Optimization Of High Risk Surgical Patients

1. Optimization Of High Risk Surgical Patients
Dr Lalit K Shah
Resident General Surgery
Moderator- Dr Chandraman Prajapati

2. Introduction
• An act, process, or methodology of making something
(such as a design, system, or decision) as perfect,
functional, or effective as possible
• To optimize the high risk surgical patients pre-operative
preparation is must
• Preoperative preparation is the preparation of a patient
requiring surgery to optimise postopeartive outcomes

3. • Operative mortality is more meaningfully expressed in
terms of deaths occuring during surgery and upto 28-30
days after surgery
• The overall 30 day mortality risk for operative procedures
in Western Europe is 0.7-1.85 % but this figure includes
high risk patients

4. • 70% of all elective procedures
have a mortality risk of <1%
• High risk group has a mortality
risk in excess of 5%
• When the risk exceeds 20%
patient are said to be at
extremely high risk

5. • By identifying high-risk patients in the preoperative phase
and planning their perioperative management, morbidity
and mortality can be reduced
• Patients who have a predicted mortality ≥5% should be
considered as ‘high risk’
• It is estimated that although the high-risk group accounts
for less than 15% of all surgical procedures, they
contribute to more than 80% of all perioperative deaths in

6. Practical approach to perioperative care of high risk patient
1. Identify the high-risk patient
2. Assess the level of risk
3. Detailed preoperative assessment
4. Optimise medical management
5. Intraoperative considerations
6. Consider specific strategies or goal directed therapy
7. Consider admission to a critical care facility postoperatively

7. Identify the high risk patient
• Risk after surgery is a complex interaction of multiple
factors which can be classified into patient and surgical
factors

9. Assess the level of risk
• A number of scoring systems have been developed over
the years with the aim of identifying high-risk patients
ASA is simple, but subject to user interpretation
MET measures exercise tolerance related to daily living
RCRI used to predict cardiac risk for non-cardiac surgery
POSSUM can only be used postoperatively and better for
some types of surgery, e.g. colorectal, vascular
CPET is non-invasive, objective and becoming
increasingly popular

10. • American Society Of Anesthesiologists (ASA) Grade

11. • Metabolic Equivalent of
Task (MET)
• Revised cardiac risk of
Lee

13. Detailed preoperative assessment
• The preparation begins from the time of contact of the
patient with the surgeon and ends on the day of surgery in
the preoperative room

14. • Preoperative assessment
History Taking
Examination
Investigations
Preoperative management of systemic diseases
Preoperative assessment in emergency surgery
Risk assessment and consent

15. Preoperative assessment in emergency surgery:
• Assessment should be the same as in elective surgery,
except that the opportunity to optimise the condition is
limited by time constraints.
• Medical assessment and treatments should be started
(e.g. as per Advanced Trauma Life Support guidelines)
even if there is no time to complete them before the start
of the surgical procedure.
• Some risks may be reduced but some may persist and,
whenever possible, these need to be explained to the
patient.

16. Start: Similar principles to that for elective surgery
Constraints: Time, facilities available
Consent: May not be possible in life-saving emergencies
Organisational efforts: For example, local/national
algorithms for treatment of the patient with multiple
injuries

18. Optimise medical management of coexisting
diseases and intraoperative consideration
• The medical management of all coexisting disease
processes should be reviewed and optimised
• The actions taken may be simple measures, such as
stopping smoking, reducing alcohol intake, losing weight,
improving nutrition and/or haemoglobin levels
• In some cases, there will be a need for more complex
investigations, review of medication or even consideration
of further surgery

19. Cardiovascular Disease
• At preoperative assessment it is important to identify the
patients who have a high perioperative risk of major
adverse cardiovascular events (MACE) including
myocardial infarction (MI), and make appropriate
arrangements to reduce this risk
• Perioperative myocardial infarction (MI) is associated with
a high mortality (15-25 per cent)
• Ischaemia and ultimately MI occur when the supply of
oxygen to the myocardium is exceeded by its demand

22. • The patient should be referred to a cardiologist if:
A murmur is heard and the patient is symptomatic
The patient is known to have poor left ventricular function
or cardiomegaly.
Ischaemic changes can be seen on ECG even if the
patient is not symptomatic (silent ischaemia, silent MIs
are frequent).
There is an abnormal rhythm on the ECG, for example
tachy-/bradycardia or heart block

25. Respiratory Disease
• Postoperative respiratory complications, such as
pneumonia, are a major cause of morbidity and mortality
especially after major abdominal and thoracic surgery
• A patient’s current respiratory status should be compared
with their ‘normal state’
• A preoperative chest radiograph or scan is useful

