management, wound reconstruction, tissue flaps

Nontechnical skills are the cognitive and social skills that underpin knowledge and expertise in high-demand workplaces. In the operating room (OR), surgeons with good nontechnical skills can effectively share information about their perceptions of ongoing situations with other team members, elicit critical information from others regarding the task and patient safety, and allow the formation of better shared mental representations about the operation in real time. In rare OR crises, surgeons use their nontechnical skills to delegate tasks and effectively manage challenging operations under time pressure. This review covers approaches in high-risk industry; the development, testing, and usage of the non-technical skills for surgeons (NOTSS) system; and the underpinning theory of nontechnical skills. Tables outline the NOTSS skills taxonomy, behavioral rating tools in surgery, and the skills taxonomy used in the aviation industry.

This review contains 3 tables, and 95 references.

Key Words: Non-technical skills, leadership, Situation Awareness, Decision Making, Communication, Teamwork, Coaching, Error, Simulation

The practice of surgery has undergone a dramatic evolution over the last century with the availability of new scientific evidence supporting different surgical techniques and management.  Evidence-based surgery is defined as the judicious and systematic application of scientific evidence to surgical decision making and the establishment of standards of surgical care. This includes efforts to appraise the strength of scientific evidence and evaluate the quality of research studies or evidence, as well as efforts to interpret and apply evidence to clinical practice. In this review, we discuss important methodology and approaches in surgical health services research to accomplish these goals and improve the quality of care in surgery. By providing this overview, we hope readers will be able to navigate the surgical literature and apply evidence-based science to their own surgical practice.

This review contains 1 figure, 3 tables, and 43 references

Keywords: bias, comparative effectiveness, confounding, evidence, external validity, implementation science, internal validity, pragmatic trials, quality, risk adjustment, surgery

With growing recognition that the quality of surgical care varies widely, good measures of performance are in high demand. An ever-broadening array of performance measures is being developed to meet these different needs; however, considerable uncertainty remains about which measures are most useful for measuring surgical quality. Current measures encompass different elements of health care structure, process of care, and patient outcomes. This review covers overview of surgical quality measures, categories of quality measures, structural measures of quality, process of care measures, direct outcome measures, matching the measure to the purpose, improving existing performance measures, and the future of performance measurement. Figures show relative ability of historical (2005-2006) measures of hospital volume and risk-adjusted mortality to predict subsequent (2007-2008) risk-adjusted mortality in US Medicare patients,  risk-adjusted mortality and morbidity for colon resection at individual hospitals before and after adjustment for reliability, variation in surgeon technical skill for 20 bariatric surgeons performing laparoscopic gastric bypass in the Michigan Bariatric Surgery Collaborative (MBSC), and relationship of surgeon technical skill and risk-adjusted complications and resource use after laparoscopic gastric bypass in the MBSC. The table lists primary strengths and limitations of structure, process, and outcome measures.

This review contains 4 highly rendered figures, 1 table, and 34 references

Surgical morbidity and mortality are major public health concerns. The outcomes of surgery have been shown to differ among providers; this variability in the outcomes of surgical procedures has long suggested opportunities to improve the quality of surgical care. Payers, health care policy makers, and surgeons’ professional organizations have implemented a range of strategies to effect large-scale quality improvement efforts targeted toward patients undergoing surgery. This review examines outcomes measurement and feedback, regional collaborative quality improvement, selective referral, pay for performance strategies, and new strategies for surgical quality improvement. Figures show example of provider desktop user interface for a regional quality collaborative; mortality after (30-day) bariatric surgery: Michigan hospitals versus non-Michigan hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) based on data from the 2007 to 2009 Michigan Bariatric Surgery Collaborative and national ACS-NSQIP registries; and percentage of mortality decline for esophagectomy, pancreatectomy, cystectomy, and lung resection attributable to increases in market concentration, based on 2001 to 2008 national Medicare data. Tables list characteristics of different strategies for improving surgical quality; components of the Institute for Healthcare improvement ventilator and central catheter insertion bundle checklists; evidence regarding the relationship between compliance with Surgical Care Improvement Project (SCIP) measures and clinical outcomes; SCIP measures retired as of January 15, 2015; and SCIP measures remaining.

