Perioperative Management Of High Risk Surgical Patient

Question 1

What is Operative Mortality

Answer 1

Deaths occurring during surgery and 28-30 days after.

Question 2

How much is the demand for oxygen delivery after surgery ?

Answer 2

Before surgery it’s 110 ml/m2 per minute.

After surgery it’s 170 ml/m2 per minute.

Question 3

Factors that predispose patient to high risk of morbidity and mortality after surgery

Answer 3

1- patient factors

2- surgical factors

Question 4

Patient factors

Answer 4

Age greater than 70. 
MI.
IHD. 
Heart failure. 
COPD.
Respiratory failure. 
Renal failure.
Uncontrolled DM. 
Morbid obesity. 
Poor nutrition.
Late stage vascular disease.

Question 5

Surgical factors

Answer 5

1- prolonged surgery I.e greater than 1.5 hours
2- type of surgery (thoracic. Abdominal. Vascular)
3- extensive surgery(oesophagectomy. Gastrectomy)
4- emergency surgery
5- massive blood loss greater than 2.5 L
6- septicaemia
7- massive trauma. Of greater than 3 organs. Greater than 2 organ systems. Or atleast 2 body cavities open.

Question 6

ASA grades

Answer 6

Grade 1- healthy- mortality 0.1%
Grade 2- mild systemic disease with no functional limitation- 1 %
Grade 3- severe systemic disease with functional limitation - 4 %
Grade 4- constant threat to life - 20 %
Grade 5- unlikely to survive 24 hours- 90%
E- emergency surgery

Question 7

Optimisation

Answer 7

Can be done in HDU or ITU

Question 8

Risk scoring systems

Answer 8

ASA
Metabolic equivalent of task(MET) 
Revised cardiac risk index of lee 
Goldman cardiac risk index 
POSSUM 
Cardiopulmonary exercise testing

Question 9

MET

Answer 9

Measure exercise tolerance of daily activities

Question 10

RCRI

Answer 10

Used to assess cardiac risk in non cardiac surgery

Question 11

POSSUM

Answer 11

Physiologic and operative severity scoring for enumeration of mortality and morbidity.

Calculated after surgery and better for some surgeries like colorectal and vascular.

Question 12

CPET

Answer 12

Anaerobic threshold of less than 11 and peak oxygen consumption VO2 of less than 15ml/kg per minute is associated with poor outcome

Question 13

Perioperative mortality in MI patients

Answer 13

15 to 25 percent

Question 14

Minimising MI in surgery

Answer 14

Delay operation by 3-6 months.
Anesthesia should avoid tachycardia. Systolic hypertension or diastolic hypotension.
Pain control is important.
Oxygen supplementation is advisable for 3-4 days postoperatively.
Post operative critical care admission.

Question 15

Respiratory failure

Answer 15

PaO2 is less than 8 kPa and PaO2/FiO2 is less than 40 kPa and patient is unable to be extubated for 48 hours post surgery.

Question 16

Respiratory optimisation

Answer 16

Arrange pre and post operative chest physio therapy and deep breathing exercises.
Consider regional anesthesia.
Give bronchodilators and steroids.

Question 17

Goal directed therapy

Answer 17

Aim of GDT is to manipulate a patients physiology to achieve targets that are associated with improved outcome using IV fluids and inotropes/vasopressin directed by measurements of cardiac output.

Cardiac Index greater than 4.5 L/m2 per minute
And
Delivery of oxygen DO2 greater than 600 ml/m2 per minute.

Question 18

CO measurement

Answer 18

By pulmonary artery catheter
Oesophageal Doppler
Lithium dilution
Pulse contour analysis equipment

Question 19

Laparoscopic surgery drawback

Answer 19

In cardiac patients

Question 20

ICORS

Answer 20

Intensive care outreach services