Adult Clinical Challenges

  • Donald M. Mathews
  • Rebecca S. Twersky


Successful ambulatory surgery begins with proper selection and screening of patients. It then requires intelligent perioperative management of the medical issues that have been identified during the preoperative evaluation. Both of these areas, preoperative evaluation and perioperative management, are constantly evolving, and maintaining a current knowledge base is a challenge for the busy ambulatory anesthesiologist.


Obstructive Sleep Apnea Continuous Positive Airway Pressure Infective Endocarditis Laryngeal Mask Airway Minimum Alveolar Concentration 


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  1. 1.
    Kinsella K, Velkoff VA. An Aging World: 2001. Washington, DC: U.S. Census Bureau; 2001.Google Scholar
  2. 2.
    Fact Sheet: The American Geriatrics Society (AGS). Available at: http://www. Accessed July 5, 2007.Google Scholar
  3. 3.
    Warner MA, Saletel RA, Schroeder DR, Warner DO, Offord KP, Gray DT. Outcomes of anesthesia and surgery in people 100 years of age and older. J Am Geriatr Soc. 1998;46:988–993.PubMedGoogle Scholar
  4. 4.
    Aldwinckle RJ, Montgomery JE. Unplanned admission rates and postdischarge complications in patients over the age of 70 following day case surgery. Anaesthesia. 2004;59:57–59.CrossRefPubMedGoogle Scholar
  5. 5.
    Fleisher LA, Pasternak LR, Herbert R, Anderson GF. Inpatient hospital admission and death after outpatient surgery in elderly patients: important of patient and system characteristics and location of care. Arch Surg. 2004;139:67–72.CrossRefPubMedGoogle Scholar
  6. 6.
    Polanczyk CA, Marcantonio E, Goldman L, et al. Impact of age on perioperative complications and length of stay in patients undergoing noncardiac surgery. Ann Intern Med. 2001;134:637–643.PubMedGoogle Scholar
  7. 7.
    Kantelip JP, Sage E, Duchene-Marullaz P. Findings on ambulatory electrocardiographic monitoring in subjects older than 80 years. Am J Cardiol. 1986;57:398–401.CrossRefPubMedGoogle Scholar
  8. 8.
    Eger EI. Age, minimum alveolar anesthetic concentration, and minimum alveolar anesthetic concentration-awake. Anesth Analg. 2001;93:947–53.CrossRefPubMedGoogle Scholar
  9. 9.
    Fragen RJ, Dunn KL. The minimum alveolar concentration (MAC) of sevoflurane with and without nitrous oxide in elderly versus young adults. J Clin Anesth. 1996;8:352–356.CrossRefPubMedGoogle Scholar
  10. 10.
    Schnider TW, Minto CF, Shafer SL, et al. The influence of age on propofol pharmacodynamics. Anesthesiology. 1999;90:1502–1516.CrossRefPubMedGoogle Scholar
  11. 11.
    Kirkbride DA, Parker JL, Williams GD, Buggy DJ. Induction of anesthesia in the elderly ambulatory patient: a double-blind comparison of propofol and sevoflurane. Anesth Analg. 2001;93:1185–1187.CrossRefPubMedGoogle Scholar
  12. 12.
    Tsui BC, Wagner A, Finucane B. Regional anaesthesia in the elderly: a clinical guide. Drugs Aging. 2004;21:895–910.CrossRefPubMedGoogle Scholar
  13. 13.
    Marcantonio ER, Goldman L, Orav EJ, Cook EF, Lee TH. The association of intraoperative factors with the development of postoperative delirium. Am J Med. 1998;105:380–384.CrossRefPubMedGoogle Scholar
  14. 14.
    Zakriya KJ, Christmas C, Wenz JF Sr., Franckowiak S, Anderson R, Sieber FE. Preoperative factors associated with postoperative change in confusion assessment method score in hip fracture patients. Anesth Analg. 2002;94:1628–1632.CrossRefPubMedGoogle Scholar
  15. 15.
