Cardiac asessment risk compatible 2008-2009

Minerva Anestesiol. 1995 May;61(5):173-81. Multivariate prediction of in-hospital
mortality associated with surgical procedures.De Ritis G,
Giovannini C, Picardo S, Pietropaoli P.condotto
• 24,654 pazienti al di sopra di 15 anni di età ,multicentrico
• gennaio 1989 - dicembre 1990
• mortalità nei ricoverati entro 30 gg.
• Variabili :
• età
• Sesso
• Pressione sistolica
• Disfunzione renale
• Disfunzione epatica
• Malattie concomitanti
• Severità della chirurgia
• Priorità della chirurgia
• Durata dell’anestesia.

• With what certainty can post-anaesthetic
outcome be predicted?
• Short, Timothy G.; Kluger, Michal T.
• Volume 11(2), April 1998, pp 209-212

Arvidsson S, Ouchterlony J, Sjosted L, Svardsudd K. Predicting
postoperative adverse events. Clinical efficiency of four general
classification systems. Acta Anaesthesiol Scand 1996;40:783-791
• prospective perioperative risk assessment
project
• 4 simple predictors on 1471 patients
• ASA physical status,
• patient age,
• surgical stress
• visual analogue scale for intuitively appreciated global
risk (RISK-VAS).
– This score was between 0 (almost certain to go through procedure with no
adverse outcome) and 10 (patient will almost certainly suffer a serious
complication).

Arvidsson S, Ouchterlony J, Sjosted L, Svardsudd K. Predicting
postoperative adverse events. Clinical efficiency of four general
classification systems. Acta Anaesthesiol Scand 1996;40:783-791
• All four classification systems correlated to postoperative
adverse events. The best predictor was RISK-VAS. Those with a
score of 4 or more had a 28-fold increased risk of suffering a
severe postoperative adverse event compared with patients with
scores of less than 4. Positive predictive value was 10% with
RISK-VAS score of 7 or more. Low numbers, low mortality and
lack of detail on choice of anaesthetic, however, make the result
difficult to interpret. It is of interest that the overall impression
of the anaesthetist correlated best with outcome, confirming the
role of experience and intuition in predicting outcome.

Klotz HP, Candinas D, Platz A, Horvath A, Dindo D, Schlumpf R,
Largiader F. Preoperative risk assessment in elective general
surgery. Ann Surg 1996;83:1788-1791.
• included the impact of surgery itself on risk stratification. In a prospective
review of 3250 patients using stepwise logistic regression analysis, ASA
status, severity of operative procedure, symptoms of respiratory disease
and malignancy were identified as significant risk factors. Patients were
ranked according to risk into low (5% complication rate), medium (18%
complication rate) and high (33% complication rate) risk categories. Using
a scoring system based on these indices, patients with an adverse
outcome were more likely to be predicted from these indices than from
ASA score alone. Both the above studies emphasize the use of some
surgical impact score on outcome. Like the APACHE scoring system in
intensive care medicine, however, these scoring systems continue to lack
sensitivity, specificity and have positive predictive values of only a few per
cent. Although useful for population assessment, outcome scores suitable
for application in individuals are still lacking.

identified as significant risk factors.
Klotz HP, Candinas D, Platz A, Horvath A, Dindo D, Schlumpf R, Largiader F. Preoperative risk
assessment in elective general surgery. Ann Surg 1996;83:1788-1791.
• ASA status,
• severity of operative procedure
• symptoms of respiratory disease
• Malignancy

outcome
Conseguenza,esito,risultato

Surgical Apgar Score
Regenbogen, Scott E. MD, MPH *+; Lancaster, R Todd MD *+; Lipsitz, Stuart R. ScD ++; Greenberg, Caprice
C. MD, MPH ++; Hutter, Matthew M. MD, MPH +; Gawande, Atul A. MD, MPH *++ Does the Surgical Apgar
Score Measure Intraoperative Performance? Annals of Surgery. 248(2):320-328, August 2008.
• lowest heart rate
• lowest mean arterial pressure
• estimated blood loss
• A score built from these 3 predictors has proved
strongly predictive of the risk of major postoperative
complications and death in general and vascular surgery.
• The score was thus developed using these 3 variables, and their beta coefficients
were used to weight the points allocated to each variable in a 10-point score (
Table 1).

Regenbogen, Scott E. MD, MPH *+; Lancaster, R Todd MD *+; Lipsitz, Stuart R. ScD ++;
Greenberg, Caprice C. MD, MPH ++; Hutter, Matthew M. MD, MPH +; Gawande, Atul
A. MD, MPH *++ Does the Surgical Apgar Score Measure Intraoperative Performance?
Annals of Surgery. 248(2):320-328, August 2008.

