Perioperative Risk Assessment

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Contents 1 More Specific Terms 2 Notes 3 More General Terms 4 Additional Terms 5 References

More Specific Terms

• cardiac risk index (CRI)
• Eagle criteria
• Goldman criteria

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]
  

• Cardiac

• complications:

• death
• 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]

• pulmonary edema
• unstable angina
• arrhythmia (life-threatening)

• risk factors (in descending order of importance)

• 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
• consider non-invasive ischemia testing - tests - Bruce protocol ( treadmill) - dipyridamole-thallium - dobutamine echocardiography - in patients with - known or suspected CAD - unreliable or unknown function status - intermediate scores on Eagle criteria or on cardiac risk index
• 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]

• 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 associated with an increased perioperative risk of CHF

• 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

• 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

• hypertension (low risk)

• systolic blood pressure ( SBP) > 200 mm Hg, or
• diastolic blood pressure ( DBP) > 120 mm Hg
• increased risk of MI & pulmonary edema
  

• Pulmonary

• complications

• occur in 1/3 of patients post-operatively
• account for 50% of peri-operative mortality
• respiratory failure with prolonged mechanical ventilation
• pneumonia
• atelectasis
• bronchospasm
• bronchitis
• pulmonary embolism

• risk factors

• upper abdominal or cardiothoracic surgery
• proximity of surgical procedure to diaphragm
• morbid obesity (> 250 lbs)
• tobacco: current use or 20 pack-year history
• chronic obstructive pulmonary disease

• pulmonary function testing

• 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

• indications

• suspected moderate to severe underlying lung disease
• pulmonary resection
  

• Neurologic

• complications

• stroke
• delirium

• risk factors

• stroke

• cardiac or vascular surgery
• older age
• postoperative atrial fibrillation
• symptomatic carotid stenosis (> 50%)

• 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
  

• Hepatic

• complications

• death
• bleeding
• infections
• liver failure

• risk factors

• cirrhosis ( Child's class C >> Child's class A)
• acute hepatitis (especially viral or alcoholic)
  

• Hematologic

• considerations

• bleeding risk
• severity &/or stability of anemia
• in older patients, preoperative hematocrit levels outside the normal range are associated with higher mortality after noncardiac surgery
• even mild preoperative anemia may increase 30 day morbidity & mortality after noncardiac surgery [18]

• evaluation

• bleeding history
• bleeding time does not predict the risk of perioperative bleeding
• assess the need for preoperative transfusion

• laboratory:

• no history of bleeding, but high-risk surgery

• aPTT & platelet count

• 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
  

• Endocrine

• risk factors

• diabetes
• hypothyroidism
• adrenal insufficiency
  

• Renal

• complications of end-stage renal disease ( ESRD)

• infection, especially pneumonia
• hyperkalemia

• complications of chronic renal insufficiency

• progressive renal dysfunction

More General Terms

• risk assessment

Additional Terms

• indications for preoperative laboratory testing
• metabolic equivalent unit (MET)
• perioperative risk stratification (relative risk of non-cardiac surgeries)
• post-operative management
• postoperative complications
• preoperative evaluation & management
• prophylaxis for venous thromboembolism
• simple fitness questions that predict risk of post-operative morbidity

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, American College of Physicians, Philadelphia 1998
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: [1]
    - 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: [2]
    - 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: [3]
14. McFalls EO et al, Coronary-artery revascularization before elective major vascular surgery N Engl J Med 2004;351:2795 PMID: [4]
15. Wu W-C et al, Preoperative Hematocrit Levels and Postoperative Outcomes in Older Patients Undergoing Noncardiac Surgery JAMA. 2007;297:2481-2488. [5]
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: [6]
    - 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: [7]
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 <PubMed> PMID: [8] <Internet> [9]
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 <PubMed> PMID: [10] <Internet> [11]
19. National Guideline Clearinghouse Guideline on the assessment of bleeding risk prior to surgery or invasive procedures. British Committee for Standards in Haematology ngc-guideline: [12]
    - Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. European Society of Cardiology ngc-guideline: [13]

perioperative risk assessment