What are key recommendations for a diplomate exam in surgery based on Schwartz for an adult patient with comorbidities undergoing various surgical procedures?

Surgical Diplomate Exam Preparation: Key Recommendations for Adult Patients with Comorbidities

Preoperative Risk Assessment and Optimization

The most critical factor in surgical outcomes for patients with comorbidities is comprehensive multidisciplinary preoperative planning, with frailty assessment superseding chronological age as the primary risk stratification tool. 1

Frailty Assessment Takes Priority Over Age

• Frailty independently predicts perioperative morbidity and mortality across all surgical procedures, regardless of chronological age. 1
• Patients with intermediate frailty scores (2-3 traits) have a 1.70-fold increased risk of any complication and 2.00-fold increased risk of serious complications. 1
• High frailty scores (≥4 traits) confer a 3.35-fold increased risk of any complication and 3.95-fold increased risk of serious complications. 1
• This relationship holds true even for ambulatory procedures like hernia repair, breast surgery, and thyroid/parathyroid operations. 1

Comorbidity Burden Assessment

• Each additional comorbidity increases hospital costs by approximately €1,198 (USD $1,300), independent of ASA classification. 2
• The median surgical patient has 5 comorbidities (range 0-18), with ASA III patients averaging 9 comorbidities and ASA IV patients averaging 12. 2
• Arterial hypertension significantly increases mortality risk (p = 0.018) and is present in 57.58% of surgical patients. 3
• Chronic kidney disease, diabetes mellitus, and hypercholesterolemia are independently associated with postoperative mortality. 3

Cardiovascular Comorbidities and Perioperative Management

Hypertension Management

• Withholding renin-angiotensin-aldosterone system (RAAS) antagonists preoperatively does not improve outcomes and may worsen them. 4
• Continue antihypertensive medications through the morning of surgery, with the possible exception of diuretics. 4
• For intraoperative hypertensive crises, clevidipine provides superior control compared to nitroglycerin, sodium nitroprusside, or nicardipine in cardiac surgery patients. 4

Beta-Blocker Considerations

• Perioperative beta-blockade is associated with increased mortality and cardiovascular morbidity in major noncardiac surgery. 4
• Continue beta-blockers in patients already taking them, but do not initiate them perioperatively unless there is a compelling cardiac indication. 4

Statin Therapy

• Continue statins perioperatively in all patients already taking them, as discontinuation increases cardiovascular risk. 5
• Be aware that statins increase risk of myopathy and rhabdomyolysis, particularly in patients ≥65 years, with renal impairment, or taking interacting medications (cyclosporine, gemfibrozil, certain antivirals). 5
• Temporarily discontinue statins if patients develop acute conditions predisposing to rhabdomyolysis (sepsis, shock, severe hypovolemia, major trauma). 5

Hematologic Considerations

Sickle Cell Disease

For patients with sickle cell disease, multidisciplinary collaboration between surgeon, anesthesiologist, and pediatric/adult hematologist is mandatory for any surgical procedure. 4

• Perform preoperative blood typing and antibody screening to expedite potential transfusions. 4
• For high-risk procedures, planned exchange transfusions should be discussed; for low-risk procedures in patients on effective hydroxyurea therapy, transfusion decisions are case-by-case. 4
• Active infection or acute sickle cell crisis (vaso-occlusive crisis, acute chest syndrome) are absolute contraindications to elective surgery. 4
• Ensure prior immunization against encapsulated bacteria before splenectomy. 4

Thromboprophylaxis

• Anticoagulation at prophylactic doses is recommended for most surgical patients with comorbidities. 4
• Early mobilization and pneumatic compression devices provide additional venous thromboembolism prevention. 4

Anesthesia Selection and Perioperative Monitoring

Anesthesia Type

• Local anesthesia with monitored anesthesia care (MAC) reduces serious 30-day complications by 34% (adjusted OR 0.66) compared to general anesthesia in ambulatory procedures. 1
• Consider regional or local techniques whenever feasible, particularly in frail patients. 1

