Perioperative Risk

Question 1

ASA Physical Status Classification and Mortality Risk (6 levels)

Answer 1

1. Normal, healthy patient 0.1%
2. Mild systemic disease 0.2%
3. Severe systemic disease 1.8%
4. Severe systemic disease, constant threat to life 7.8%
5. Moribund patient, not expected to survive w/out surgery 9.4%
6. Brain dead organ donor

Question 2

Overall surgical risk depends on 3 factors:

Answer 2

1. Specific surgical risk
2. Patient specific clinical variables
3. Exercise capacity / tolerance (> 4 METs, < 4 METs)

Question 3

Risk level?

Non-vascular major abdominal
Infra-inguinal vascular
Carotid, head & neck
Orthopedic  
Prostate

Answer 3

Intermediate risk

Question 4

Risk level?

Endoscopic
Ophthalmologic
Dental
Skin/superficial

Answer 4

Low risk

Question 5

Risk level?

Emergent
Major thoracic
Aortic or supra-inuginal vascular surgery
Procedures expecting major fluid shifts or blood loss

Answer 5

High risk

Question 6

Four factors which may lead to delay or cancellation of surgery:

Answer 6

1. Unstable coronary syndromes (USA, recent MI)
2. Decompensated HF, new HF, Class IV HF
3. Significant or new arrhythmias
4. Severe valvular disease (AS or symptomatic MS)

Question 7

Class IV HF

Answer 7

Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.

Question 8

Risk factors for post op pneumonia and resp failure

Answer 8

Upper abdominal or cardiothoracic procedures

Prolonged anesthesia (>4hrs)

Age>60

Tobacco abuse (>20 pack years)

COPD/HF/OSA/Pre-op sepsis

Hypoalbuminemia

Impaired cognition

Question 9

What is “bridging” and when is it used

Answer 9

Bridge = switch to heparin or lovanox. Heparin can be “turned on and off” much faster, perioperatively

Bridging for patients on warfarin (mechanical valves, a fib, etc)

Only recommended for high risk patients

Question 10

Who gets a pre op EKG

Answer 10

Asymptomatic women ≥ 50 or men ≥ 45

Known cardiac hx