This review contains 3 highly rendered figures, 5 tables and 74 references.

To be a good surgeon, one must be technically good and scientifically sound, but also ethical to the degree that has traditionally been demanded by our profession. In this chapter, the authors discuss what ethical problems in surgery are and how they might be approached. Respect for autonomy, nonmaleficence, beneficence, and justice define Principlism that forms the backbone of most discourse in clinical medical ethics. Consequentialism/utilitarianism, deontology, virtue ethics, “ethics of care”, and casuistry are all covered. The authors then scrutinize several contemporary problems in surgical ethics. Described and discussed in depth are issues associated with the ‘end of life’; surrogate decision making, futility, “do not resuscitate” orders in the operating room, conflicts of interest, industry payments, and surgical innovation, informed consent, and refusal of care. This review is not meant to be an exhaustive treatment of surgical ethics but a survey highlighting the most common ethical problems.

This review contains 2 figures, 11 tables, and 61 references

Keywords: Autonomy, nonmaleficence, beneficence, justice, principlism, medical ethics, surgery, informed consent, do not resuscitate, living will, advanced directives

The medical profession continues to be challenged along the entire range of its cultural values and its traditional roles and responsibilities. This review explores the meaning of professionalism, translating the theory of professionalism into practice, and the future of surgical professionalism. A table offers the elements of the American College of Surgeons’ Code of Professional Conduct.

This review contains 1 table and 32 references

Keywords: medical ethics, virtue-based medicine, patient care, professionalism

As individuals complete their surgical residencies and fellowships, their attention must soon turn toward choosing their career path. This review aims to help those individuals in making informed choices that will properly prepare a successful future in surgical practice. Included here is a survey of some principles that will help guide individuals to proper decision making, an analysis of several different practice settings, sections on negotiations, benefits, and contracts, and a guide to making a smooth transition and developing a successful practice. Helpful tips and possible pitfalls, such as general dos and don’ts for applying and interviewing, are also presented to ensure that the trainee is well prepared and well aware. Figures show a template for curriculum vitae format, a sample resume, a sample executive summary, a contract worksheet, an onboarding timeline, and screenshots of Surgeon Specific Registry. Tables list types of surgical practice, a summary of a personnel file, benefits packages, and lessons learned in kindergarten. Also included are suggested readings related to the topic of surgical practice management.

This review contains 6 figures, 4 tables, 13 references, and 8 additional readings.

As healthcare expenditures rise, payers and providers have increasingly recognized the importance of measuring and improving value. Surgical care accounts for a significant percentage of total healthcare expenditures in the United States, and efforts to improve value globally must take into account the unique challenges and opportunities specific to elective surgical care. This situation makes it essential that surgeons have a thorough understanding of surgical value, its measurement, improvement, and incentivization efforts predicated on it. Toward that end, this review (1) explores the fundamental concept of value in healthcare, particularly as applied to surgery, (2) surveys the challenges in measuring surgical cost and quality, (3) describes the framework of value improvement, (4) identifies selected tools to help surgeons improve the value of care provided, and (5) discusses the increasing role that value-based competition is likely to play in the American healthcare industry.

This review contains 5 figures, 3 tables, and 56 references.

Key Words: healthcare costs, quality improvement, surgery, surgical value, value, value-based competition, value improvement

This review provides strategies for avoiding lawsuits and advice for dealing with a lawsuit if one is ever filed. Medical malpractice is explained, as are the personal issues for the defendant physician. Strategies for preventing malpractice suits are presented, including those relative to communication and interpersonal skills, the informed consent process, and documentation. Advice is provided for what surgeons should do if sued or threatened with a lawsuit, including measures for assisting in the defense and settling claims versus trying a case. Preparing for a deposition is discussed. How a surgeon should act when serving as a defendant or witness in a courtroom trial is presented.

This review contains 5 tables, and 23 references.