    Moller JT, Cluitmans P, Rasmussen LS, et al. Long-term postoperative cognitive dysfunction in the elderly ISPOCD1 study. ISPOCD investigators. International Study of Post-Operative Cognitive Dysfunction. Lancet. 1998;351:857–861. Erratum in: Lancet. 1998;351:1742.CrossRefPubMedGoogle Scholar
  16. 16.
    Parikh SS, Chung F. Postoperative delirium in the elderly. Anesth Analg. 1995;80: 1223–1232.CrossRefPubMedGoogle Scholar
  17. 17.
    Ward B, Imarengiaye C, Peirovy J, Chung F. Cognitive function is minimally impaired after ambulatory surgery. Can J Anaesth. 2005;52:1017–1021.CrossRefPubMedGoogle Scholar
  18. 18.
    Johnson T, Monk T, Rasmussen LS, et al. ISPOCD2 Investigators. Postoperative cognifi tive dysfunction in middle-aged patients. Anesthesiology. 2002;96:1351–1357.CrossRefPubMedGoogle Scholar
  19. 19.
    Williams-Russo P, Sharrock NE, Mattis S, Szatowski TIP, Charlson ME. Cognitive effects after epidural vs. general anesthesia in older adults. JAMA. 1995;274: 44–50.CrossRefPubMedGoogle Scholar
  20. 20.
    Canet J, Rader J, Rasmussen LS, et al. ISPOCD2 investigators. Cognitive dysfunction after minor surgery in the elderly. Acta Anaesthesiol Scand. 2003;47;1204–1210.CrossRefPubMedGoogle Scholar
  21. 21.
    Vaurio LE, Sands LP, Wang Y, Mullen EA, Leung JM. Postoperative delirium: the importance of pain and pain management. Anesth Analg. 2006;102:1267–1273.CrossRefPubMedGoogle Scholar
  22. 22.
    Chung F, Lavelle PA, McDonald S, Chung A, McDonald NJ. Cognitive impairment after neuroleptanalgesia in cataract surgery. Anesth Analg. 1989;68:614–618.CrossRefPubMedGoogle Scholar
  23. 23.
    Chung FF, Chung A, Meier RH, Lautenschlaeger E, Seyone C. Comparison of perioperative mental function after general anaesthesia and spinal anaesthesia with intravenous sedation. Can J Anaesth. 1989;36:382–387.CrossRefPubMedGoogle Scholar
  24. 24.
    Fredman B, Sheffer O, Zohar E, et al. Fast-track eligibility of geriatric patients undergoing short urologic procedures. Anesth Analg. 2002;94:560–564.CrossRefPubMedGoogle Scholar
  25. 25.
    Cook DJ. Geriatric anesthesia. In: Solomon DH, LoCicero J III, Rosenthal RA, eds. New Frontiers in Geriatric Research. New York, NY: American Geriatrics Society; 2004:9–52.Google Scholar
  26. 26.
    Chung F, Mezei G, Tong D. Adverse events in ambulatory surgery. A comparison between elderly and younger patients. Can J Anaesth. 1999;46:309.CrossRefPubMedGoogle Scholar
  27. 27.
    Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery. J Am Coll Cardiol. 2007;50: 159–241.CrossRefGoogle Scholar
  28. 28.
    Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100:1043–1049.PubMedGoogle Scholar
  29. 29.
    Lackland DT. Systemic hypertension: an endemic, epidemic, and a pandemic. Semin Nephrol. 2005;25:194–197.CrossRefPubMedGoogle Scholar
  30. 30.
    Comfere T, Sprung J, Kumar MM, et al. Angiotensin system inhibitors in a general surgical population. Anesth Analg. 2005;100:636–644.CrossRefPubMedGoogle Scholar
  31. 31.
    Friedman Z, Chung F, Wong DT. Ambulatory surgery adult patient selection criteria—a survey of Canadian anesthesiologists. Can J Anaesth. 2004;51:437–443.CrossRefPubMedGoogle Scholar
  32. 32.
    Kaluza GL, Joseph J, Lee JR, Raizner ME, Raizner AE. Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol. 2000;35: 1288–1294.CrossRefPubMedGoogle Scholar
  33. 33.
    Forgosh LB, Movahed A. Assessment of cardiac risk in noncardiac surgery. Clin Cardiol. 1995;18:556–562.CrossRefPubMedGoogle Scholar
  34. 34.
