The High-risk Surgical Patient

Description

It is well known that certain diseases and patient conditions are associated with increased perioperative risk. The aim of this book is to define and identify the clinical factors that warrant a broader and  more detailed assessment of pre-operative surgical risk in difficult and unusual clinical settings. One of the sections is dedicated to the main pathway of peri- and post-surgical critical care based on the  patient-specific deterioration risk and associated diseases; here, a panel of selected  experts describes the correct patient-oriented pathways for complex or unscheduled surgical operations in order to reduce the operative risk. In addition, the book describes the latest trends in minimally invasive surgical techniques that are associated with peri- and post-operative risk reduction,  and provides  an overview of recent advances in surgical simulation, focusing on  perspectives in surgical research to increase patient safety. Guidance is also provided on extracorporeal membrane oxygenation (ECMO), Left Ventricular Assist Devices (LVADs), and   their management in patients requiring emergency surgery.  The book will help surgical trainees recognize cases with  the highest surgical risk and identify the most common complications at an early stage. Foreword Preface Contents Contributors Part I: Identification and Characterisation of High-Risk Surgical Patients 1: Defining the High-Risk Surgical Patient References 2: The Frail Patient in the Operating Room: Practical Steps to Reduce the Operative Risk 2.1 Introduction 2.2 Frailty and Surgery: The Game Changer 2.3 Frail Assessment Tools: In Need for Feasibility to Expand the Recognition 2.4 Frailty, Ageing, and the High-Risk Surgical Patient 2.5 Frailty and Surgery in Elderly Patients: The New Comprehensive Paradigm 2.6 How to Improve the Outcomes of the Older Frail Surgical Patients 2.7 Physical Performance 2.8 Nutrition 2.9 Mental Health and Cognitive Dysfunction 2.10 Solid Organ Transplant Surgery and Frailty: Times Are (a)Changing 2.11 Conclusions References 3: The High Risk Surgical Patients: The Pathophysiologic Perspective 3.1 Anemia 3.2 Pathophysiology of Oxygen Debt 3.3 Conclusions References 4: Monitoring and Interpretation of Vital Signs in the High-Risk Surgical Patients 4.1 Heart Rate 4.1.1 Heart Rate and Circulating Blood Volume 4.1.2 Heart Rate and Increased O2 Demand 4.2 Blood Pressure 4.3 Respiratory Rate 4.4 Body Temperature 4.4.1 Effector Organs Response to Increased Body Temperature 4.4.2 Effector Organ Responses to Decreased Body Temperature 4.4.3 Effects of Body Temperature Changes 4.5 Pulse Oximetry References 5: Evaluation and Critical Care Management of the Burn Patient 5.1 Introduction 5.2 Burn Category 5.3 Burn Extention Measurement 5.4 Pathophysiology of Wound Healing [2–5] 5.5 Shock: Ebb and Flow Phase 5.6 Sepsis 5.7 Inhalation Injury 5.8 First-Line Treatment 5.9 On Admittance 5.9.1 Primary Survey 5.9.2 Secondary Survey 5.10 Resuscitation from Burn Shock 5.10.1 Standard Monitoring Criteria 5.11 Nutrition [5, 8, 9, 12] 5.12 Wound Covering [4, 5, 8–10, 12] 5.13 Surgical Management 5.14 Criteria for Transfer a Patient to a Burn Centre [8, 9] 5.15 Clinical Scenario 5.15.1 Put the Actions in Order 5.15.2 Choose the Most Correct Answer 5.15.2.1 Choose the Correct Answer 5.15.3 Choose the Correct Solution References 6: Acid–Base Abnormalities in Surgical Patients Admitted to Intensive Care Unit 6.1 Introduction 6.2 Metabolic Acid–Base Disorders in Surgical Patients 6.2.1 Metabolic Acidosis 6.2.1.1 Clinical Manifestations Lactic Acidosis Lactate Metabolism Mechanisms of Anaerobic Lactate Production Mechanisms of Aerobic Lactate Production Treatment of Lactic Acidosis Unmeasured Anion Acidosis Ketoacidosis Post-surgical Euglycemic Diabetic Ketoacidosis Hyperchloremic Metabolic Acidosis Situations More Frequently Associated with Hyperchloremic Acidosis in the Postoperative Period Deleterious Effects of Hyperchloremic Acidosis 6.2.2 Metabolic Alkalosis 6.2.2.1 Pathophysiology Generation of Metabolic Alkalosis Maintenance of Metabolic Alkalosis 6.2.2.2 Causes of Metabolic Alkalosis Response of Metabolic Alkalosis to Chloride Administration 6.2.2.3 Clinical Manifestations 6.2.2.4 Treatment 6.2.3 Complex Metabolic Disorders 6.3 Respiratory Acid–Base Disorders 6.3.1 Physiopathology 6.3.2 Clinical Manifestations 6.3.3 Treatment References 7: Pre-operative Cardiovascular Risk Assessment in Non-cardiac General Surgery 7.1 Introduction 7.2 The Changing Landscape of Perioperative Evaluation 7.3 Pathophysiological Basis of Risk Stratification 7.4 Clinical Evaluation 7.4.1 Heart Failure (HF) 7.4.2 Coronary Artery Disease 7.4.3 Valvular Heart Disease 7.4.4 Arrhythmias 7.4.5 Pulmonary Hypertension 7.5 Determination of Functional Capacity 7.6 Intervention-Related Factors 7.6.1 Type of Surgery 7.6.2 Type of Anaesthesia 7.7 Complementary Tests for Cardiovascular Risk Assessment 7.7.1 Echocardiography 7.7.2 Non-invasive Imaging Test: Stress Test and Coronary Computed Tomography (CCT) 7.7.3 Invasive Coronary Angiography 7.7.4 Biomarkers 7.8 Management of Perioperative Antithrombotic Therapy 7.8.1 Antiplatelet Therapy 7.8.2 Anticoagulant Therapy 7.9 Practical Flow Chart References 8: Post-operative Liver Failure and Pre-operative Evaluation of the Risk of Surgery in Patients with Liver Disease 8.1 Introduction 8.2 Definition of POLF 8.3 Pre-operative Risk Factors 8.3.1 Patient-Related Risk Factors 8.3.2 Surgery-Related Risk Factors 8.4 Pre-operative Evaluations 8.4.1 Volumetric Evaluation 8.4.2 Biochemical Assessment of Liver Function 8.4.3 Liver Functional Assessment 8.5 Conclusions References 9: Radiology for Surgeons: Improving the Diagnostic Accuracy in the High-Risk Surgical Patient References 10: Oncologic Emergencies in Patients Undergoing Major Surgery 10.1 Introduction 10.2 Febrile Neutropenia (FN) 10.3 Venous Thromboembolism (VTE) 10.4 Superior Vena Cava Syndrome (SVCS) 10.5 Tumor Lysis Syndrome (TLS) 10.6 Hypercalcemia of Malignancy 10.7 Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) 10.8 Neuro-Oncologic Emergencies 10.8.1 Neoplastic Epidural Spinal Cord Compression (ESCC) 10.8.2 Chemotherapy-Induced Myasthenic Crisis (MC) References 11: The High-Risk Pediatric Surgical Patient 11.1 Introduction 11.2 Anesthesia-Related Morbidity and Mortality 11.2.1 Perioperative Morbidity 11.2.2 Perioperative Mortality 11.2.3 Post-operative Adverse Events and Post-arrest Mortality 11.3 Defining the Risk 11.4 The High-Risk Patient 11.4.1 The Premature, the Neonate, and the Infant 11.4.2 The Patient with Congenital Heart Disease and Complex Syndromes 11.4.2.1 The High-Risk Lesions Single Ventricle Physiology Patients with Williams–Beuren Syndrome (WS) and Non-WS Elastin Arteriopathy Patients with Cardiomyopathy (Hypertrophic, Restrictive, and Dilated) Patients with Ventricular Assist Devices Association with Complex Genetic Syndromes 11.4.3 The Patient with Pulmonary Hypertension 11.4.4 The Patient with Respiratory or Airway Disease 11.5 Conclusions References 12: Difficult Intubation in the High-Risk Surgical Patient 12.1 Introduction 12.2 Airway Management 12.3 Airway Assessment 12.4 Techniques and Devices for Airway Management 12.4.1 Mask Ventilation 12.4.2 Tracheal Intubation 12.4.3 Alternative Airway Techniques and Devices 12.4.3.1 Video Laryngoscopy 12.4.3.2 Fiber-Optic Bronchoscopy 12.4.3.3 Supraglottic Airway Devices 12.4.3.4 Surgical Airway Surgical Technique Cricothyrotomy Vs. Tracheostomy 12.5 Approach to the Difficult Airway 12.5.1 Anticipated Difficult Airway 12.5.2 Unanticipated Difficult Intubation with Easy Mask Ventilation 12.5.3 Unanticipated Difficult Intubation with Difficult Mask Ventilation 12.5.4 Muscle Relaxation 12.5.5 Extubation of the Difficult Airway Patient 12.6 Difficult Airway and the High-Risk Patient 12.6.1 Critically Ill Patients 12.6.2 The Trauma Patient 12.6.3 Morbid Obese Patients 12.7 Future Considerations References 13: Recognition and Early Management of Sepsis in Frail Patients 13.1 Sepsis Biomarkers 13.2 Principles of Therapy of Surgical Infections in Sepsis References 14: Preoperative Evaluation for Complex Pulmonary Surgery: How Can We Balance the Risk? 14.1 Patient Preoperative Assessment 14.2 Cardiological Status Evaluation 14.3 Respiratory Functional Status Evaluation 14.4 Surgical Approach and Analgesic Therapy 14.5 Physical Therapy and Rehabilitation References 15: Assessment of Pre-operative Risk in Complex Cardiac Surgery 15.1 Introduction 15.2 Model Development, Performance Evaluation, and Validation of Risk Scores 15.3 Assessing Risk Stratification in Cardiac Surgery 15.4 Analysis of Risk Scores in Cardiac Surgery 15.5 Conclusion References Part II: Strategies to Improve the Outcome in High-Risk Surgical Patients 16: Patient Safety in Surgery: Strategies to Achieve the Best Outcome in the High-Risk Surgical Patient 16.1 Complexity and the Divided Brain 16.2 Patient Safety and High-Risk Surgery References 17: Strategies to Reduce the Risk of Post-operative Pulmonary Complications 17.1 Introduction 17.2 Predicting PPCs 17.2.1 Risk Prediction Models 17.3 Pre-operative Strategies 17.3.1 Optimisation of Co-morbidities 17.3.2 Prehabilitation 17.3.3 Smoking Cessation 17.4 Intra-operative Strategies 17.4.1 General or Regional Anaesthesia 17.4.2 Protective Ventilation 17.4.3 Oxygen Titration 17.4.4 Airway Management and Use of Neuromuscular Blocking Drugs 17.4.5 Emergence from Anaesthesia 17.4.5.1 Drug Choice and Reversal Strategy for Neuromuscular Blocking Drugs 17.5 Post-operative Strategies 17.5.1 Post-operative Respiratory Support 17.5.1.1 Continuous Positive Airway Pressure 17.5.1.2 Nasal High Flow Therapy (NHFT) 17.5.2 Analgesia Optimisation 17.5.3 Other Post-operative Measures 17.5.3.1 Physiotherapy, Mobilisation and Oral Hygiene Bundles 17.5.3.2 Nasogastric Tubes References 18: Prevention and Management of Perioperative Neurological Complications in High-Risk Surgical Patients 18.1 Central Nervous System Vascular Disease 18.2 Carotid Stenosis 18.3 Spinal Cord Ischaemia (SCI) 18.4 Cognitive Impairment: Dementia, Delirium, POCD 18.4.1 Dementia 18.4.2 Delirium 18.4.3 Postoperative Cognitive Decline (POCD) 18.5 Other Neurodegenerative Diseases (Parkinson’s Disease) 18.6 Epilepsy 18.7 Multiple Sclerosis 18.8 Myasthenia Gravis and Other Neuromuscular Diseases 18.9 Headache 18.10 Visual Loss 18.11 Conclusions References 19: Acute Aortic Syndrome (AAS): A High-Risk Missed Diagnosis in the Emergency Department 19.1 Introduction 19.2 AAS Epidemiology 19.3 AAS Clinical Presentation 19.4 AAS Etiopathogenesis 19.4.1 Changes of the Aortic Wall with Aging 19.5 AAS: Peculiar Features 19.5.1 Different Manifestations of AAS 19.5.1.1 Aortic Dissection 19.5.1.2 AD Epidemiology and Natural History 19.5.1.3 Etiology 19.5.1.4 AD Clinical Presentation 19.5.1.5 AD Classification 19.5.2 Intramural Hematoma (IMH) 19.5.2.1 IMH 19.5.2.2 IMH Etiopathogenesis 19.5.2.3 IMH Clinical Presentation and Natural History 19.5.3 Penetrating Aortic Ulcer (PAU) 19.5.3.1 Definition 19.5.3.2 Natural History 19.5.3.3 PAU Clinical Presentation 19.6 AAS Diagnosis 19.6.1 AAS Radiological Findings 19.6.1.1 CT 19.6.1.2 Transthoracic Echocardiography (TTE) 19.6.1.3 Transesophageal Echocardiography (TEE) 19.6.1.4 Magnetic Resonance Imaging (MRI) 19.6.1.5 Specific Imaging Findings for Every Particular Kind of AAS 19.7 Treatment 19.7.1 Medical Management of AAS 19.7.2 AD 19.7.2.1 Type A Aortic Dissection 19.7.2.2 Type B Aortic Dissections 19.7.3 IMH 19.7.4 PAU 19.8 Follow-Up After AAS and Prognosis References 20: Trans-Catheter Interventional Treatment of Structural Heart Diseases 20.1 Introduction 20.2 Transcatheter Aortic Valve Implantation 20.3 From Prohibitive Surgical Risk Patient to Low Risk 20.4 Patients’ Selection for TAVI 20.5 Different TAVI System 20.5.1 Edwards Lifesciences-SAPIEN 20.5.2 Medtronic CoreValve 20.5.3 Abbott St. Jude Portico 20.5.4 Boston Acurate Neo 20.6 Alternative Access for TAVI