Key words: claim, communication, defendant, informed consent, lawsuit, malpractice, medical records, negligence, suit

The 1999 report of the Institute of Medicine, To Err Is Human: Building a Safer Health System, made national headlines with its estimates of the frequency and severity of adverse events in health care, including that as many as 98,000 medical error–related deaths occur each year in the United States. The observation that the basic principles of human error are highly applicable to clinical practice has markedly advanced our understanding and willingness to address error in this setting. This review seeks to address the characteristics of systems in general and the system of surgical care in particular. It describes the growing knowledge of factors that affect human performance and how these factors contribute to adverse surgical outcomes. The review also outlines current obstacles to improving safety,  identifies  systems approaches to making improvements, and discusses ways in which surgeons can take the lead in overcoming these obstacles. An overall goal is that acceptance of error and a willingness to investigate its underlying causes will allow health care professionals to make use of the lessons learned from study of nonmedical systems. Tables include definitions of terms related to patient safety, the operation profile, handoff coordination and communication objectives and relevant strategies, nonmedical system techniques applicable to medical systems, Agency for Healthcare Quality and Research patient safety indicators, National Quality Forum list of health care facility–related serious reportable events, and examples of surgically relevant quality improvement practices appropriate for widespread implementation. Figures include the Swiss Cheese Model representing the relationship between latent and active errors and adverse outcomes, a schematic depiction of the process by which system failures may lead to injury, the Systems Engineering in Patient Safety Model of work system and patient safety, and a depiction of contrasting characteristics of medical practice in the 20th and 21st centuries.

This review contains 4 figures, 7 tables, and 165 references.

Consensus statements and regulatory guidelines endorse the process of identifying patients at increased risk for surgical morbidity and mortality. This is termed prognostic testing, and it identifies patients who are deemed to be too sick to benefit from the anticipated gain of surgery. However, much more valuable than prognostic testing is predictive, or directive, testing. A predictive test pinpoints the patient’s problem that will benefit from a specific available intervention. This review covers what is risk?, changing paradigms of surgical success, building a case for moderation, so, does anyone disagree?, timing, frailty and age (and the eyeball test), is the heart the only organ that counts?, changing paradigms, the enhanced importance of functional capacity, resting electrocardiogram, exercise stress testing, ventricular function testing, stair climbing: putting it all together, pulmonary function tests, obstructive airway disease, perioperative nutrition, how can we make surgery safer?, enhanced recovery after surgery, putting it all together, extended enhanced recovery after surgery, tight glucose control, smoking cessation, and timing of collaboration with anesthesia. Figures show routine preoperative tests for elective surgery (adapted from the National Institute for Health and Care Excellence clinical guideline 3, preoperative assessment strategies and recommended risk-reducing therapy relative to American Society of Anesthesiologists (ASA) classification performed by the surgeon and age, ASA Class I and II patients may be safely be evaluated by an anesthesiologist on the day of their scheduled surgery for a full preoperative history and physical examination, flow volume loop. Tables list ASA physical status classification, effect of abnormal screening results on physician behavior, and minimum preoperative test requirements at the Mayo Clinic (in 1997).

This review contains 4 highly rendered figures, 3 tables, and 111 references

Process improvement is a skill all physicians need to be familiar with. This is particularly true for surgeons, who work in complex systems requiring multidisciplinary care in the health care system’s most expensive location: the operating room. Surgical leaders need to be familiar with the techniques and themes of process improvement. The current literature suggests that formal process improvement programs can be effective in improving clinical, operational, and financial performance of hospitals. This review outlines a general approach to process improvement, in addition to providing evidence for the efficacy of process improvement in health care, a definition of processes, and the history of process improvement. Tables outline forms of waste applied to health care and heuristic approaches to project improvement. Figures include a project charter, control chart, X-bar control chart, Pareto table and chart, Fishbone cause-and-effect diagram, diagrams of the Plan-Do-Study-Act process and cost/payoff matrix, statistical software control charts, and process flow maps.

This review contains 10 figures, 3 tables, and 22 references

Keywords: Operating room, surgery, surgical leader, multidisciplinary team, waste, project carter, control chart, Pareto table, health care improvement