Contents

Search

perioperative risk assessment

Notes: - spinal anesthesia is NOT safer than general anesthesia - poor functional capacity (< 4 METS) indicates high risk - perioperative mortality correlates with functional status, independent of age - screen for alcohol abuse (AUDIT-C) - alchohol abuse before surgery increases risk of postoperative complications - abstinence prior to surgery diminishes risk [12] - screen for obstructive sleep apnea === Cardiac (also see cardiac stress testing) === 1) complications: a) death b) myocardial infarction (MI) - greatest risk with 3-vessel or left main coronary artery disease - greatest risk within 1st 24-72 hours after surgery - most perioperative MIs are asymptomatic [17] c) pulmonary edema d) unstable angina e) arrhythmia (life-threatening) 2) risk factors (in descending order of importance) a) coronary artery disease (CAD) - defined as any of: - typical angina - Q-waves on ECG - prior myocardial infarction (MI) - prior angiographic evidence of CAD - prior functional study (i.e. treadmill) indicating CAD - high risk (5-25% complication rate) - unstable coronary syndromes - severe stable angina - low risk (1-5% complication rate) - mild stable angina - good functional status - preoperative electrocardiogram indicated [12] - consider non-invasive ischemia testing in patients with - known or suspected CAD - unreliable or unknown function status - intermediate scores on Eagle criteria or on cardiac risk index - tests include Bruce protocol (treadmill), dipyridamole-thallium; dobutamine echocardiography - asymptomatic patients s/p CABG are at low risk - delay post-MI non-cardiac surgery (if possible) - 4-6 weeks after uncomplicated MI - 6 months after complicated MI - no benefit from coronary intervention before non-cardiac surgery [14] b) congestive heart failure (CHF) - decompensated CHF - high risk for perioperative pulmonary edema - increased risk of death - optimize therapy, if possible, prior to surgery - compensated CHF - increased risk of perioperative pulmonary edema - no known risk for other complications - conservative management - dilated & hypertrophic cardiomyopathies are associatedmwith an increased perioperative risk of CHF c) severe valvular heart disease - symptoms are the most important risk factor - aortic stenosis - mitral stenosis - acute mitral or aortic regurgitation - valve repair prior to non-cardiac surgery may be indicated d) significant cardiac arrhythmia - high risk - high grade AV block - symptomatic ventricular arrhythmias with structural heart disease - supraventricular arrhythmias with uncontrolled ventricular response - low risk - rhythm other than sinus rhythm (i.e. atrial fibrillation) - ECG evidence of left ventricular hypertrophy - left bundle-branch block - ST-T abnormalities e) hypertension (low risk) - systolic blood pressure (SBP) > 200 mm Hg, or - diastolic blood pressure (DBP) > 120 mm Hg - increased risk of MI & pulmonary edema f) pulmonary hypertension [12] === Pulmonary === 1) complications a) occur in 1/3 of patients post-operatively b) account for 50% of peri-operative mortality c) respiratory failure with prolonged mechanical ventilation d) pneumonia e) atelectasis f) bronchospasm g) bronchitis h) pulmonary embolism 2) risk factors [12] a) older age b) chronic obstructive pulmonary disease c) tobacco: current use or 20 pack-year history d) chronic heart failure e) poor general health status &/or functional dependence f) low serum albumin g) renal insufficiency h) morbid obesity (> 250 lbs)* i) obstructive sleep apnea j) pulmonary hypertension [12] k) upper abdominal or cardiothoracic surgery l) proximity of surgical procedure to diaphragm m) head & neck surgery n) neurosurgery o) major vascular surgery p) surgeries lasting > 3 hours q) emergency surgery r) general anesthesia* * minor or possible risk factor [12] 3) pulmonary function testing a) FEV1 - good predictor of surgical risk - if FEV1 > 2L, patient can safely undergo procedure - if FEV1 < 1L - high risk of post-operative pulmonary complication - avoid elective procedures adjacent to diaphragm b) indications - suspected moderate to severe underlying lung disease - pulmonary resection === neuropsychiatric === 1) complications a) stroke b) delirium 2) risk factors a) stroke - cardiac or vascular surgery - older age - postoperative atrial fibrillation - symptomatic carotid stenosis (> 50%) b) delirium - older age - poor cognitive status - poor functional status - history of alcoholism - thoracic surgery - abdominal aortic aneurysm repair - abnormal electrolytes - abnormal glucose - perioperative use of Demerol or benzodiazepines c) depression (Geriatric Depression Scale score > 4) increase risk for postoperative delirium [21] === Hepatic === 1) complications a) electrolyte & fluid imbalances b) delirium c) coagulation disorders & bleeding d) infections e) impaired clearance of medications f) renal failure g) liver failure h) death 2) risk factors a) cirrhosis (Child's class C >> Child's class A) b) acute hepatitis (especially viral or alcoholic) === Hematologic === 1) considerations a) bleeding risk b) severity &/or stability of anemia c) in older patients, preoperative hematocrit levels outside the normal range are associated with higher mortality after noncardiac surgery d) even mild preoperative anemia may increase 30 day morbidity & mortality after noncardiac surgery [18] 2) evaluation a) bleeding history b) bleeding time does not predict the risk of perioperative bleeding c) assess the need for preoperative transfusion 3) laboratory: a) no history of bleeding, but high-risk surgery - aPTT & platelet count b) suggestive history of bleeding disorder & high-risk surgery - aPTT, PT, fibrinogen, platelet count, vWF assays, factor VIII, factor IX, clot lysis, alpha-2 plasmin inhibitor, factor XIII ) prophylaxis for venous thromboembolism === Endocrine === - risk factors a) diabetes mellitus, especially insulin-dependent diabetes mellitus b) hypothyroidism c) adrenal insufficiency d) hyponatremia [19] === Renal === 1) complications of end-stage renal disease (ESRD) a) infection, especially pneumonia b) hyperkalemia 2) complications of chronic renal insufficiency - progressive renal dysfunction - hyponatremia [19] 3) serum creatinine >= 2.0 mg/dL constitutes cardiac risk factor [21] 4) a BUN/creatinine ratio indicates azotemia, but does not confer an increased risk for postoperative delirium [21]