Implantation 20.6.1 Subclavian/Axillary 20.7 Direct-Aortic 20.7.1 Trans-Carotid 20.7.2 Trans-Apical 20.7.3 Trans-Caval 20.8 Trans-Catheter Mitral Procedures 20.8.1 Transcatheter Edge-to-Edge Mitral Valve Repair 20.8.2 MitraClip™ System 20.8.3 PASCAL™ Transcatheter Valve Repair System 20.8.4 Transcatheter Mitral Valve Chordal Repair 20.8.5 NeoChord™ 20.8.6 HARPOON™ Mitral Valve Repair System 20.8.7 Indirect Mitral Annuloplasty 20.9 Carillon™ Mitral Contour System 20.9.1 Direct Mitral Annuloplasty 20.9.2 Transcatheter Mitral Valve Implantation 20.9.3 Tiara 20.9.4 Evoque 20.9.5 Tendyne 20.9.6 Intrepid 20.10 Transcatheter Tricuspid Valve Interventions 20.10.1 TriClip 20.10.2 Pascal TV Repair System 20.10.3 Cardioband Annuloplasty System References 21: New Technologies in Urologic Surgery: Robotic and Minimally Invasive Procedures 21.1 Introduction 21.2 Minimally Invasive Surgery in Urology 21.3 Minimally Invasive Surgery for the Management of Renal Cancer in High-Risk Surgical Patients 21.4 Minimally Invasive Surgery for the Management of Prostate Cancer in High-Risk Surgical Patients 21.5 Minimally Invasive Surgery for the Management of Bladder Cancer in High-Risk Surgical Patients 21.6 Minimally Invasive Surgery for the Management of Benign Disease in High-Risk Surgical Patients 21.7 Conclusion References 22: New Trends in Vascular Surgery: Less Open and More Endovascular Procedures 22.1 Introduction 22.2 Thoracic Aorta and Aortic Arch Pathologies 22.2.1 Abdominal and Thoracoabdominal Aorta Aneurysms 22.2.2 Peripheral Artery Disease (PAD) and Acute Limb Ischemia 22.2.3 Visceral Arteries 22.2.4 Carotid Stenosis 22.3 Conclusions References 23: New Trends in Laparoscopic Procedures in the Emergency Abdominal Surgery 23.1 Laparoscopy for Abdominal Emergencies 23.2 Acute Appendicitis 23.3 Acute Cholecystitis 23.4 Perforated Peptidic Ulcer 23.5 Acute Diverticulitis 23.6 Small Bowel Obstruction 23.7 Ventral Hernias 23.8 Incarcerated/Strangulated Hernias 23.9 Abdominal Trauma 23.10 Contraindication References 24: New Trends in the Treatment of Severe Acute Pancreatitis 24.1 Introduction 24.2 Presentation, Diagnosis, and Etiology 24.3 Assessment of Severity 24.4 Management Goals in Severe Acute Pancreatitis 24.5 General Principles in the ICU Care 24.6 Antibiotics 24.7 Enteral Feeding 24.8 Surgical and Endoscopic Interventions 24.8.1 Biliary Pancreatitis 24.8.2 Infected Pancreatic Necrosis 24.8.3 Other Pancreatic Complications 24.8.4 Abdominal Compartment Syndrome 24.8.5 Colon Perforation 24.8.6 Gangrenous Cholecystitis 24.9 Outcome References 25: Point-of-Care Ultrasound in the Preoperative Evaluation of the High-Risk Surgical Patient Requiring Urgent Non-cardiac Surgery 25.1 Introduction 25.2 The Clinical Evaluation by PoCUS 25.3 Gastric Content 25.4 Identification/Management of the Difficult Airway 25.5 Assessment for Causes of Respiratory Distress 25.6 Cardiovascular Assessment 25.7 Abdominal Evaluation 25.8 Conclusions References 26: Perioperative Monitoring in High-Risk Surgical Patients: A Step-by-Step Approach 26.1 Why Perioperative Monitoring Matters 26.2 First Step: Identify a High-Risk Patient 26.3 Second Step: Decide What to Monitor 26.4 Third Step: Choose a Monitoring Device and Create a Protocol for Use 26.5 Fourth Step: Continue Monitoring a Postoperative Patient 26.6 Conclusions References 27: High-Risk Pancreatic Anastomosis: Prediction, Mitigation, and Management of Postoperative Pancreatic Fistula 27.1 Introduction 27.2 Prediction and Prevention of Pancreatic Fistula—Preoperative Setting 27.3 Mitigation Strategies in High-Risk Anastomoses—Intraoperative Setting 27.4 Management of Pancreatic Fistula—Postoperative Setting 27.5 Conclusions References Part III: New Trends in Acute Care of High-Risk Surgical Patients 28: Anesthesia in High-Risk Surgical Patients with Uncommon Disease 28.1 Introduction 28.2 Neurologic [2] 28.3 Ears, Nose, and Throat (ENT) [16] 28.4 Cardiovascular [26] 28.5 Respiratory [49] 28.6 Hepatic [57] 28.7 Renal [81] 28.7.1 Glomerular Diseases 28.7.2 Tubular Diseases 28.8 Muscular [103] 28.8.1 Skin [113] 28.9 Hematologic [147] 28.10 Endocrine [150] 28.11 Mitochondrial [174] 28.12 Conclusions References 29: Perioperative Management and Surgical Challenges in Patients with Spinal Cord Dysfunction 29.1 Introduction 29.2 Anesthesiologic Challenges in People with Spinal Cord Injury/Disorder 29.3 Autonomic Dysreflexia 29.4 Neurogenic Bowel Dysfunction 29.5 Neurogenic Bladder 29.6 Infective Complications 29.7 Antithrombotic Prophylaxis 29.8 Pressure Ulcers 29.9 Problems Related to the Musculoskeletal System 29.10 Pregnancy 29.11 Clinical Case 29.12 Conclusions References 30: Non-invasive Ventilation in the High-Risk Surgical Patients 30.1 Introduction 30.1.1 Acute Respiratory Complications 30.1.2 The Formation of Atelectasis Is Favored by the Following Pathophysiological Elements 30.1.2.1 Direct Compression on the Lung Parenchyma by the Diaphragm 30.1.2.2 Direct Injuries 30.1.2.3 Postoperative Pain 30.1.2.4 Respiratory Muscles and Surgery 30.1.2.5 Bariatric Surgery 30.1.2.6 Frailty 30.1.2.7 Aetiology 30.2 Risk Factors for Extubation Failure 30.3 Non-invasive Ventilation 30.4 The fan: Constitutive Elements and Operating Principles 30.4.1 Patient-Self-Inflicted Lung Injury (P-SILI) Further Reading 31: Extracorporeal Life Support (ECLS) for Critically Ill Patients in the Emergency Department 31.1 Introduction 31.1.1 The Role of ECLS in the Emergency Department 31.2 Basics of ECLS 31.2.1 General Features 31.2.2 Veno-Arterial ECMO (VA ECMO) 31.2.3 Veno-Venous ECMO (VV ECMO) 31.3 Cardiocirculatory Failure 31.3.1 Cardiogenic Shock: Definition and Pathophysiology 31.3.2 Cardiogenic Shock: Etiologies and ECLS Indications 31.3.3 Right Heart Failure and Pulmonary Embolism 31.3.4 Refractory Cardiac Arrest 31.4 Respiratory Failure 31.5 Conclusions and Future Directions References 32: Perioperative Management of Severe Bleeding and Coagulopathy in High-Risk Surgical Patients 32.1 Introduction 32.2 Perioperative