|02.07.20-17:34 |02.07.20-17:34 |02.07.20-17:34 The Surgical Handbook MichaelKarsy,MD,PhD,MSc NeurosurgicalResident DepartmentofNeurosurgery UniversityofUtahMedicalCenter SaltLakeCity,Utah HussamAbou-Al-Shaar,MD NeurosurgicalResident DepartmentofNeurologicalSurgery UniversityofPittsburghMedicalCenter Pittsburgh,Pennsylvania JianGuan,MD Neurosurgeon DepartmentofNeurosurgery PacificNeuroscienceInstitute Torrance,California RebeccaKim,MD,MPH Instructor DepartmentofSurgery MedicalCollegeofWisconsin Milwaukee,Wisconsin JeffreyB.Horn,MD AssistantClinicalProfessor DepartmentofAnesthesiology UniversityofUtahMedicalCenter SaltLakeCity,Utah 115illustrations Thieme NewYork(cid:129)Stuttgart(cid:129)Delhi(cid:129)RiodeJaneiro |03.07.20-16:09 LibraryofCongressCataloging-in-PublicationDataisavail- Important note: Medicine is an ever-changing science ablewiththepublisher. undergoing continual development. 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EdifícioRodolphodePaoli,25ºandar Av.NiloPeçanha,50–Sala2508, RiodeJaneiro20020-906Brasil +55213172-2297 Coverdesign:ThiemePublishingGroup TypesettingbyTNQTechnologies,India Thisbook,includingallpartsthereof,islegallyprotectedby copyright.Anyuse,exploitation,orcommercializationout- PrintedinUSAbyKingPrintingCompany,Inc. 54321 sidethenarrowlimitssetbycopyrightlegislation,without ISBN978-1-68420-128-0 thepublisher’sconsent,isillegalandliabletoprosecution. Thisappliesinparticulartophotostatreproduction,copy- Alsoavailableasane-book: ing,mimeographing,preparationofmicrofilms,andelec- eISBN978-1-68420-129-7 tronicdataprocessingandstorage. |02.07.20-17:34 Tomywife,Odessa,andchildren,PenelopeandPhilip,fortheircontinuedsupport.Toallmymentorsand patientswhohavecontinuedtoteachmeeveryday. –MichaelKarsy Tomyparents,IzzatandLina,fortheirendlessloveandencouragement.Tomybrothersandmymentors fortheircontinuoussupportandguidance. –HussamAbou-Al-Shaar Tomyparents,withoutwhomnoneofthiswouldbepossible. –JianGuan Tothestudentsandresidentswhoinspireusalltokeepteaching,learning,andaskingwhy. –RebeccaKim Tomybeautifulwife,Melissa,anddaughter,Charlotte,fortheirunwaveringsupportanddedicationto ourfamily.Withouttheirloveandsupport,mylifewouldbetrivial.ToDr.MarkHarris,MD,MPH,forhis mentorshipandresolutecollaborationonthispersonalandprofessionaljourney. –JeffreyB.Horn |03.07.20-14:24 Contents Preface........................................................... xx Acknowledgments............................................... xxi Contributors ................................................... xxii 1 GeneralPerioperativeandOperativeManagement .................... 1 EditedbyJeffreyB.HornandMarkHarris 1.1 PerioperativeRisk.............................................................. 1 EmileeBorgmeierandJeffreyDillon 1.1.1 Overview ...................................................................... 1 1.1.2 AdverseEvents.................................................................. 1 1.1.3 PerioperativeManagement:WhoDoIOrderFurtherTestingfor?...................... 3 1.1.4 RiskCalculators................................................................. 5 1.2 PerioperativeMedicalOptimization............................................. 5 MichaelKarsy 1.3 FundamentalsofAnesthesiology................................................ 11 JeffreyB.Horn,MarkHarris,andStephenSams 1.3.1 StandardsforBasicAnesthesiaMonitoring.......................................... 11 1.3.2 AnesthesiaBasics................................................................ 14 1.3.3 NeuraxialAnesthesia ............................................................ 15 1.3.4 OtherAnesthesiaComplications................................................... 22 1.3.5 PostanestheticCareUnit(PACU)................................................... 26 1.3.6 AnesthesiaPostoperativeManagement............................................. 27 1.4 WoundClosureandInfection................................................... 32 MichaelKarsy 1.4.1 PreoperativeAntibiotics.......................................................... 32 1.4.2 SurgicalWoundClosure.......................................................... 36 1.4.3 PostoperativeFevers:CategoriesofCauses.......................................... 37 1.4.4 WoundInfection,Dehiscence,andManagement..................................... 37 1.5 SurgicalInstruments........................................................... 39 MichelleD.Ford 1.5.1 InstrumentCategories ........................................................... 39 1.5.2 QualitiesofSurgical-GradeStainlessSteel........................................... 44 1.5.3 InstrumentMaintenance......................................................... 44 1.5.4 SterilizationMethods............................................................ 44 1.5.5 Electrosurgery.................................................................. 45 References .................................................................... 46 vi |02.07.20-17:34 Contents 2 CriticalCareforSurgeons................................................. 49 EditedbyMilosBuhavac 2.1 OrganSystem–BasedAssessmentintheSICU ................................... 49 DorotheaRosenberger 2.1.1 Summary...................................................................... 49 2.1.2 CommonIndicationsforAdmissionstotheSICU .................................... 49 2.1.3 PathwaysofAdmissiontotheSICU................................................ 49 2.1.4 PhysiologicSystem–BasedAssessment............................................. 50 2.1.5 NeurologicSystem.............................................................. 50 2.1.6 CardiovascularSystem........................................................... 50 2.1.7 Pulmonary/RespiratorySystem................................................... 51 2.1.8 RenalandGenitourinarySystemwithFluidStatusandElectrolytes.................... 