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Psychiatric illness is common in patients presenting for surgery. Overall health and surgical outcomes are adversely affected by the presence of psychiatric comorbidities.

As new treatment modalities become available, their perioperative implications need to be evaluated. These implications include drug-drug interactions, hemodynamic effects, bleeding risk, and factors affecting perioperative exacerbation of the underlying psychiatric illness.

From our review of the recent literature we continue to support the continuation of psychoactive agents in the perioperative period, taking into consideration the effects these agents have on concomitant drug use in the perioperative period; and the risks of withholding them at a high-stress time.

From our review of the recent literature we continue to support the continuation of psychoactive agents in the perioperative period, taking into consideration the effects these agents have on concomitant drug use in the perioperative period; and the risks of withholding them at a high-stress time.

In this review, we discuss recent developments and trends in the perioperative management of thrombocytopenia.

Large contemporary data base studies show that preoperative thrombocytopenia is present in about 8% of asymptomatic patients, and is associated with increased risks for bleeding and 30-day mortality. Traditionally specific threshold platelet counts were recommended for specific procedures. However, the risk of bleeding may not correlate well with platelet counts and varies with platelet function depending on the underlying etiology. Evidence to support prophylactic platelet transfusion is limited and refractoriness to platelet transfusion is common. A number of options exist to optimize platelet counts prior to procedures, which include steroids, intravenous immunoglobulin, thrombopoietin receptor agonists, and monoclonal antibodies. selleck chemical In addition, intraoperative alternatives and adjuncts to transfusion should be considered. It appears reasonable to use prophylactic desmopressin and antifibrinolytic agents, whereas activated recombinant factor VII could be considered in severe bleeding. Other options include enhancing thrombin generation with prothrombin complex concentrate or increasing fibrinogen levels with fibrinogen concentrate or cryoprecipitate.

Given the lack of good quality evidence, much research remains to be done. However, with a multidisciplinary multimodal perioperative strategy, the risk of bleeding can be decreased effectively.

Given the lack of good quality evidence, much research remains to be done. However, with a multidisciplinary multimodal perioperative strategy, the risk of bleeding can be decreased effectively.

An increasing number of patients with endocrine disorders will present to the operating rooms. In this review, we outline the common endocrine disorders that the anesthesiologist may face in the perioperative time span, review the controversies in optimal management, as well as summarize the recent literature for the management of these complex patients.

Perioperative management of pheochromocytoma and paraganglioma has been facilitated by improved medical management and the adoption of minimally invasive surgical techniques. An improved understanding of the sequelae of carcinoid syndrome has resulted in safer perioperative management. Perioperative glycemic management requires a fundamental understanding of perioperative fluid resuscitation and adverse events associated with the new generation oral hyperglycemic agents to prevent avoidable complications.

Endocrine disorders will commonly present in the perioperative time period and the anesthesiologist plays a critical role in achieving good operative outcomes.

Endocrine disorders will commonly present in the perioperative time period and the anesthesiologist plays a critical role in achieving good operative outcomes.

Surgery remains integral to treating solid cancers. However, the surgical stress response, characterized by physiologic perturbation of the adrenergic, inflammatory, and immune systems, may promote procancerous pathways. Anesthetic technique per se may attenuate/enhance these pathways and thereby could be implicated in long-term cancer outcomes.

To date, clinical studies have predominantly been retrospective and underpowered and, thus limit meaningful conclusions. More recently, prospective studies of regional anesthesia for breast and colorectal cancer surgery have failed to demonstrate long-term cancer outcome benefit. However, based on the consistent observation of protumorigenic effects of surgical stress and that of volatile anesthesia in preclinical studies, supported by in vivo models of tumor progression and metastasis, we await robust prospective clinical studies exploring the role of propofol-based total intravenous anesthesia (cf. inhalational volatiles). Additionally, anti-adrenergic/anti-inflrge, prospective, randomized control trials are urgently needed to inform evidence-based clinical practice guidelines.

This review examines how functional capacity informs preoperative risk stratification, as well as strengths and limitations of options for estimating functional capacity.

Functional capacity (or cardiopulmonary fitness) overlaps with other important characteristics, including muscular strength, balance, and frailty. Poor functional capacity is associated with postoperative morbidity, especially noncardiovascular complications. Both patient interviews and exercise tests are used to assess functional capacity. The usual approach of an unstructured patient interview does not predict outcomes. Structured interviews that incorporate validated questionnaires (Duke Activity Status Index) or standardized questions about physical activity (ability to climb stairs) do predict moderate-or-severe complications and cardiovascular complications. Among exercise tests, cardiopulmonary exercise testing (CPET) has shown the most consistent association with risks of complications. Other tests (6-min walk test, incremental shuttle walk test, stair climbing) might predict complications, but still require further high-quality evaluation.

A straightforward way to better assess functional capacity is a structured interview with validated questionnaires or standardized questions about physical activities. Functional capacity can also be assessed by exercise tests, with the strongest evidence supporting CPET. Although some simpler exercise tests have shown promise, more research remains needed to better define their role in preoperative evaluation.

A straightforward way to better assess functional capacity is a structured interview with validated questionnaires or standardized questions about physical activities. Functional capacity can also be assessed by exercise tests, with the strongest evidence supporting CPET. Although some simpler exercise tests have shown promise, more research remains needed to better define their role in preoperative evaluation.