26. • Make a note of the severity of the asthma and COPD,
such as past hospital admissions for treatment of the
condition, records of pulmonary function tests, use of oral
steroids,home oxygen, non-invasive ventilation support
and evidence of right heart failure

27. • The patient should be referred to a respiratory physician
if:
There is a severe disease or significant deterioration.
Major surgery is planned in a patient with significant
respiratory comorbidities.
Right heart failure is present – dyspnoea, fatigue,
tricuspid regurgitation, hepatomegaly and oedematous
feet.
The patient is young and has severe respiratory problems
(indicates a rare condition)

29. Gastrointestinal Disease
• Patients are advised not to take solids within 6 hours and
clear fluids within 2 hours before anaesthesia to avoid the
risk of acid aspiration syndrome
• In patients with liver disease, the cause of the disease
needs to be known, as well as any evidence of clotting
problems, renal involvement and encephalopathy.
• Elective surgery should be postponed until any acute
episode has settled (e.g. cholangitis)

30. • Patients with hiatus hernia, obesity, pregnancy and
diabetes are at high risk of pulmonary aspiration, even if
they have been NBM before elective surgery. Clear
antacids, H2-receptor blockers, e.g. ranitidine, or proton
pump inhibitors, e.g. omeprazole, may be given at an
appropriate time in the preoperative period.

31. Genitourinary Disease
• Underlying conditions leading to chronic renal failure,
such as DM, HTN and ischaemic heart disease, should be
stabilised before elective surgery
• UTI should be treated before embarking on elective
surgery
• For emegency procedures, antibiotics should be started
and care taken to ensure that pt maintains good urine
output before, during and after surgery

32. Endocrine Disorders
• Diabetes and associated cardiovascular and renal
complications should be controlled to as near normal level
as possible before elective surgery
• HbA1c should be checked
• Patients with DM should be first on the operating list and if
they are operated on in the morning advised to omit the
morning dose of medication and breakfast

33. Coagulation Disorders
• Patients with a strong family history or previous history of
thrombosis should be identified
• Pateints with a low risk of thromboembolism can be given
thromboembolism-deterrent stockings
• High risk patients with a history of recurrent DVT,
pulmonary embolism and arterial thrombosis will be on
warfarin

34. • Warfarin should be stopped before surgery and replaced
by low molecular weight heparin or factor Xa inhibitors

35. • Orders regarding previous medication
1. oral anti-hypertensive drugs- continue till the day of
surgery
2. oral hypoglycemic drugs
-minor/intermediate surgery: stop 24 hours prior
-major surgery: stop 24 hours prior and put patient on
insulin

36. 3. Anti-psychotic/depressant/epileptic
-cotinue till day of surgery except TCA stop 21 days prior
and lithium stop 24-28 days prior
4. Throid medication cotinue till day of surgery

37. 5. Anti coagulants
-Aspirin: continue till day of surgery
-clopidegrol: stop 7 days prior
-ticlopidine: stop 14 days prior
-warfarin: stop 3-4 days prior
-LMWH: stop 12-24 hour prior
-unfractioned heparin: stop 6 hour prior

38. Specific strategies and goal directed therapy
Specific strategies
• Initiation of perioperative B-blockade remains
controversial, patients already taking B-blockers must
continue their medication
• Fluids guided by GDT can reduce complications from
surgery
• Inotropes and/or vasopressors are still required in many
high-risk patients

39. Goal-directed therapy
• Persistent inadequate tissue perfusion is a major factor in
the development of perioperative organ failure
• High-risk patients who survive without multiorgan failure
are known to have higher cardiac indices (CI) and oxygen
delivery (DO,) than those who die
• This led to the concept of goal-directed therapy (GDT)

40. • The aim of GDT is to manipulate a patient’s physiology to
achieve targets that are associated with an improved
outcome (CI >4.5 L/m’ per minute, DO, >600 mL/m’ per
minute) using intravenous fluids and inotropes directed by
measurements of cardiac output (CO).

41. Critical care facility
• Optimal care in the high-risk group should be extended to
include postoperative support which for a majority of
these patients means admission to a critical care bed.
• Reports from the National Confidential Enquiry into
Patient Outcome and Death (NCEPOD) show that the
majority of postoperative deaths in the UK occur more
than 5 days after surgery.
• Admission to a critical care unit allows for early
intervention and a level of care that is difficult to deliver in
the ward environment during this crucial period

45. • Bailey & Love 27th edition
• Sabiston Textbook Of Surgery 21st edition
• ESA Guidelines
• Pubmed