Latest Articles
- The changing profile of anesthetic practice: an update for internists
BACKGROUND Internists are commonly consulted to "clear" patients for anesthesia and surgery. Newer anesthetic agents and techniques now extend limits and possibilities beyond what many internists were taught.
OBJECTIVE To update internists on recent changes in anesthetic management and how they affect the preoperative evaluation.
SUMMARY Recent advances in anesthetic management include new monitoring standards, balanced anesthetic technique, new agents, equipment changes, better understanding of human factors, and expanded pain management techniques.
CONCLUSIONS Postoperative care will likely assume increasing importance in determining anesthesia-related morbidity and mortality. For this reason, increased interaction and cooperation between surgeons, internists, and anesthesiologists are needed.
- The role of multiple risk factors in cardiovascular morbidity and mortality
BACKGROUND Cardiovascular disease remains the leading cause of death in the United States.
OBJECTIVE To identify important modifiable cardiovascular risk factors and appropriate interventions.
DISCUSSION The three most important modifiable risk factors are hypertension, cigarette smoking, and dyslipidemia. Systolic hypertension poses a greater risk than diastolic, but the prognostic significance of diastolic blood pressure may have been underestimated. When a smoker quits, the cardiovascular risk soon approaches that of the nonsmoker. Cardiovascular risk increases progressively with elevations of the serum total cholesterol level above 200 mg/dL. Recently identified risk factors include hyperinsulinemia and left ventricular hypertrophy.
CONCLUSION Each patient deserves an evaluation of cardiovascular risk followed by education about and therapy for those risk factors that can be changed. When more than one risk factor is present, as is often the case, the increase in risk may be synergistic rather than additive.
- Theophylline in the ambulatory treatment of chronic obstructive lung disease: resolving a controversy
BACKGROUND Recent reports of a high frequency of theophylline toxicity, which usually occurs at theophylline blood levels >20 μg/mL, coupled with the recent addition of metered-dose, inhaled anticholinergics to the beta-2 agonist inhalers already available for treatment of chronic obstructive pulmonary disease, has led some authors to suggest that theophylline should no longer be used in the ambulatory management of this disease.
OBJECTIVE The author suggests an alternate approach to theophylline dosing as a means of resolving the current controversy.
SUMMARY Because of the log-linear relationship between bronchodilation and blood level, little bronchodilator efficacy is lost by using a target therapeutic theophylline blood level of 10 ± 2 μg/mL. This target provides a greater range between therapeutic and toxic blood levels than the 17 ± 2 μg/mL therapeutic target blood level that has also been recommended.
CONCLUSIONS Because theophylline has a different mode of action than the sympathomimetic or anticholinergic drugs, it continues to have a useful place in the ambulatory management of chronic obstructive pulmonary disease.