Bleeding 32.3 Pathomechanisms of Perioperative Bleeding in Major Surgery 32.4 Perioperative Coagulation Monitoring 32.4.1 Viscoelastic Hemostatic Assays (VHA) 32.5 Procoagulant Interventions According to the ESAIC Guidelines [1] 32.6 Allogeneic Blood Transfusions According to the ESAIC Guidelines [1] 32.7 Facilitating PBM Guidelines Implementation References 33: Endovascular Management of Post-Operative Bleeding 33.1 Introduction 33.2 Diagnostic 33.3 The Role of Interventional Radiology (IR) 33.4 After Liver Surgery 33.5 After Pancreatic Surgery 33.6 After Nephrectomy 33.7 After Liver Transplantation 33.8 After Digestive Tract Surgery References 34: Evaluation and Management of Malnutrition in the High-Risk Surgical Patient 34.1 Introduction 34.2 Nutritional Assessment 34.2.1 Medical History 34.2.2 Clinical Examination 34.2.3 Biochemical Analyses 34.2.4 Nutritional Risk Screening and Assessment Tests 34.3 Problems During the Perioperative Period 34.4 Energy Requirements 34.5 Nutritional Therapy 34.5.1 Oral Nutrition 34.5.2 Nutritional Therapy 34.5.2.1 Enteral Versus Parenteral Nutrition 34.6 The Role of Nutrients in Recovery 34.7 Monitoring References 35: The Role of Selective Drug Therapy in Reducing Mortality in the High-risk Surgical Patients (Tranexamic Acid, Selective Bowel Tract Decontamination, Levosimendan, Beta-blockers, Insulin, Aprotinin, and Statins) 35.1 Introduction 35.2 Drugs Increasing Survival 35.2.1 Tranexamic Acid 35.2.2 Levosimendan 35.2.3 Selective Decontamination of the Digestive Tract 35.3 Drugs Increasing Mortality 35.3.1 Beta-blockers 35.3.2 Insulin Glycemic Control 35.3.3 Statins 35.3.4 Aprotinin 35.4 Other Drugs 35.5 Conclusions References 36: Strategies for Advanced Mechanical Circulatory Support in Refractory Cardiogenic Shock 36.1 Definition of Cardiogenic Shock 36.2 Advanced Mechanical Circulatory Support: Strategies in Refractory Cardiogenic Shock 36.2.1 Advanced Mechanical Circulatory Support as a Bridge to Recovery 36.2.2 Advanced Mechanical Circulatory Support as a Bridge to Heart Transplantation 36.2.3 Advanced Mechanical Circulatory Support as a Bridge to Decision or Bridge to Bridge 36.2.4 Advanced Mechanical Circulatory Support as Permanent Therapy 36.3 Choice of the Device for Circulatory Support 36.3.1 Profound Refractory Cardiogenic Shock or Cardiac Arrest (Risk of Impending Death) 36.3.2 Progressive Refractory Cardiogenic Shock 36.4 Advanced Mechanical Circulatory Support in Refractory Cardiogenic Shock: Clinical Scenarios 36.4.1 De Novo Acute Scenarios 36.4.1.1 Fulminant Myocarditis 36.4.1.2 Acute Myocardial Infarction 36.4.1.3 Mechanical Complications of Myocardial Infarction 36.4.1.4 Massive Pulmonary Embolism Complicated by Refractory Cardiogenic Shock 36.4.2 Decompensation of Chronic Cardiomyopathies 36.4.2.1 Advanced Mechanical Circulatory Support in Refractory Cardiogenic Shock Caused by Chronic Cardiomyopathies References 37: Evaluation and Management of Patients with Left Ventricular Assist Device (LVAD) Requiring Noncardiac SurgicalProcedures 37.1 Introduction 37.2 Left Ventricular Assistance Device Models 37.3 Principles of Continuous Flow Left Ventricular Assistance Device Physiology 37.3.1 Pump Parameters 37.3.2 Monitoring Pump Parameters 37.4 Acquired Coagulopathy and Anticoagulation 37.5 Left Ventricular Assistance Device-Associated Complications 37.5.1 Infections 37.5.2 Bleedings 37.5.3 Thrombosis 37.6 Incidence of Noncardiac Surgical Procedures in Patients with Continuous Flow Left Ventricular Assistance Device 37.6.1 Emergency Surgery, Laparoscopic Surgery 37.6.2 Laparoscopy in Left Ventricular Assistance Device Patient 37.7 Perioperative Evaluation 37.7.1 Past Medical History and Organ Function 37.7.2 Pharmacotherapy 37.7.3 Imaging 37.7.4 Laboratory and Electrocardiography 37.7.5 Left Ventricular Assistance Device and Implantable Cardioverter-Defibrillator Information 37.8 Anesthetic Considerations 37.8.1 Induction of General Anesthesia 37.8.1.1 Antibiotics 37.8.1.2 Patients Positioning 37.8.2 Intraoperative Monitoring 37.8.3 During Anesthesia 37.8.4 Postoperative Period Management 37.9 Cardiopulmonary Resuscitation References 38: Rescue Surgery and Failure to Rescue 38.1 Introduction 38.2 What Is a Complication? 38.3 Rescue Surgery 38.4 Failure to Rescue References 39: Endoscopic Submucosal Dissection for Early Malignant Epithelial Neoplasms of the Digestive Tract in Frail and Elderly Patients 39.1 Introduction 39.2 Histologic Criteria and Evaluation for Endoscopic Submucosal Dissection 39.3 Therapeutic Strategies and Technical Consideration 39.4 How to Estimate the Depth of Tumor Infiltration 39.5 Conclusions References 40: Advanced Therapeutic Endoscopy for Acute Pancreatic and Biliary Diseases in Frail Patients 40.1 Acute Cholangitis 40.2 Acute Cholecystitis 40.3 Acute Pancreatitis 40.4 Pancreatic Pseudocysts and WOPN 40.5 Postoperative and Traumatic Bile Leaks 40.6 Postoperative Pancreatic Leaks 40.7 Periampullary Duodenal Perforations References 41: Appropriate Perioperative Therapy in Patients with Chronic Heart Failure Undergoing Surgery 41.1 Intraoperative Management 41.2 Perioperative Management of Patients with Chronic Heart Failure 41.3 Direct Consequence of Anaesthesia on Systemic Hemodynamics in Patients with Chronic Heart Failure 41.4 Conclusion References 42: Robot-Assisted Pancreatic Surgery: Safety and Feasibility 42.1 Introduction 42.2 Robotic Pancreaticoduodenectomy (RPD) 42.3 Robotic Distal Pancreatectomy (RDP) with or Without Splenectomy 42.4 Robotic Enucleation (RE) 42.5 Robotic Atypical Resections (RAR) 42.6 Perioperative Management 42.7 Discussion 42.8 Conclusions References 43: Safety of Minimally Invasive Laparoscopic Approach in Major Liver Surgery 43.1 Introduction 43.2 Potential Advantages of Minimally Invasive Liver Surgery 43.3 Current Evidence and Recommendations for LLR 43.4 Key Points for Safe Perioperative Management of Patients Undergoing Minimally Invasive Liver Surgery 43.5 Safe Adoption of Laparoscopic