Frequenza delle complicanze a seconda del Surgical Apgar
Score
Regenbogen, Scott E. MD, MPH *+; Lancaster, R Todd MD *+; Lipsitz, Stuart R. ScD ++; Greenberg, Caprice C.
MD, MPH ++; Hutter, Matthew M. MD, MPH +; Gawande, Atul A. MD, MPH *++ Does the Surgical Apgar
Score Measure Intraoperative Performance? Annals of Surgery. 248(2):320-328, August 2008.
80
70
60
50
40
30
20
10
0
Ko maggiori
0-2
3-4
5-6
7-8
9-10
%

• We find that even after detailed adjustment for comorbidity
• and procedure-specific risk factors, the amount of
• blood loss, lowest heart rate, and lowest blood pressure were
• still important predictors of the risk of a major complication.
• The Surgical Apgar Score, therefore, conveyed useful prognostic
• information, either in isolation or in combination with
• assessments of the risks that patients brought to the operating
• room. It also may provide an immediate assessment of how
• well or poorly the operation has gone for a patient. In this
• cohort, surgical teams could cut a patient’s risk-adjusted
• odds of major complications nearly in half with a score of
• 9 –10, or conversely, nearly triple the risk-adjusted odds
• with scores 4.
• This finding, that intraoperative blood loss, heart rate,
• and blood pressure are critical predictors of postoperative
• risk, is consistent with a variety of previous observations.

• In summary, we have found that a simple clinimetric
• surgical outcome score can provide both clinical surgeons
• and surgical safety researchers with useful and important
• information. The Surgical Apgar Score integrates components
• of patient susceptibility, procedure complexity, and
• operative performance, providing a measure of immediate
• postoperative condition and prognostication beyond standard
• risk-adjustment. As a decision-support tool, the score can
• inform postoperative prognostication, communication, and
• triage, regardless of the sophistication of preoperative risk
• stratification available. Finally, as a simple intraoperative
• outcome measure and safety improvement metric, it may
• prove useful as an indicator of surgical performance

Il rischio perioperatorio nei malati mentali
Ann Surg. 2008 Jul;248(1):31-8.Postoperative complications in the seriously mentally ill: a systematic review of the literature.
Copeland LA, Zeber JE, Pugh MJ, Mortensen EM, Restrepo MI, Lawrence VA
• Da quel poco che è stato pubblicato la schizofrenia emerge come
fattore di rischio per mortalità e morbilità,quest’ultima
peculiare per frequenza di ileo paralitico postop e confusione mentale.
• questi pazienti sembrerebbero resistenti al dolore .
• Pazienti affetti da disordini depressivi seri presentano una
elevate incidenza di delirio postop e di confusione
mentale.
• Da notare che tali complicanze sono più frequenti quando si
sospendono le terapie abituali nel periodo preop.
– Ann Surg. 2008 Jul;248(1):31-8.Postoperative complications in the seriously mentally ill: a systematic review of the literature.
Copeland LA, Zeber JE, Pugh MJ, Mortensen EM, Restrepo MI, Lawrence VA

• Table 1: Surgical risk scores classified by
outcome measure and need for intra-operative
information
• Scores predicting mortality Scores predicting
morbidity
• Scores not requiring operative information
ASA1 ASA
• APACHE-II8 APACHE-II
• Donati Score16 Goldman Cardiac Risk Index3
• Hardman Index38 Veltkamp Score44

Cardiac Risk Index in Noncardiac Surgery
Criteria Finding
Age (yr) >70 5
Cardiac status MI within 6 mo 10
Ventricular gallop or jugular venous distention (signs of heart
failure)
11
Significant aortic stenosis 3
Arrhythmia other than sinus or premature atrial contractions 7
≥5 premature ventricular contractions/min 7
General medical condition Po2 < 60 mm Hg, Pco2 > 50 mm Hg, K < 3 mmol/L, HCO3 <20
mmol/L, BUN > 50 mg/dL, serum creatinine > 3 mg/dL, elevated
AST, a chronic liver disorder, or bedbound
3
Type of surgery needed Emergency surgery 4
Intraperitoneal, intrathoracic, or aortic surgery 3
*Risk is based on the total number of points:
Level I: 0–5
Level II: 6–12
Level III: 13–25
Level IV: >25
Adapted from Goldman L et al: Multifactorial index of cardiac risk in noncardiac surgical procedures. New
England Journal of Medicine 297:845–850, 1977.

aoNmnauryaIuaemvosSPar talpnegg Preoperative ity
Risk Factors and Surgical Complexity Are More
Predictive of Costs Than Postoperative Complications: A Case Study
Using the National Surgical Quality Improvement Program (NSQIP)
Database [Ann Surg 242(4):463-471, 2005. © 2005 Lippincott
Williams & Wilkins]

aoNmnauryaIuaemvosSPar talpnegg Table Greatest Increase in Mean Variable Direct Costs
ity
The 25 Preoperative Risk Factors Associated With the
3. Comparison of Individual and Sequentially Combined Multiple Linear Regression Models of Preoperative Risk Factors, Surgical
Complexity, and Postoperative Complications Versus Transformed Costs
Table 4. The 10 Postoperative Complications Associated With the Greatest Increase in Mean Variable Direct Costs

aoNmnauryaIuaemvosSPar talpnegg Table ity
3. Comparison of Individual and Sequentially Combined Multiple Linear Regression Models of Preoperative Risk Factors, Surgical
Complexity, and Postoperative Complications Versus Transformed Costs

aoNmnauryaIuaemvosSPar talpnegg ity

Figure 1. Preoperative risk factor cost predictions versus actual transformed
costs. A multivariate regression of all the preoperative risk factors predicted
33% of the variation in costs (P < 0.001). The quartic root transformation
yielded the best fit of the data.

