الفهرس 
CARDIOVASCULAR COMPLICATIONSOnly 14 pages are availabe for public view
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Abstract
Successful perioperative evaluation and management of high-risk cardiac patients undergoing urologic surgery requires a careful history, physical examination, careful teamwork and communication between surgeon, anesthesiologist, and the consultant. In general, indications for further cardiac testing and treatments are the same as in the non-operative setting, but their timing is dependent on several factors, including the urgency of surgery, patient-specific risk factors, and surgery-specific considerations.
The use of both non-invasive and invasive preoperative testing should be limited to those circumstances in which the results of such tests will clearly affect patient management.
Intraoperative and postoperative use of ST-segment monitoring can be useful to monitor patients with known CAD, with computerized ST-segment analysis, when available, used to detect myocardial ischemia during the perioperative period, and this type of monitoring may be considered in patients with single or multiple risk factors for CAD who are undergoing surgery.
In patients having urologic surgery, myocardial infarction is the most common fatal complication. By extrapolation of the cardioprotective properties from patients with established coronary artery disease, β blockers have been promoted as potentially improving cardiovascular outcomes perioperatively.
Eagle et al. found that patients undergoing low-risk procedures are unlikely to derive benefit from CABG before low-risk surgery; however, patients with multivessel disease and severe angina undergoing high-risk surgery might well benefit from revascularization before non-ardiac surgery
DVT prophylaxis should be considered in all patients undergoing urologic surgical procedures. In many patients undergoing low-risk procedures, early ambulation may be the only DVT prophylactic measure that is indicated. However, in patients with a high-risk profile undergoing a high-risk procedure, an assessment of all risk factors inherent to the patient and planned procedure should dictate the appropriate DVT prophylaxis.
Urinary diversions can be divided in non-continent diversions, continent diversions, and orthotopic neobladders. Currently, the majority of urinary diversions are constructed from terminal ileum or ileocolonic segments of the intestine.
Complications can occur soon after diversion, many complications, however, will only become clear many months or years after the surgical procedure. Therefore, long-term followup and prevention of complications is mandatory.
Despite the introduction of many minimally invasive techniques, TURP still remains the gold standard in the surgical management of benign prostatic enlargement. The review highlights the progress that has been made in the physiologic understanding, diagnosis, and management of TURP syndrome. It also highlights the fact, however, that even with this understanding, the condition is difficult to eliminate, predict, diagnose, and manage.
In particular, the diagnosis and treatment rely on clinical acumen and a multidisciplinary team approach.
TED may facilitate early detection and successful management of patients with TURP syndrome. Endoscopic surgery is a rapidly expanding area, and complications similar to TURP syndrome are increasingly reported from other specialties, e.g., during hysteroscopic surgery. Thus, the increasing requirement to detect and manage TURP (-like) syndromes may promote applications of TED, Successive patients may present with almost completely opposite clinical pictures so that one patient may need treatment for hypertension and fluid overload while another may need support for hypotension. The same patient may need support for both fluid overload and subsequently hypotension in different phases of TURP syndrome.
Early identification and treatment of urosepsis is crucial. Urosepsis as a result of UTI is a serious condition, commonly caused by Gram negative bacteria. Urosepsis leads to profound disruption in the normal hemodynamic status of affected patients, with deleterious effects on renal, cardiac, respiratory, and hepatic function. Such patients are best managed in the intensive care setting with IV fluids and broad-spectrum antibiotics as soon after presentation as possible.
Pulmonary complications are a major cause of morbidity and mortality in the perioperative period. These complications range in clinical severity from asymptomatic hypoxemia to acute respiratory failure necessitating the reinitiation of mechanical ventilation.
Acute upper airway obstruction that results in stridor following extubation is a medical emergency, which requires immediate attention and may necessitate reintubation. In addition, atelectasis, bronchospasm, alveolar hypoventilation, pulmonary edema, increased intraabdominal pressure, chemical aspiration, and infection can all contribute to postoperative respiratory dysfunction.
The combination of a directed history and physical examination, plain chest radiograph, and measurement of arterial blood gas values generally narrows the differential diagnosis. Initial treatment should be supportive, using supplemental oxygen, inhaled bronchodilators, mechanical clearance of secretions, and possibly noninvasive mechanical ventilation. Subsequent therapy is guided by the underlying condition or conditions responsible for acute decompensation.
Malnutrition was defined as ‘‘a subacute or chronic state of nutrition in which a combination of varying degrees of over- or undernutrition and inflammatory activity has led to a change in body composition and diminished function’’.
Malnutrition has long been recognised as a risk factor for postoperative morbidity and mortality. Traditional metabolic and nutritional care of patients undergoing major elective surgery has emphasised preoperative fasting and re-introduction of oral nutrition 3-5 d after surgery. Attempts to attenuate the consequent nutritional deficit and to influence post-operative morbidity and mortality have included parenteral and enteral feeding.
Since, malnutrition is associated with increased morbidity and mortality, prevention or correction of nutrient depletion has the potential to minimize malnutrition-related complications. The goals of nutritional assessment are to identify patients who have, or are at risk of developing protein energy malnutrition, and to treat them and then monitor the adequacy of nutrition therapy.
Healing from surgery is complex, and many factors, including nutritional status, can affect the outcome. A proper diet is essential for healing. Beginning before surgery and continuing throughout the healing process, you may require extra calories, protein, vitamins, and minerals, as well as adequate fluids to help maintain hydration to support circulation of nutrients.
Surgical interventions, and abdominal surgery in particular,are frequently accompanied by the occurrence of postoperative ileus, intestinal obstruction, volvolus and fistula. All these are a multifactorial surgical complication that requires a multifactorial treatment approach. Minimal invasive surgery to reduce surgical stress, epidural analgesia to block inhibitory reflexes, minimizing opioid use, and attenuation of intestinal inflammation by anti-inflammatory interventions should reduce postoperative ileus to a minimum. The development of safe and easy-to-use treatments to prevent intestinal inflammation will play a key role in controlling postoperative ileus and all these complicatins.
Stimulation of the vagal anti-inflammatory pathway, by interventions such as enteral administration of lipids, is one of the promising interventions contributing to a further reduction of postoperative ileus. Most patients with pseudo-obstruction ,obstruction and volvolus respond to conservative therapy or neostigmine. Endoscopic decompression and surgical interventions are indicated in urgent cases and cases not respond to conservative therapy.
Neurologic complications include delayed awakening (not regaining consciousness within 60 to 90 minutes), which may be caused by hypoxia, hypothermia, or electrolyte imbalances. Abrupt awakening or prolonged paralysis may also occur. Although nerve injuries may occur during any of a variety of urologic procedures, the most common circumstances in which we have encountered these events involve brachial plexus injuries after surgery in the flank position, femoral nerve injuries from radical pelvic surgery, and lower extremity nerve injury from procedures in the lithotomy position.
Drug reactions of pharmacologic agents commonly prescribed for urologic diseases. Also the use of systemic chemotherapy carries important benefits in the treatment of genitourinary cancers. The potential benefits of this chemotherapy come at a cost to the patient in the form of toxicity, both acute and delayed, which can have a substantial impact on quality of life.