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Management of Acute Heart Failure

    • The initial assessment of the patient with suspected AHF should focus on immediate life-threatening conditions. Careful attention should be paid to vital signs. Hypoxia should be treated with supplemental oxygenation and may be a marker for impending respiratory failure. The history should help ascertain possible causes of exacerbation of HF, as well as risk factors or symptoms suggestive of HF mimics.
    • Nesiritide is a recombinant BNP that, similar to NTG, is a venous, arterial, and coronary dilator. Several early trials demonstrated improved hemodynamics with nesiritide, with a suggestion of some clinical benefit. However, data from these trials failed to demonstrate a mortality benefit and questions arose about the possibility of increased renal insufficiency and worse mortality with its use.
    • Sodium nitroprusside can be similarly used to decrease both preload and afterload. Observational data have suggested a mortality benefit in AHF patients treated with nitroprusside, but randomized trial data appear to be limited to patients with acute myocardial infarction and have not been able to demonstrate a mortality decrease.

Cardiac Arrhythmias, Acute Coronary Syndromes, and Heart Failure in the Surgical Patient

    • To recognize and treat important cardiac arrhythmias in the surgical patient using the latest advances
    • Most up to date guidelines in management of Acute Coronary Syndrome (ACS) in Surgical Patients
    • Recent progress in management ofheart failure in postoperative and traumatic patients

Surgical Management of Ulcerative Colitis

    • As laparoscopic surgery becomes increasingly pervasive, both a hand-assisted and straight laparoscopic colectomy and proctectomy with ileal pouch-anal anastomosis (IPAA) have become more common, with outcomes equivalent to or even improved compared with an open approach.
    • Since the introduction of infliximab, biologic therapy has become more prevalent in the inflammatory bowel disease patient population. These medications should be held as long as possible prior to an elective operation as they have been associated with increased infectious complications following IPAA.
    • Despite biologic therapy, in the setting of an acute flare of ulcerative colitis, 50% of patients treated with intravenous steroids and an induction done of anti–tumor necrosis factor–α will still go on to have a colectomy within the year.
    • The relatively recent introduction of enhanced recovery after surgery protocols in our postoperative care has improved postoperative pain scores and decreased the length of hospital stays. These protocols use a multimodality pain management plan that avoids systemic narcotics, minimizes intravenous fluid administration, enforced early ambulation, and early enteral intake on the night of surgery. The expected length of stay following IPAA is now typically 3 days.
    • As an increasing number of immunosuppressive drugs are being introduced for the treatment of ulcerative colitis, a three-stage approach to IPAA is being more commonly employed. A three–stage approach is used for patients who require emergency surgery, are in poor medical condition due to their underlying disease, or are significantly immunosuppressed.

Hemostasis and its Regulation

    • Two new tests are now available: thromboelastography and the thrombin generation test.
    • Both assays provide much more information than the conventional clotting times 
    • New generations of devices allow both tests to be performed in an automated manner, leading to greater reproducibility and less variation among laboratories.

Lymphatic Mapping and Sentinel Node Biopsy

    • The dual-tracer technique of lymphatic mapping has the highest accuracy rates, and most melanoma surgeons prefer this method. Methylene blue is generally avoided due to the high rate of skin necrosis at the site of injection. It should not be considered in melanoma patients in whom the injection site is not going to be excised and should not be considered in breast cancer patients unless a total mastectomy is being performed. Isosulfan blue is most commonly used but is associated with a rare incidence of anaphylaxis. Thus, isosulfan blue should never be used in a setting without direct anesthesia care provided.

Lymphatic Mapping and Sentinel Node Biopsy

    • The dual-tracer technique of lymphatic mapping has the highest accuracy rates, and most melanoma surgeons prefer this method. Methylene blue is generally avoided due to the high rate of skin necrosis at the site of injection. It should not be considered in melanoma patients in whom the injection site is not going to be excised and should not be considered in breast cancer patients unless a total mastectomy is being performed. Isosulfan blue is most commonly used but is associated with a rare incidence of anaphylaxis. Thus, isosulfan blue should never be used in a setting without direct anesthesia care provided.

Evaluation of Leg Pain

    •  Lumbar radiculopathy can cause pain, paresthesia, weakness, reflex changes, and sensory loss and is often isolated to a territory along a specific nerve root. Additionally, symptoms are bilateral in almost 70% of patients. The neurologic examination is often normal in these patients. The straight leg raise (SLR) test has been shown to have a fairly high sensitivity (91%) but low specificity (26%) in detecting lumbar disk herniation.
    • Computed tomographic angiography (CTA) has increased in popularity for the diagnosis and treatment planning of PAD as the technology has improved. Currently, with 64-slice multidetector imaging, a CTA with runoff can evaluate the chest, abdomen, and legs in a few seconds.
    • Surgical intervention is reserved for patients who fail conservative management. Laminectomy is most frequently performed, with favorable results in the absence of spondylolithesis. With the addition of spondylolithesis, fusion is frequently required.

Evaluation of Leg Pain

    •  Lumbar radiculopathy can cause pain, paresthesia, weakness, reflex changes, and sensory loss and is often isolated to a territory along a specific nerve root. Additionally, symptoms are bilateral in almost 70% of patients. The neurologic examination is often normal in these patients. The straight leg raise (SLR) test has been shown to have a fairly high sensitivity (91%) but low specificity (26%) in detecting lumbar disk herniation.
    • Computed tomographic angiography (CTA) has increased in popularity for the diagnosis and treatment planning of PAD as the technology has improved. Currently, with 64-slice multidetector imaging, a CTA with runoff can evaluate the chest, abdomen, and legs in a few seconds.
    • Surgical intervention is reserved for patients who fail conservative management. Laminectomy is most frequently performed, with favorable results in the absence of spondylolithesis. With the addition of spondylolithesis, fusion is frequently required.
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