Intraoperative Neurophysiological Monitoring (IONM)

IONM is NOT medically necessary for routine anterior cervical discectomy and fusion (ACDF) in patients with cervical stenosis and radiculopathy without myelopathy, tumor, trauma, or significant deformity. 6

• IONM may be justified when severe cord compression with documented myelopathy is present, using multimodal monitoring (MEPs + SSEPs) with 84.2% sensitivity and 93.7% specificity. 6
• Surface EMG during ACDF has insufficient evidence for routine use. 6
• For routine spine surgery, changes in evoked potentials do not reliably predict neurological injury or alter surgical outcomes. 6

Specific Surgical Scenarios

Cervical Spine Surgery

ACDF is appropriate for multi-level cervical disc disease with radiculopathy or myelopathy that has failed conservative management. 7

• ACDF achieves more rapid pain reduction and reduces kyphosis risk compared to anterior cervical discectomy alone. 7
• For severe cervical myelopathy (mJOA score ≤12), progressive neurological deficits, or persistent symptoms despite conservative treatment, surgical decompression is indicated. 8
• Untreated cervical myelopathy carries high risk for progressive neurological deterioration and potential catastrophic spinal cord injury. 7
• MRI is the preferred imaging modality, but degenerative findings are common in asymptomatic patients >30 years, requiring clinical correlation. 8

Cataract Surgery

Preoperative medical evaluation including history and physical examination does not reduce systemic or ocular complications in cataract surgery. 4

• For patients with severe systemic diseases (COPD, poorly controlled hypertension, recent MI, unstable angina, poorly controlled CHF, poorly controlled diabetes), preoperative medical evaluation by primary care physician may be warranted. 4
• Intracameral antibiotic administration reduces postoperative bacterial endophthalmitis risk; topical antibiotics do not add benefit. 4
• Topical NSAIDs reduce early postoperative cystoid macular edema, though long-term benefit is unproven. 4

Minimally Invasive Mitral Valve Surgery

• Arterial hypertension (present in 57.58% of patients) significantly increases mortality risk. 3
• Postoperative mortality is associated with chronic kidney disease, diabetes mellitus, and hypercholesterolemia. 3
• New-onset atrial fibrillation occurs in 19.2% of patients; 4% require postoperative pacemaker implantation. 3
• Average mechanical ventilation duration is 540.8 minutes, with significant positive correlation between ventilation duration and 30-day mortality. 3

Postoperative Management

Infection Prevention

• Prophylactic antibiotics should be tailored to procedure type: vancomycin or cephalosporins post-splenectomy, procedure-specific protocols for cardiac surgery. 4
• Monitor and promptly remove unnecessary foreign bodies and indwelling equipment. 4

Pain and Nausea Management

• Ondansetron is recommended for prevention of postoperative nausea and vomiting. 4
• Develop individualized pain management strategies based on patient's prior pain management history. 4

Monitoring and Follow-up

• Involve nutrition team postoperatively, including assessment for laxative requirements. 4
• Use vasoconstricting agents cautiously post-cardiac surgery as they may lead to poor peripheral perfusion and acidosis. 4
• Ventilation duration directly correlates with 30-day mortality; prioritize early extubation when clinically appropriate. 3

Common Pitfalls to Avoid

• Do not rely solely on ASA classification for risk stratification; it ignores multimorbidity and has limited predictive ability. 2
• Do not assume imaging findings correlate with clinical symptoms; false-positives and false-negatives are common, particularly in cervical spine MRI. 8
• Do not initiate beta-blockers perioperatively in beta-blocker-naïve patients; this increases mortality. 4
• Do not perform routine preoperative medical evaluations for cataract surgery; they do not improve outcomes. 4
• Do not use IONM routinely for ACDF without myelopathy; it is not medically necessary and does not improve outcomes. 6