Liver Resections 43.6 Failures of the Minimally Invasive Laparoscopic Approach 43.7 The Robotic Approach 43.8 Integration with the New Technologies References Part IV: Improving Patients’ Safety and Prevention of Major Complications 44: Major Complications in Hepatobiliary and Pancreatic Surgery 44.1 Hepatobiliary Surgery 44.1.1 Hemostatic and Thrombotic Complications During Major Liver Resection 44.1.1.1 Post-hepatectomy Hemorrhage (PHH) 44.1.1.2 Vascular Thrombosis 44.1.2 Bile Leakage 44.1.3 Liver Failure 44.1.3.1 Evaluation of Portal Hypertension (PH) 44.1.3.2 Indication for Artificial Liver 44.1.3.3 Indication for Liver Transplantation (LT) 44.2 Pancreatic Surgery 44.2.1 Pancreatic Fistula (PF) 44.2.2 Delayed Gastric Emptying (DGE) After PD 44.2.3 Post Pancreatectomy Hemorrhage (PPH) 44.2.4 Ischemic Complications 44.2.5 Portal Vein Thrombosis (PVT) 44.2.6 Biliary Complications 44.2.7 Postoperative Acute Pancreatitis (POAP) References 45: Major Complications After Esophageal, Gastric, and Bariatric Surgery 45.1 Esophageal Surgery 45.1.1 Anastomotic Leakage 45.1.2 Conduit Necrosis/Failure 45.1.3 Recurrent Laryngeal Nerve Injury 45.1.4 Chyle Leak 45.2 Gastric Surgery 45.2.1 Anastomotic Leak 45.2.2 Postoperative Bleeding 45.2.3 Postoperative Bowel Obstruction 45.2.4 Duodenal Leak 45.2.5 Postoperative Pancreatic Complications 45.3 Bariatric Surgery 45.3.1 Fistula 45.3.2 Bleeding 45.3.3 Herniation 45.3.4 Anastomotic Stenosis 45.3.5 Gastric Erosion 45.3.6 Intestinal Small Bowel Obstructions References 46: Major Complications of Vascular Surgery 46.1 Graft Thrombosis 46.1.1 Introduction 46.1.2 General Principles 46.1.3 Clinical Presentation 46.1.4 Therapy 46.2 Anastomotic Aneurysms 46.2.1 Incidence and Anatomic Location 46.2.2 Pathogenesis 46.2.2.1 Local Factors Arterial Wall Degeneration Suture Line Disruption Infection and/or Inflammation Technical Errors 46.2.2.2 Systemic Factors Prevention 46.2.3 Pathogenesis Clinical Diagnosis 46.2.4 History and Physical Examination 46.2.5 Imaging 46.2.6 Surgical Treatment 46.2.6.1 Indications for Treatment 46.2.6.2 Femoral Anastomosis 46.2.6.3 Aortic and Iliac Anastomosis 46.2.6.4 Carotid Anastomosis 46.2.7 Outcomes 46.3 Aortoenteric Fistulae 46.3.1 Treatment 46.4 Endovascular Complications 46.4.1 Access Site Complications 46.4.1.1 Groin, Retroperitoneal Hematoma, or Bleeding on Medial Brachial Fascial Compartment 46.4.1.2 Arteriovenous Fistula 46.4.1.3 Pseudoaneurysm (PSA) Thrombosis Nerve Injury 46.4.2 Procedure-Specific Complications 46.4.2.1 Dissection 46.4.2.2 Embolization 46.4.2.3 Perforation 46.5 Graft Infection 46.5.1 Introduction 46.5.2 Epidemiology 46.5.3 Classification 46.5.4 Diagnosis 46.5.5 Treatments and Outcomes: General Principles References 47: Major Complications of Urologic Surgery 47.1 Endoscopic Procedures 47.2 Laparoscopic, Open Surgical Procedures References 48: Major Complications of Thoracic Surgery 48.1 Introduction 48.2 The Aftermath of Surgery 48.2.1 Standard 48.2.2 Recent Developments in Postoperative Management 48.2.3 Enhanced Recovery After Surgery (ERAS) 48.3 Complications 48.3.1 General Considerations 48.3.2 Hemorrhagic complications 48.3.3 Respiratory 48.3.3.1 Bronchial Congestion 48.3.3.2 Pneumonia 48.3.3.3 Acute Respiratory Distress Syndrome (ARDS) 48.3.3.4 Empyema After Pneumonectomy 48.3.4 Surgery 48.3.4.1 Anastomosis 48.3.4.2 Surgical Planning 48.3.4.3 Intersegmental plane 48.3.5 Anesthetic Management 48.3.6 Cardiac Complications 48.3.6.1 Atrial Fibrillation (AF) 48.3.6.2 Acute Coronary Syndrome (ACS) 48.3.7 Chylothorax 48.3.8 Post-pneumonectomy Syndrome 48.3.9 Nerve Lesions 48.3.9.1 Recurrent Nerve Injury 48.3.9.2 Phrenic Nerve Lesion 48.3.9.3 Treatment 48.4 Prevention of Complications 48.5 Conclusions References 49: Major Complications of Cardiac Surgery 49.1 Introduction 49.2 Stroke 49.3 Renal Failure 49.4 Prolonged Ventilation 49.5 Reoperation 49.5.1 Surgical Issues 49.5.2 Dual Antiplatelet Therapy Before Cardiac Surgery 49.6 Deep Sternal Wound Infection/Mediastinitis 49.6.1 Preoperative Prevention 49.6.2 Intraoperative Surgical Prevention 49.6.3 Postoperative Surgical Prevention 49.6.4 Management of Sternal Infections References 50: Major Complications of Abdominal Organ Transplantation Surgery 50.1 Liver Transplantation (LT) 50.1.1 Vascular Complications 50.1.1.1 Hepatic Artery 50.1.1.2 Portal Vein 50.1.1.3 Inferior Vena Cava (IVC) and Hepatic Veins 50.1.2 Biliary Complications (BCs) 50.1.3 Early Graft Dysfunction (EGD) and Primary Non-function (PNF) 50.1.4 Acute Allograft Rejection (AR) 50.2 Kidney Transplantation (KT) 50.2.1 Bleeding 50.2.2 Vascular Complications 50.2.3 Lymphocele 50.2.4 Urological Complications (UC) 50.2.4.1 Ureteral Complications 50.2.5 Rejection 50.2.6 Graft Function 50.3 Pancreas Transplantation (PT) 50.3.1 Surgical Complications 50.3.1.1 Vascular Thrombosis 50.3.1.2 Leak 50.3.1.3 Bleeding 50.3.2 Non-surgical Complications 50.3.2.1 Graft Pancreatitis 50.3.2.2 Delayed Graft Function (DGF) and Primary Non-function (PNF) 50.3.2.3 Rejection (PR) 50.4 Small Bowel Transplantation 50.4.1 Infections 50.4.2 Rejection 50.4.3 Graft Versus Host Disease (GVHD) References 51: Corticosteroid Insufficiency in High-Risk Surgical Patients 51.1 Introduction 51.2 Definition of Corticosteroids Insufficiency (Table 51.1) 51.2.1 Adrenal Insufficiency 51.2.2 Critical Illness-Related Corticosteroids Insufficiency 51.3 Mechanisms for Corticosteroids Insufficiency in the High-Risk Surgical Patient 51.3.1 Predisposing Factors 51.3.2 Drugs-Related Corticosteroids Insufficiency 51.3.3 Ischemic or Hemorrhagic Damage 51.3.4 Inflammation 51.4 Diagnosis of Corticosteroids Insufficiency in the High-risk Surgical Patient 51.4.1 Clinical Symptoms 51.4.2 Laboratory Testing 51.4.2.1 Standard Laboratory Testing 51.4.2.2 Endocrine Testing 51.4.2.3 Inflammatory Biomarkers 51.5 Treatment 51.5.1 Prevention of Perioperative Corticosteroids Insufficiency 51.5.2 General Management 51.5.3 Hormone Replacement Therapy for Adrenal Insufficiency 51.5.4 