Risk factors surgical patients

The benefit of carotid endarterectomy for prevention of recurrent stroke has been studied previously in major trials.25,26 A recent meta-analysis has been completed that has combined these clinical trials to evaluate 6,092 patients.27 Carotid endarterectomy has been shown to be beneficial for preventing ipsilateral stroke in patients with symptomatic carotid artery stenosis of 70% or greater and is recommended in these patients. In patients with symptomatic stenosis of 50% to 69%, a moderate reduction in risk is seen in clinical trials. In all patients with stenosis of 50% to 69% and a recent stroke, carotid endarterectomy is appropriate. In other patients, surgical risk factors and surgeon skill should be considered prior to surgery. The patient should have, at a minimum, a life expectancy of 5 years, and the surgical risk of stroke and/or death should be less than 6%. Carotid endarterectomy is not beneficial for symptomatic carotid stenosis less than 50% and should not be considered in these patients. 

Additionally, the patient needs to be counseled on the necessity of prophylactic antibiotics prior to any dental or surgical procedure in order to prevent recurrent infections. This is critical in patients with risk factors that predispose them to developing IE, such as prosthetic heart valves, other valvular defects, or previous IE. 

In addition to medical and surgical management, non-pharmacologic interventions that reduce risk factors for developing osteomyelitis should be communicated to the patient. Examples include smoking cessation, weight-control, exercise, and good nutrition.2 Additionally, a diabetic patient... 

Prophylaxis should be continued throughout the period of risk. For general surgical procedures and medical conditions, prophylaxis can be discontinued once the patient is able to ambulate regularly and other risk factors are no longer present. Most clinical trials support the use of antithrombotic therapy for 21 to 35 days after total hip replacement and hip fracture repair surgeries. 

The Study of the Efficacy of Nosocomial Infection Control (SENIC) identified four independent risk factors for postoperative wound infections operations on the abdomen, operations lasting more than 2 hours, contaminated or dirty wound classification, and at least three medical diagnoses. Patients with at least two SENIC risk factors who undergo clean surgical procedures have an increased risk of developing surgical wound infections and should receive antimicrobial prophylaxis. 

Foot ulcers cause significant morbidity and impaired quality of life and are the most important risk factor for lower extremity amputation. The lifetime risk of a foot ulcer is up to 15% for patients with diabetes and 15-27% of all ulcers result in surgical removal of bone (Jeffcoate and Harding, 2003). Major amputation incidence is around 0.5% of patients with diabetes per year (NICE, 2004). Peri-operative mortality for major amputations is 10-15% and 3-year survival rates can be as low as 50%. 

Aortic arch atheroma is now increasingly diagnosed by transesophageal echocardiography in patients with TIAs or ischemic stroke, but so far there are no surgical, or indeed medical, treatment options over and above controlling vascular risk factors and antiplatelet drugs. One trial of medical treatment has been started, the Aortic Arch Related Cerebral Hazard (ARCH) trial (MacLeod et al. 2004). 

Only a few serious attempts have been made to sort out which other patient-related factors affect perioperative stroke risk, and then which factors are independent from each other so they can be used in combination to predict surgical risk in individuals (Sundt et al. 1975 McCrory et al. 1993 Goldstein et al. 1994 Riles et al. 1994 Golledge et al. 1996 Kucey et al. 1998 Ferguson et al. 1999). Risk factors almost certainly include hypertension, peripheral... 

Epilepsy develops in 14-20% of patients, and putative risk factors include subdural hematoma, cerebral infarction, disability on discharge, ventricular drain insertion and surgical treatment (Olafsson et al. 2000 Claassen et al. 2003). 

Apart from surgical and interventional therapy of occlusive carotid artery disease, the major approach to preventing vascular disease and subsequent stroke is to pay close attention to the control of modifiable risk factors such as hypertension, smoking, diabetes, and hypercholesterolemia. Coumadin, an anticoagulant, is effective for the primary and secondary prevention of stroke in patients with atrial fibrillation. Aspirin, clopidogrel, and the combination of aspirin and cUpyridamole have been proven to be effective for secondary stroke prevention along with the antihypertensive combination of indap-amide and perindopril. 

Severe injection site reactions have been extensively detailed in six patients who had local cutaneous necrosis or indurated erythema after 1-10 months of treatment with low-dose interferon alfa (284). Four patients had concomitant risk factors known to reduce microcirculation, that is beta-blockers, dihydroergotamine, and cigarette smoking. The lesions healed after medical treatment in five patients, but one required surgical excision. The ulcers healed slowly and full recovery occurred only after a mean of 16 weeks after drug withdrawal. The lesions did not recur after interferon alfa re-administration at the other injection sites. 

Three episodes of thrombosis occurred in patients who had taken thahdomide (25-100 mg/day) for up to 2 years (32). However, ah had other risk factors (heterozygous protein C resistance in one and surgical intervention or trauma in the others), so a causal role of thahdomide was debatable. 

The risk of a surgical site infection (SSI) is determined from both the type of surgery and patient-specific risk factors however, most commonly used classification systems only account for procedure-related risk factors. 

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