    American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Cardiac Rhythm Management Devices. Practice advisory for the perioperative management of patients with cardiac rhythm management devices: pacemakers and implantable cardioverter-defibrillators: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Cardiac Rhythm Management Devices. Anesthesiology. 2005;103:186–198.CrossRefGoogle Scholar
  35. 35.
    Salukhe TV, Dob D, Sutton R. Pacemakers and defibrillators: anaesthetic implications. Br J Anaesth. 2004;93:95–104.CrossRefPubMedGoogle Scholar
  36. 36.
    NAEPP Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma—Update on Selected Topics 2002. Available at: guidelines/asthma. Accessed December 30, 2005.Google Scholar
  37. 37.
    Bishop MJ. Preoperative corticosteroids for reactive airway? Anesthesiology. 2004; 100:1047–1048.CrossRefPubMedGoogle Scholar
  38. 38.
    Pizov R, Brown RH, Weiss YS, et al. Wheezing during induction of general anesthesia in patients with and without asthma. A randomized, blinded trial. Anesthesiology. 1995;82:1111–1116.CrossRefPubMedGoogle Scholar
  39. 39.
    Eshima RW, Maurer A, King T, et al. A comparison of airway responses during desfl urane and sevoflurane administration via a laryngeal mask airway for maintenance of anesthesia. Anesth Analg. 2003;96:701–705.PubMedGoogle Scholar
  40. 40.
    Salem M, Tainsh RE, Bromberg J, Loriaux DL, Chernow B. Perioperative glucocorticoid coverage. A reassessment 42 years after the emergence of a problem. Ann Surg. 1994;219:416–425.CrossRefPubMedGoogle Scholar
  41. 41.
    Warner DO. Helping surgical patients quit smoking: why, when, and how. Anesth Analg. 2005;101:481–487.CrossRefPubMedGoogle Scholar
  42. 42.
    Gentili ME, Deleuze A, Estebe JP, Lebourg M, Ecoffey C. Severe respiratory failure after infraclavicular block with 0.75% ropivacaine: a case report. J Clin Anesth. 2002;14:459–461.CrossRefPubMedGoogle Scholar
  43. 43.
    Flegal KM. Epidemiologic aspects of overweight and obesity in the United States. Physiol Behav. 2005;86:599–602.CrossRefPubMedGoogle Scholar
  44. 44.
    Connery LE, Coursin DB. Assessment and therapy of selected endocrine disorders. Anesthesiol Clin North Am. 2004;22:93–123.CrossRefGoogle Scholar
  45. 45.
    Hall WD, Watkins LO, Wright JT, et al. African-American Lipid and Cardiovascular Council. The metabolic syndrome: recognition and management. Dis Manag. 2006; 9:16–33.CrossRefPubMedGoogle Scholar
  46. 46.
    Schein OD, Katz J, Bass EB, et al. The value of routine preoperative medical testing before cataract surgery. N Engl J Med. 2000;342:168–175.CrossRefPubMedGoogle Scholar
  47. 47.
    Jellish WS, Kartha V, Fluder E, Slogoff S. Effect of metoclopromide on gastric fluid volumes in diabetic patients who have fasted before elective surgery. Anesthesiology. 2005;102:904–909.CrossRefPubMedGoogle Scholar
  48. 48.
    Farling PA. Thyroid disease. Br J Anaesth. 2000;85:15–28.CrossRefPubMedGoogle Scholar
  49. 49.
    Davies KE, Houghton K, Montgomery JE. Obesity and day-case surgery. Anaesthesia. 2001;56:1112–1125.PubMedGoogle Scholar
  50. 50.
    Nielsen KC, Guller U, Steele SM, Klein SM, Greengrass RA, Pietrobon R. Influence of obesity on surgical regional anesthesia in the ambulatory setting: an analysis of 9,038 blocks. Anesthesiology. 2005;102:181–187.CrossRefPubMedGoogle Scholar
  51. 51.
    White PF. The role of non-opioid analgesic techniques in the management of pain after ambulatory surgery. Anesth Analg. 2002;94:577–585.CrossRefPubMedGoogle Scholar
  52. 52.
    Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea. Available at: Accessed July 22, 2007.Google Scholar
  53. 53.
    Benumof JL. Obstructive sleep apnea in the adult obese patient: implications for airway management. Anesthesiol Clin North America. 2002;20:789–811.CrossRefPubMedGoogle Scholar
  54. 54.
    Sladen RN. Anesthetic considerations for the patient with renal failure. Anesthesiol Clin North America. 2000;18:863–882.CrossRefPubMedGoogle Scholar
  55. 55.
    Kloner RA, Hale S, Alker K, Rezkella S. The effects of acute and chronic cocaine use on the heart. Circulation. 1992;85:407–419.PubMedGoogle Scholar
  56. 56.
    O’Connor AD, Rusyniak DE, Bruno A. Cerebrovascular and cardiovascular complications of alcohol and sympathomimetic abuse. Med Clin North Am. 2005:89;1343–1358.CrossRefPubMedGoogle Scholar
  57. 57.
    Kvolik S, Glavas-Obrovac L, Sakic K, Margaretic D, Karner I. Anaestheic implications of anticancer chemotherapy. Eur J Anaesth. 2003;20:859–871.CrossRefGoogle Scholar
  58. 58.
    Drugs of choice for cancer. Treat Guidel Med Lett. 2003:1;41–52.Google Scholar
  59. 59.
    Thorne AC, Orazem JP, Shah NK, et al. Isoflurane versus fentanyl: hemodynamic effects in cancer patients treated with anthracyclines. J Cardiothorac Vasc Anesth. 1993;7:307–311.CrossRefPubMedGoogle Scholar
  60. 60.
    Sessler DI. Complications and treatment of mild hypothermia. Anesthesiology. 2001; 95:531–543.CrossRefPubMedGoogle Scholar
  61. 61.
    Shaw AD, Morgan M. Nitrous oxide: time to stop laughing? Anaesthesia. 1998; 53:213–215.CrossRefPubMedGoogle Scholar
  62. 62.
    Centers for Disease Control and Prevention. World AIDS Day, December 1, 2003. MMWR. 2003;52:1145., accessed November 3, 2007.Google Scholar
  63. 63.
    Olkkola KT, Palkama VJ, Neuvonen PJ. Ritonavir’s role in reducing fentanyl clearance and prolonging its half-life. Anesthesiology. 1999;91:681–685.CrossRefPubMedGoogle Scholar
  64. 64.
    Barbaro G. Cardiovascular manifestations of HIV infection. Circulation. 2002;106: 1420–1425.CrossRefPubMedGoogle Scholar
  65. 65.
    Ferrero S, Bentivoglio G. Post-operative complications after caesarean section in HIV-infected women. Arch Gynecol Obstet. 2003;268:268–273.CrossRefPubMedGoogle Scholar
  66. 66.
    Fox M, Forgacs I. Gastro-esphageal reflux disease. Br Med J. 2006;332:88–93.CrossRefGoogle Scholar
  67. 67.
    Huyse FJ, Touw DJ, Strack van Schundel R, de Lange JJ, Slaets JPJ. Psychotropic drugs and the perioperative period: a proposal for a guideline in elective surgery. Psychosomatics. 2006;47:8–22.CrossRefPubMedGoogle Scholar
  68. 68.
    Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005;352: 1112–1120.CrossRefPubMedGoogle Scholar
  69. 69.
    Gillman PK. Monoamine oxidase inhibitors, opioid analgesics and serotonin toxicity. Br J Anaesth. 2005;95:434–441.CrossRefPubMedGoogle Scholar
  70. 70.
    Reines HD, Seifert PC. Patient safety: latex allergy. Surg Clin North Am. 2005: 85;1329–1340.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Donald M. Mathews
    • 1
  • Rebecca S. Twersky
    • 2
    • 3
  1. 1.New York Medical College, Department of AnesthesiologySt. Vincent Catholic Medical Centers—St. Vincent’s ManhattanNew YorkUSA
  2. 2.Department of AnesthesiologySUNY Downstate Medical CenterBrooklyn
  3. 3.Ambulatory Surgery UnitLong Island College HospitalBrooklynUSA

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