Corticotherapy for Critical Illness-Related Corticosteroids Insufficiency 51.5.4.1 Trauma 51.5.4.2 Cardiac Surgery 51.5.4.3 Non-cardiac Surgery 51.6 Conclusion References 52: The Rationale Use of Antimicrobials in Septic Surgical Patients 52.1 Introduction 52.2 Choosing the Appropriate Antibiotic 52.2.1 Penetration and Pharmacokinetics 52.2.2 Time-Dependent Killers and Concentration-Dependent Killers 52.2.3 Bacteriostatic Vs Bactericidal 52.2.4 De-Escalation 52.2.5 Dose and Duration 52.3 Antibiotic Stewardship 52.4 Culture 52.5 Surgical Site Infections 52.5.1 Prophylaxis 52.5.2 MRSA 52.5.3 SSI Treatment 52.6 Biofilm 52.6.1 Invasive Fungal Infections References 53: Major Complications of Heart Transplant Surgery 53.1 Introduction 53.2 Primary Graft Failure (PGF) 53.2.1 Risk Factors for PGF 53.2.2 Biomarkers 53.3 Atrial Thrombosis at the Suture Site 53.3.1 Treatment 53.4 Valvular Incompetence for Atrial Wall Distortion 53.4.1 Treatment 53.4.2 Valvular Surgery in Donor’s Hearts Before HT 53.5 Cardiac Tamponade 53.5.1 Diagnosis 53.5.2 Treatment 53.6 Pseudo-Cor-Triatriatum 53.7 Distortion of the Pulmonary Trunk 53.8 Sinoatrial Block and Arrhythmias 53.9 Complications Related to Aortic Anastomosis 53.10 Mediastinitis 53.11 Donor/Recipient Mismatch in Size 53.12 Conclusion References 54: Major Complications of Lung Transplant Surgery 54.1 Introduction 54.2 Primary Graft Dysfunction 54.2.1 Pathophysiology 54.2.2 Therapy 54.3 Bleeding 54.4 Donor–Recipient Size Mismatch 54.5 Ischemia-Reperfusion Injury 54.5.1 Strategies to Prevent IRI 54.6 Bronchial Anastomotic Complications 54.6.1 Risk Factors for Airway Complications 54.6.2 Bronchial Vascularisation 54.7 Vascular Complications 54.7.1 Pulmonary Arterial Obstructions 54.7.1.1 Treatment 54.7.2 Pulmonary Venous Obstruction 54.7.2.1 Diagnosis 54.7.2.2 Treatment 54.8 Conclusions References 55: 3D Printing Technology in Medicine: A Personalised Approach Towards a Safer Surgical Practice 55.1 Role of 3D Printing in Medicine 55.1.1 Surgical Planning 55.1.2 Medical Education and Specialist Training 55.2 Production Workflow 55.2.1 Understanding the Need 55.2.2 Image Acquisition and Processing 55.2.3 3D Printing the Model 55.2.4 Postprocessing and Validation 55.3 3D-Printed Organ Models for Surgical Applications 55.3.1 State of the Art 55.3.2 Design and Fabrication Approaches 55.3.2.1 All-Printed Organ Models 55.3.2.2 Hybrid-Assembling Organ Models 55.4 PRINTMED-3D: The Project 55.4.1 Integrated Platform for Three-Dimensional Medical Technologies: An Innovative Idea 55.4.2 A Revolutionary Approach 55.4.3 General Manufacturing Method 55.4.4 Quantitative and Functional Characterisation 55.5 Models for Specialist Training: Neurosurgery 55.5.1 Mould Design and Manufacturing Approach 55.5.2 Meningioma Resection Simulator 55.6 Models for Surgical Planning: Liver Surgery 55.6.1 Mould Design and Manufacturing Approach 55.6.2 Liver Transplantation Phantom 55.7 Conclusion References 56: Multiorgan Procurement for Transplantation as a Way to Improve Surgical Education 56.1 Multiorgan Procurement as a Learning Opportunity for Surgical Practice 56.2 Multiorgan Procurement: A Challenge in Creating the Trained Surgeon in the Twenty-First century 56.3 Brief History of Multiorgan Donation and Procurement 56.4 Advantages of Training in Organ Procurement as a Basis for General Surgical Practice 56.5 Basic Maneuvers and Logistics During Multiorgan Procurement 56.6 The Split Liver, Living Donor Liver, and Pancreas Procurement: An Advanced Training in Hepatobiliary and Pancreatic Surgery 56.7 Trauma Surgery and Multiorgan Procurement 56.8 Conclusions References 57: From “See One, Do One, Teach One” to Hands-On Simulation and Objective Assessment in Surgical Training 57.1 Introduction 57.2 Methods for Surgical Training 57.2.1 Box Trainer 57.2.2 Virtual Simulators 57.2.3 Virtual Scenarios for Team Training 57.2.4 Augmented Reality 57.2.5 Animal Lab 57.2.6 Cadaver Lab 57.2.7 Preceptoring and Proctoring 57.2.8 Telementoring 57.2.9 Telerobotic Assistance 57.2.10 Online Platforms 57.2.11 Activities Improving Surgical Performance 57.2.12 Non-technical Skills for Surgeons 57.3 Special Topics Regarding Surgical Training 57.3.1 The Role of Minimally Invasive Surgery in Surgical Training 57.3.2 Training Outside the Clinical Environment 57.3.3 Objective Assessment in Surgical Training 57.4 Progressive Surgical Training Model 57.5 Conclusions References 58: New Trends in Surgical Education and Mentoring by Immersive Virtual Reality: An Innovative Tool for Patient’s Safety 58.1 The Shifting Landscape of Surgery Education 58.2 Fundamentals of Immersive Virtual Reality 58.3 Application of IVR in Surgical Education and Planning 58.3.1 IVR in Surgical Education 58.3.2 IVR in Preoperative Planning 58.4 Drawbacks of IVR 58.5 Our Experience Using IVR and Future Directions References 59: Artificial Intelligence in the Management of Difficult Decisions in Surgery and Operating Room Optimization 59.1 Introduction 59.1.1 Supervised Learning 59.1.2 Unsupervised Learning 59.1.3 Reinforcement Learning 59.2 Machine Learning in Medicine 59.2.1 Artificial Neural Networks 59.2.2 Fuzzy Expert Systems 59.2.3 Evolutionary Computation 59.2.4 Hybrid Intelligent Systems 59.3 Intensive Care Units and Operating Room Logistics 59.4 Perioperative Optimization 59.4.1 Preoperative Period 59.4.2 Operating Room Period 59.4.3 Postoperative Period 59.5 Application of AI in the COVID-19 Epidemic 59.6 Limitations and Ethical Implications of Artificial Intelligence 59.7 Future Directions References Part V: Identifying the High-Risk Trauma Patient 60: Trauma Surgeons Training Programs 60.1 From Trauma Surgeon to the Acute Care Surgeon: An Evolving Concept Towards a Paradigm Shift 60.2 Practical Courses Self-assessment Test (Three Questions, Four Answers) References 61: Telemedicine for Prehospital Trauma Care: A Promising Approach 61.1 Telemedicine for Prehospital Trauma Care 61.2 Key Challenges for Telemedicine in Acute Trauma Care 61.3 Telemedicine