Related

cardiac stress testing perioperative management perioperative risk stratification (relative risk of non-cardiac surgeries) post-operative management postoperative complication preoperative evaluation & management preoperative laboratory testing simple fitness questions that predict risk of post-operative morbidity

Specific

cardiac risk index (CRI) Eagle criteria Goldman criteria

General

risk assessment

References

  1. John Adler, UCSF Fresno visiting lecturer, May 28, 1998
  2. Goldman Anesth Analg 80:810 1995
  3. AHA/ACC Task Force, Circulation 93:1278 1996
  4. Celli Med Clin North Am 77:309 1993
  5. Kroenke et al Chest 104:1445 1993
  6. Gerraty et al Stroke 24:1115 1993
  7. Marcantonio J Am Med Assoc 271:134 1994
  8. Messmore & Godwin Med Clin North Am 78:625 1994
  9. Salem et al Ann Surg 4:416 1994
  10. Schiff & Emanuele J Gen Int Med 10:154 1995
  11. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 341-350
  12. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018, 2022.
  13. Journal Watch 22(9):67, 2002 - Eagle KA et al, ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol. 2002 Feb 6;39(3):542-53. No abstract. PMID: 11823097 - Auerbach AD, Goldman L. beta-Blockers and reduction of cardiac events in noncardiac surgery: clinical applications. JAMA. 2002 Mar 20;287(11):1445-7. PMID: 11903032 - Auerbach AD, Goldman L. beta-Blockers and reduction of cardiac events in noncardiac surgery: scientific review. JAMA. 2002 Mar 20;287(11):1435-44. Review. PMID: 11903031
  14. McFalls EO et al, Coronary-artery revascularization before elective major vascular surgery N Engl J Med 2004;351:2795 PMID: 15625331
  15. Wu W-C et al, Preoperative Hematocrit Levels and Postoperative Outcomes in Older Patients Undergoing Noncardiac Surgery JAMA. 2007;297:2481-2488. http://jama.ama-assn.org/cgi/content/full/297/22/2481
  16. Bradley KA et al. Alcohol screening and risk of postoperative complications in male VA patients undergoing major non-cardiac surgery. J Gen Intern Med 2011 Feb; 26:162. PMID: 20878363 - Harris AHS et al. Preoperative alcohol screening scores: Association with complications in men undergoing total joint arthroplasty. J Bone Joint Surg Am 2011 Feb; 93:321 PMID: 21325583
  17. Devereaux PJ et al, Characteristics and Short-Term Prognosis of Perioperative Myocardial Infarction in Patients Undergoing Noncardiac Surgery A Cohort Study Annals of Internal Medicine 2011, 154:523-528 PMID: 21502650 http://www.annals.org/content/154/8/523.abstract
  18. Musallam KM et al Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study The Lancet, Early Online Publication, 6 October 2011 PMID: 21982521 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2811%2961381-0/abstract
  19. Leung AA et al Preoperative Hyponatremia and Perioperative Complications Arch Intern Med. Published online September 10, 2012 PMID: 22965221 http://archinte.jamanetwork.com/article.aspx?articleid=1357514 - Vassalotti JA and DuPree E Preoperative Hyponatremia: An Opportunity for Intervention? Comment on "Preoperative Hyponatremia and Perioperative Complications" Arch Intern Med. Published online September 10, 2012 PMID: 22965069 http://archinte.jamanetwork.com/article.aspx?articleid=1357510
  20. Fleisher LA et al 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 PMID: 25091544 http://content.onlinejacc.org/article.aspx?articleid=1893784 - Kristensen SD et al 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management. The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J (2014). August 2014 PMID: 25086026 http://eurheartj.oxfordjournals.org/content/early/2014/07/28/eurheartj.ehu282.extract
  21. Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  22. Smilowitz NR, Berger JS. Perioperative cardiovascular risk assessment and management for noncardiac surgery: A review. JAMA 2020 Jul 21; 324:279. PMID: 32692391 Review. https://jamanetwork.com/journals/jama/fullarticle/2768470