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INTRODUCTION

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The neurohospitalist has the responsibility of caring for the hospitalized medically fragile neurological patient but also understanding the risk stratification for surgery and the potential anesthetic and medical complications that are unique to neurological patients who are having emergent or elective procedures. The neurohospitalist should be able to describe the relative surgical risk to the patient. Protocols for stratifying surgical risk have been developed, some of which are available as apps on digital devices. Where possible we have mentioned whether an app is currently available.

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Important aspects of perioperative management of the neurologic patients include management of chronic neurologic disorders (seizures, neuromuscular disorders, multiple sclerosis [MS], neurodegenerative diseases), appropriate risk stratification for surgical procedures, minimizing cerebrovascular risk during any hospitalization or procedure, minimizing sedation by choosing appropriate agents, and prevention of delirium.

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This chapter will review the following topics:

  1. Preoperative risk assessment

  2. Timing of surgical procedures with comorbid cerebrovascular disease

  3. Seizure disorder management perioperatively

  4. Neuromuscular disorder management perioperatively

  5. Neurodegenerative disorders, including Parkinson disease, management perioperatively

  6. MS management perioperatively

  7. Perioperative delirium prevention and treatment

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PART 1—CARDIAC RISK ASSESSMENT1

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CASE 35-1

A 70-year-old man presents with a transient ischemic attack (TIA). After admission, he develops right lower abdominal pain with associated fever and elevated white blood cell count. He is diagnosed with acute appendicitis and needs emergent abdominal surgery. His past history is significant for smoking with chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD) with prior myocardial infarction (MI) and 2 drug-eluting stents (DES) placed 10 months ago, type 2 diabetes, atrial fibrillation, and a recent cognitive decline. His current medicines are warfarin for atrial fibrillation, clopidogrel and aspirin for DES, amlodipine plus hydrochlorothiazide for hypertension, lopressor and atorvastatin for CAD, insulin for diabetes mellitus (DM), and donepezil for cognitive decline. You are asked to supply the preoperative risk and manage his medicines pre- and postoperatively.

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How do you perform preoperative risk assessment?

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  • The medical or surgical team may perform this clinical assessment.

  • The patient’s demographics, past medical history, functional status, current active medical illnesses, and the procedure planned all contribute to this assessment.

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How is the urgency and risk of the procedure assigned?

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  • The American Heart Association (AHA) has defined the urgency and risk for procedures.

  • Urgency is defined as follows:

    • Emergency is used to describe a threat to life or limb with no or minimal time for clinical evaluation, usually within 6 hours.

    • Urgency describes a threat to life or limb with time for a limited clinical evaluation prior to the surgical procedure, usually 6–24 hours.

    • Time-sensitive references a negative outcome if there is a delay of more than 1–6 weeks for an evaluation and significant management changes to be made.

    • Elective is used when a procedure may be delayed for up to 1 year to perform clinical evaluation and institute appropriate ...

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