in Acute Trauma Care 61.3.1 Telemedical Assistance 61.3.2 Telemedical Prenotification and Digital Medical Direction 61.4 Future Technology Innovations in Prehospital Trauma Care 61.4.1 Mobile Robotic Arm for Prehospital Ultrasound 61.4.2 Aerial Systems and Mobile Applications for Resuscitation 61.5 Conclusion References 62: New Trends in Critical Care Assessment and Management of the Trauma Patient 62.1 Introduction 62.2 Resuscitation Techniques 62.2.1 Crystalloid Resuscitation 62.2.2 Permissive Hypotension 62.2.3 Damage Control Resuscitation 62.3 Product Utilization 62.3.1 Component Therapy vs. Whole Blood 62.3.2 Direct Peritoneal Resuscitation 62.4 Guiding Resuscitation 62.4.1 Point-of-Care Ultrasound: FREE/FATE 62.4.2 Damage Control Surgery 62.5 Conclusion References 63: Potentially Preventable Trauma Deaths: A Challenge for Trauma Care Systems 63.1 Introduction 63.1.1 Definition of Preventable Trauma Deaths (PTDs) 63.2 The Burden of the Problem 63.3 How to Reduce Preventable Trauma Deaths to Zero Self-assessment Test References 64: Updates in the Management of Complex Pancreatic Trauma 64.1 Introduction 64.2 Presentation and Diagnosis 64.3 Assessment of Severity 64.4 Management of Pancreatic Injuries 64.5 Missed Pancreatic Injuries 64.6 Outcome and Postoperative Complications 64.7 Recent Guidelines References 65: Updates in the Management of Complex Liver Trauma 65.1 Introduction 65.2 Liver Trauma Classification 65.3 Management Strategies 65.4 Non-operative Management of Liver Injury 65.5 Requirements of NOM in Severe Injuries 65.6 Complications of NOM 65.7 Extension of NOM 65.8 Follow-Up References 66: Updates in the Management of Complex Renal Trauma 66.1 Introduction 66.2 Aetiology 66.3 Anatomy 66.4 Assessment 66.5 Team Brief/Handover 66.6 Primary Survey 66.7 History 66.8 Haematuria 66.9 Laboratory Tests 66.10 Radiological Investigations 66.11 Grading 66.12 Management 66.13 Conservative Management 66.14 Angiography and Embolisation 66.15 Iatrogenic Renal Vascular Injury 66.16 Indications for Surgery 66.17 Intraoperative Intravenous Pyelography (IVP) 66.18 Surgical Technique 66.19 Complications 66.20 Urinary Extravasation 66.21 Delayed Bleeding 66.22 Decreased Function 66.23 Hypertension References 67: Updates in the Management of Complex Chest Trauma 67.1 Introduction 67.2 Pulmonary Parenchyma and Airway-Related Injuries 67.2.1 Pulmonary Injuries 67.2.1.1 Pulmonary Contusions 67.2.1.2 Pulmonary Lacerations 67.2.2 Airway-Related Injuries 67.3 Chest Wall Injuries 67.3.1 Classification 67.3.2 Diagnostics 67.3.3 Indication and Contraindication for Osteosynthesis of the Ribs 67.3.4 Surgical Approaches References 68: Updates in the Management of Complex Cardiac Injuries 68.1 Introduction 68.2 A Brief History 68.3 Incidence 68.4 Initial Management and Assessment 68.5 Sternotomy, Thoracotomy and Pericardial Interventions 68.6 Adjuncts and Tricks 68.7 Mechanical Circulatory Support 68.8 Operative Repair of Specific Injuries 68.8.1 Laceration/Rupture 68.8.2 Coronary Artery 68.8.3 Valve Injury 68.8.4 Septal Defects 68.8.5 Retained Cardiac Missiles 68.8.6 Impalement Injuries 68.8.7 Surgery for Injuries not Directly Involving the Heart 68.8.8 Pericardium 68.8.9 Follow Up 68.9 Conclusions References 69: The Ongoing Dilemma of Thoracoabdominal Injuries: Which Cavity and When? 69.1 Introduction 69.2 Definition, Perspective, Our Experience 69.3 The Dilemma: Which Cavity and When. The Rational for Surgical Approaches 69.4 Conclusions References 70: Subclavian Vessel Injuries: An Anatomic and Surgical Challenge to the Surgeon 70.1 Introduction 70.2 Historical Perspective and Incidence 70.3 Anatomy 70.4 Incidence 70.5 Clinical Presentation 70.6 Diagnosis 70.7 Surgical Management 70.8 Morbidity 70.9 Outcomes and Mortality 70.10 Conclusions References 71: Management of Complex Laryngotracheal Injuries: A Challenging Surgical Emergency 71.1 Introduction 71.2 Aetiology 71.3 Pathophysiology 71.3.1 Blunt Neck Trauma 71.3.2 Penetrating Neck Trauma 71.4 History and Physical Examination Findings 71.5 Evaluation 71.5.1 Flexible Laryngoscopy 71.5.2 Imaging Studies 71.5.3 Esophagoscopy 71.6 Anaesthesia in Laryngotracheal Trauma 71.7 Protocol for Different Grades of Injury 71.7.1 Grade I and II 71.7.2 Grade III 71.7.3 Grade IV 71.7.4 Grade V 71.8 Thoracic Trachea and Bronchial Injury 71.9 Esophageal Injury 71.10 Laryngotracheal Injury with Vascular Injury 71.11 Long-Term Complications of Laryngotracheal Trauma References 72: Complex Duodenal Injuries 72.1 Surgical Anatomy 72.2 Epidemiology 72.3 Clinical Presentation 72.4 Imaging Studies 72.5 Laboratory Studies 72.6 Nonoperative Management 72.7 Operative Management 72.7.1 Duodenal Wall Hematomas 72.7.2 Exposure of Duodenal Injuries 72.7.3 Management of Minor or Moderately Severe Duodenal Injuries 72.8 Management of Severe Duodenal Injuries 72.9 Outcomes References 73: Abdominal and Peripheral Vascular Injuries: Critical Decisions in Trauma 73.1 Abdominal 73.1.1 Introduction 73.1.2 Epidemiology 73.1.3 Pathophysiology 73.1.3.1 Blunt Trauma 73.1.3.2 Penetrating Trauma 73.1.4 Clinical Presentation and Diagnosis 73.1.5 Treatment 73.1.5.1 Prehospital Resuscitation 73.1.5.2 Emergency Department Resuscitation 73.1.5.3 Options for Management of Injuries to Abdominal Vessels: Non-Operative Management 73.1.5.4 Options for Management of Injuries to Abdominal Vessels: Endovascular Management 73.1.5.5 Options for Management of Injuries to Abdominal Vessels: Operative Management 73.1.6 Summary 73.2 Peripheral 73.2.1 Introduction 73.2.2 Epidemiology 73.2.3 Pathophysiology 73.2.4 Clinical Presentation and Diagnosis 73.2.4.1 Hemorrhagic Signs 73.2.4.2 Ischemic Signs 73.2.4.3 Hidden and in Development Clinical Pictures 73.2.4.4 Doppler Ultrasound Scan 73.2.4.5 CT Angiogram 73.2.4.6 Arteriography 73.2.5 Treatment 73.2.5.1 Minor Arterial Trauma 73.2.5.2 Major Arterial Trauma 73.2.5.3 Methods of Arterial Repair 73.2.5.4 Role of Fasciotomy 73.2.6 Summary References 74: Updates in the Management of