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CHAPTER 111: Preoperative Assessment of the High-Risk Surgical Patient 1053

3. Adequate treatment of sepsis and shock, with recognition of the CHAPTER Preoperative Assessment
important role of surgery or interventional radiology in the iden-
tification and drainage of areas of sepsis such as intra-abdominal of the High-Risk Surgical
abscesses. 111
4. Judicious use of intravenous fluids to maintain adequate perfusion Patient
while avoiding overhydration and pulmonary edema. Robert Chen
5. Optimal use of analgesics to control pain without producing Jameel Ali
respiratory depression.
6. Administration of supplemental oxygen to hypoxemic patients to
improve arterial oxygenation. KEY POINTS
7. Treatment (as specific as possible) of any identifiable cause of • Perioperative risk assessment by careful history, physical examina-
hypoxemia; for example, bronchodilator therapy for a patient with tion, and selective investigation is essential for directing therapy in
bronchospasm, or antibiotic therapy directed against a specific the high-risk surgical patient.
organism isolated in a patient with a pneumonic process. • To decrease mortality and morbidity, major medical illnesses must
8. Preoperative pulmonary assessment, especially in patients with be identified and appropriately managed.
poor pulmonary reserve and most especially in those undergoing • Delirium is a common postoperative complication that can be
lung resection. This will allow an assessment of the relative risk of anticipated given risk factors.
postoperative morbidity.
9. Institution of mechanical ventilation when the above measures fail. • Perioperative cardiac morbidity can be minimized with preemptive
medical management which includes the perioperative administra-
Frequently, mechanical ventilation can be avoided if strict attention tion of β-blockers in very select patients.
is paid to preventive measures. Also, vigorous application of these
principles immediately after the patient is stabilized can shorten the • Postoperative pulmonary complications can be reduced by aggres-
duration of mechanical ventilation considerably. 76,77 sive pre- and postoperative care.
• Diabetes mellitus and steroid dependence must be completely
managed to significantly influence perioperative morbidity and
mortality.
KEY REFERENCES

• Ali J, Weisel RD, Layug AB, et al. Consequences of postoperative
alterations in respiratory mechanics. Am J Surg. 1974;128:376.
• Burch JM, Ortiz VB, Richardson RJ, et al. Abbreviated laparotomy As indicated in Chap.110, surgery and anesthesia trigger a host of physi-
and planned reoperation for critically injured patients. Ann Surg. ologic responses. Anesthesiologists have described elective surgery as
1991;215:476. “planned trauma.” Thus they prepare for all the traumatic sequelae that
• Casaer MP, Mesotten D, Hermans G, et al. Early versus late will occur such as blood loss and fluid shifts, increased myocardial oxygen
parenteral nutrition in critically ill adults. N Engl J Med. 2011; demands, respiratory changes caused by intubation and ventilation with
365:506. supplemental oxygen, increased plasma cortisol of the stress response,
• Craig DB, Wahba WM, Don HF, et al. “Closing volume” and its and coagulopathy to name a few. In the average otherwise healthy
relationship to gas exchange in seated and supine positions. J Appl patient, these responses result in no major untoward postoperative
Physiol. 1971;31:717. events. However, in the medically compromised patient, the additional
burden of surgical stress can prove to be very challenging and sometimes
• CRASH-2 Trial Collaborators. Effects of tranexamic acid on insurmountable. Such patients frequently require detailed evaluation and
death, vascular occlusive events, and blood transfusion in trauma monitoring in the preoperative as well as postoperative periods in the
patients with significant hemorrhage (CRASH-2): a randomised, intensive care unit (ICU). Careful planning, preoperative assessment, and
placebo-controlled trial. Lancet. 2010;376:23. management of identified abnormalities in these patients are crucial to
• Fouche Y, Sikorski R, Dutton RP. Changing paradigms in surgical optimize chances of a good postoperative outcome. A major component
resuscitation. Crit Care Med. 2010;38(9):S411. of this planning involves the assessment of risks for intraoperative and
• Griesdale DE, De Souza RJ, Van Dam RM, et al. Intensive postoperative morbidity. Patients with cardiac, respiratory, and renal
insulin therapy and mortality among critically ill patients: a abnormalities pose special risks for postoperative complications. In this
meta-analysis including NICE-SUGAR study data. CMAJ. 2009; chapter, we present guidelines for identifying and managing patients at
180(8):827. risk of developing postoperative morbidity.
• Magder S. Clinical usefulness of respiratory variations in arterial
pressure. Am J Respir Crit Care Med. 2004;169:151. PREOPERATIVE SCREENING
• Moore FA, Feliciano DV, Andrassy RJ, et al. Early enteral feeding, Table 111-1 is a system of perioperative screening for patients at
compared with parenteral, reduces postoperative septic complica- St Michael’s Hospital in Toronto, Canada. Patients identified preop-
tions: the results of a meta-analysis. Ann Surg. 1992;216:172. eratively with severe disease (Table 111-1) or gravid patients for non-
• von Ungern-Sternberg BS, Regli A, Schneider MC, et al. Effect obstetric surgery should be seen by an anesthesiologist in an outpatient
of obesity and site of surgery on perioperative lung volumes. Br J clinic where there is time for preoperative risk stratification and disease
Anaesth. 2004;92:202. optimization if possible. If conditions are found that warrant a delay in
surgery, early identification minimizes the impact of other scheduled sur-
geries. At that juncture, additional advice from Internal Medicine or medi-
cal subspecialties is sought as necessary for postoperative management.
REFERENCES Codifying or classification leads to more rapid and precise com-
munication among clinicians: shock classification, solid organ injury
Complete references available online at www.mhprofessional.com/hall grading, and subarachnoid hemorrhage classification are such examples.

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