51 2.1.9 GastrointestinalandNutritionStatus.............................................. 51 2.1.10 Metabolic,EndocrineSystem..................................................... 51 2.1.11 Infection,HematologicSystem,Skin,andWoundHealing ............................ 52 2.1.12 SeverityofIllness:ScoringSystemsintheSICU ..................................... 52 2.2 NeurologicalMonitoring....................................................... 53 MichaelKarsyandGregoryW.J.Hawryluk 2.2.1 NeurologicalStatusinCriticallyIllPatients......................................... 53 2.2.2 MonitoringIndications.......................................................... 54 2.2.3 IntracranialPressureManagement................................................ 55 2.2.4 ElevatedIntracranialPressureManagement........................................ 56 2.2.5 OtherNeurologicalMonitors..................................................... 56 2.3 VentilatorManagement ....................................................... 57 MichaelKarsy 2.4 Hemodynamics ............................................................... 62 LandonBlumelandDavidDorsey 2.4.1 Importance.................................................................... 62 2.4.2 Prevalence..................................................................... 62 2.4.3 NoninvasiveBloodPressureMonitoringTechniques................................. 62 2.4.4 InvasiveMonitoringTechniques.................................................. 62 2.4.5 IndicationsforInvasiveHemodynamicMonitoring.................................. 63 2.4.6 TreatmentofHemodynamicDerangements ........................................ 63 2.4.7 AssessmentofVolumeStatusandVolumeResponsiveness............................ 63 2.4.8 AutoregulationandIndividualizedApproachtoHemodynamicManagement ........... 64 2.4.9 ConditionsNecessitatingElevatedMaps ........................................... 65 2.4.10 ConditionsNecessitatingLowerthanExpectedMAP................................. 65 2.4.11 WhenIsTreatment/ResuscitationAdequate? ....................................... 65 2.4.12 Shock......................................................................... 66 2.4.13 VasoactiveAgents .............................................................. 68 2.5 CardiacArrhythmiainSurgicalPatients......................................... 68 MichaelKarsy 2.5.1 Introduction................................................................... 68 2.5.2 Treatment..................................................................... 68 2.5.3 PerioperativeCardiacRiskAssessment............................................. 74 2.5.4 MyocardialInfarction ........................................................... 75 vii |02.07.20-17:34 Contents 2.6 NutritionoftheCriticalCareandPostsurgicalPatient ............................ 75 MichaelKarsy 2.6.1 NutritionOverview.............................................................. 75 2.6.2 EnteralNutrition................................................................ 76 2.6.3 ParenteralNutrition............................................................. 77 2.7 Fluids,Electrolytes,andAcid-BaseAbnormalities ................................ 77 MichaelKarsy 2.7.1 Fluids.......................................................................... 77 2.7.2 Electrolytes..................................................................... 79 2.7.3 Acid/BaseEvaluation............................................................. 81 2.8 HematologyandCoagulation................................................... 84 MichaelKarsy 2.8.1 Hematology.................................................................... 84 2.8.2 PlateletsandClottingFactors...................................................... 85 2.8.3 Transfusion..................................................................... 88 2.9 AcuteKidneyInjury............................................................ 89 MichaelKarsy 2.10 InfectionsintheSurgicalICU.................................................... 91 AdrienneCareyandEmilySpivak 2.10.1 NosocomialFeverandLeukocytosis................................................ 91 2.10.2 Catheter-RelatedBloodStreamInfection(CRBSI)..................................... 92 2.10.3 IndwellingCatheters............................................................. 93 2.10.4 Catheter-AssociatedUrinaryTractInfection(CA-UTI)................................. 93 2.10.5 Hospital-AcquiredPneumonia/Ventilator-AssociatedPneumonia ...................... 96 2.10.6 Clostridioides(formerlyClostridium)DifficileColitis ................................. 97 2.10.7 Candidemia .................................................................... 99 2.10.8 ComplicatedIntra-abdominalInfections,Peritonitis.................................. 99 2.10.9 NecrotizingFasciitis ............................................................. 100 2.10.10 PenicillinAllergy................................................................ 101 References .................................................................... 102 3 Trauma...................................................................... 105 EditedbyRebeccaKimandMilosBuhavac 3.1 AdvanceTraumaLifeSupport(ATLS)andGeneralApproachtoTrauma............. 105 MichaelKarsy,AustinCannon,AndreaWeitz,andMilosBuhavac 3.1.1 Epidemiology................................................................... 105 3.1.2 TriageandAssessment........................................................... 105 3.1.3 Imaging........................................................................ 109 3.2 SpecificInjuryPatternsinTrauma............................................... 111 MichaelKarsy,AustinCannon,AndreaWeitz,andMilosBuhavac 3.3 SpecificInjuryPatientGroupsinTrauma......................................... 117 MichaelKarsy,AustinCannon,AndreaWeitz,andMilosBuhavac viii