Complex Craniofacial Injuries 74.1 Definition and Epidemiology 74.1.1 Scoring Systems 74.2 Establishing the Priorities: Life-Sight Saving Injuries 74.2.1 Airways and Breathing 74.2.2 Circulation 74.2.3 Eyes 74.2.4 Treatment of Life-Sight Saving Injuries 74.2.5 Imaging and Diagnostic Tools 74.3 Associated Injuries 74.3.1 Traumatic Brain Injury 74.3.2 Cervical Spine Injury 74.3.3 Others 74.4 Updates in Surgical Treatment 74.4.1 Timing of Definitive Treatment 74.4.2 Intraoperative Airways Management 74.4.3 General Principle, Surgical Approaches, and Sequencing 74.5 Innovations and Technology 74.5.1 CAS in Acute Care Setting 74.5.2 Secondary Reconstruction 74.6 Multidisciplinary Management of Facial and Skull Base Injuries 74.6.1 Diagnosis and Preoperative Management 74.6.2 Treatment Indications 74.6.3 Surgical Technique 74.6.4 Postoperative Management 74.7 Special Part: Gunshot Injuries 74.7.1 Definition and Epidemiology 74.7.2 General Management and Priorities 74.7.3 Timing and Surgical Treatment References 75: Non-Operative Management of Blunt Traumatic Injuries 75.1 What Is NOM? 75.2 Why Perform NOM? 75.3 General Principles 75.3.1 NOM for Spleen Injuries 75.3.2 NOM for Liver Injuries 75.3.3 NOM for Pancreas Injury 75.3.4 NOM for Kidney Injury 75.4 Particular Concerns About NOM 75.4.1 Long-Term Outcomes 75.4.2 Timing of Venous Thromboembolism (VTE) Prevention References 76: Recent Advances in Minimally Invasive Surgery for Spinal Trauma 76.1 Introduction 76.2 Indications for Minimally Invasive Surgery 76.3 Percutaneous Pedicle Screw Instrumentation 76.3.1 Surgical Technique 76.3.2 Outcomes 76.3.3 Limitations 76.3.4 Percutaneous Pedicle Screw Instrumentation with Fusion 76.4 Percutaneous Vertebral Augmentation 76.4.1 Surgical Technique 76.4.2 Outcomes 76.5 Lateral Approaches to the Spine 76.5.1 Outcomes for Treatment of Trauma 76.6 Navigation and Robotic Guidance References 77: Current Perspectives of Interventional Radiology in Trauma 77.1 Introduction 77.2 Treatment Modalities 77.3 Specific Organ System Management 77.3.1 Aorta 77.3.2 Liver 77.3.3 Spleen 77.3.4 Kidney 77.3.5 Pelvis 77.3.6 Extremities 77.4 Other Organs References 78: Strategies to Control Hemorrhage in the Trauma Patient 78.1 Introduction 78.2 Point of Injury Strategies 78.3 Intravascular Control 78.4 Operative Control 78.5 Future 78.6 Conclusion References 79: Selective Use of Anesthetics in Patients with Major Trauma 79.1 Introduction 79.2 Primary Survey and Monitoring 79.2.1 Assessing the Airway 79.2.2 Induction and Intubation 79.2.3 Special Considerations for Airway Management 79.3 Hemodynamic Considerations 79.3.1 Fluids in Resuscitation 79.3.2 Coagulopathy in Trauma 79.4 Perioperative Care 79.4.1 Intraoperative Considerations 79.4.2 Postoperative Considerations 79.5 Special Populations 79.5.1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) 79.5.2 Thoracic Trauma 79.5.3 Pregnancy 79.5.4 Traumatic Brain Injury and Spinal Cord Injury 79.5.5 Burns References 80: Lifesaving and Emergency Surgical Procedures in Trauma Patients 80.1 Emergency Surgical Airway Management in Trauma Patients 80.1.1 Surgical Cricothyroidotomy 80.1.2 Cricothyroidotomy: Traditional Technique 80.1.3 Percutaneous Bougie-Assisted Cricothyroidotomy 80.1.4 Percutaneous Cricothyroidotomy Technique (PCT) 80.1.5 Needle Cricothyrotomy (NC) and Percutaneous Transtracheal Jet Ventilation (PTTJV) 80.2 Management of Massive Intrathoracic Hemorrhage: Surgical Procedures and Damage Control Techniques 80.2.1 Tube Thoracostomy 80.2.2 Finger Thoracostomy 80.2.3 Anterolateral Thoracotomy 80.2.4 Posterolateral Thoracotomy 80.2.5 Emergency Department Thoracotomy (EDT) 80.2.6 Clamping the Pulmonary Hilum for Evacuation of Bronchovascular Air Embolism 80.2.7 Pulmonary Tractotomy 80.2.8 Median Sternotomy, Cardiopulmonary Bypass (CPB), and ECMO for Traumatic 80.2.8.1 Cardiothoracic Emergencies 80.2.8.2 Cardiopulmonary Bypass for Blunt Cardiac Trauma 80.2.8.3 CPB for Injury of the Thoracic Aorta 80.2.8.4 ECMO for Massive Lung Injuries and for Organ Procurement 80.3 Overview of Surgical Procedure in Patients with Complex Abdominal Organ Injuries 80.3.1 Basic Strategy for Complex Liver Injuries 80.3.2 Damage Control Surgery (DCS) for Liver Injuries 80.3.3 Surgical Strategy for Associated Vascular Injuries of the Liver 80.3.4 Total Hepatic Vascular Exclusion and Supracoeliac Aortic Clamping 80.3.5 Emergency Liver Transplantation After Total Hepatectomy and Veno-Venous Bypass 80.3.6 Hepatic Necrosis After Emergency Procedures 80.3.7 Pancreaticoduodenal Injuries 80.4 Complex Abdominal Vascular Injuries 80.4.1 Mattox and Cattell–Braasch Maneuvers 80.4.2 Control of the Supracoeliac Abdominal Aorta 80.4.3 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for Regional Perfusion Optimization 80.4.4 Pre-Peritoneal Pelvic Packing (PPP) for Inferior Retroperitoneal Bleeding Secondary to Complex Pelvic Injuries References 81: Extracorporeal Membrane Oxygenation (ECMO) in Trauma Patients 81.1 Introduction 81.1.1 Time Trends and Indications for ECLS in Trauma Patients 81.1.2 Challenges of Using ECLS in Trauma: Anticoagulation and Surgery 81.2 Chest Trauma and Acute Respiratory Distress Syndrome 81.3 Cardiac Trauma and Traumatic Cardiac Arrest 81.4 Hemorrhagic Conditions 81.5 Traumatic Brain Injury (TBI) 81.6 Hypothermia and Drowning 81.7 Burn Injuries 81.8 ECLS in Military Settings 81.9 ECLS for Trauma in Children 81.10 Predictors for Survival 81.11 Conclusions and Future Directions References 82: The Role of Trauma Surgeon in Mass Casualties 82.1 Introduction 82.2 Disaster 82.3 Disaster Planning 82.4 Trauma Surgeon as Team Leader 82.5 The Triage 82.6 Trauma Care in the Disaster Area 82.7 Evacuation and Transportation of Critically Ill Patients 82.8 Definitive Surgical Treatment on the Field and in the Hospital 82.9 Incident Command Center 82.10 Escalating the Surgical Response 82.11 Creation of Medical Response Teams 82.12 The Surgeon’s Role in the Aftermath 82.13 Training 82.14 Conclusions References