• Clean wounds
• The wound is considered to be clean when the
operative
• procedure does not enter into a normally
colonized
• viscus or lumen of the body. SSI rates in this
class of
• procedures are less than 2%, depending upon
clinical
• variables, and often originate from

• : Arch Otolaryngol Head Neck Surg. 2003
Jul;129(7):739-45. Links
• APACHE II, POSSUM, and ASA scores and the
risk of perioperative complications in
patients with oral or oropharyngeal cancer.
• de Cássia Braga Ribeiro K, Kowalski LP.
• Hospital Cancer Registry and Department of
Head and Neck Surgery and
Otorhinolaryngology, Centro de Tratamento e
Pesquisa Hospital do Câncer A. C. Camargo,

Ann Surg. 2007 Jul;246(1):91-6. The AFC score: validation of a 4-item predicting
score of postoperative mortality after colorectal resection for cancer or
diverticulitis: results of a prospective multicenter study in 1049 patients.Alves A
, Panis Y, Mantion G, Slim K, Kwiatkowski F, Vicaut E.
• age older than 70 years
• neurologic comorbidity
• underweight (body weight loss >10% in <6
months)
• emergency surgery
• All significantly increased postoperative
mortality after resection for cancer or
diverticulitis.

Ireson CL, Schwartz RW. Measuring
outcomes in surgical patients. Am J
Surg.
2001;181:76-80

Arch Surg. 2001 Jan;136(1):55-9. Comment in: Arch Surg. 2001 Mar;136(3):353.
Risk stratification in emergency surgical patients: is the APACHE II score a
reliable marker of physiological impairment? Koperna T, Semmler D, Marian F.

Arch Surg. 2001 Jan;136(1):55-9. Comment in: Arch Surg. 2001 Mar;136(3):353. Risk
stratification in emergency surgical patients: is the APACHE II score a reliable marker
of physiological impairment? Koperna T, Semmler D, Marian F.

Arch Surg. 2001 Jan;136(1):55-9. Comment in: Arch Surg. 2001 Mar;136(3):353. Risk stratification in
emergency surgical patients: is the APACHE II score a reliable marker of physiological impairment?
Koperna T, Semmler D, Marian F.

Preoperative and Long-term Cardiac Risk Assessment Predictive Value of23 Clinical Descriptors,
7 Multivariate Scoring Systems, and Quantitative Dipyridamole Imaging in 360 Patients.JEAN
LETTE, M.D.*,t DAVID WATERS, M.D.,t HELENE BERNIER,* PATRICK CHAMPAGNE, B.Sc.,*.JEAN
LASSONDE, M.D.,* MICHEL PICARD, M.D.,4 MICHEL CERINO, M.D.,* STANLEY NATTEL,
M.D.,tYVAN BOUCHER, M.D.,* FRANCOISE HEYEN, M.D.,* and SERGE DUBE.

Predictive value of dipyridamole-thallium
imaging and five clinical
scoring systems based on
multifactorial analysis.
Lette J, Waters D, Lassonde J,
Dubé S, Heyen F, Picard M,
Morin M.

Table 2. The 25 Preoperative Risk Factors Associated With the Greatest Increase in Mean Variable Direct Costs

Table 3. Comparison of Individual and Sequentially Combined Multiple Linear Regression Models of
Preoperative Risk Factors, Surgical Complexity, and Postoperative Complications Versus Transformed Costs

Postoperative mortality after inpatient surgery:
Incidence and risk factors.Karamarie Fecho,Anne T Lunney,Philip G Boysen,
Peter Rock,Edward A Norfleet. Therapeutics and Clinical Risk Management
0000:0(0) 1–8
• Purpose: This study determined the incidence of and identifi ed risk factors for 48 hour (h)
and 30 day (d) postoperative mortality after inpatient operations.
• Methods: A retrospective cohort study was conducted using Anesthesiology’s
Quality Indicator database as the main data source. The database was
queried for data related to the surgical procedure, anesthetic care, perioperative adverse
events, and birth/death/operation dates. The 48 h and 30 d cumulative incidence of
postoperative mortality was calculated and data were analyzed using Chi-square or Fisher’s
exact test and generalized estimating equations.
• Results: The 48 h and 30 d incidence of postoperative mortality was 0.57% and 2.1%,
respectively. Higher American Society of Anesthesiologists physical status scores,
extremes of age, emergencies, perioperative adverse events and postoperative
Intensive Care Unit admission were identifi ed as risk factors.
• The use of monitored anesthesia care or general anesthesia versus regional or combined
anesthesia was a risk factor for 30 d postoperative mortality only.
• Time under anesthesia care, perioperative hypothermia, trauma, deliberate hypotension
and invasive monitoring via arterial, pulmonary artery or cardiovascular catheters were not
identifi ed as risk factors.
• Conclusions: Our fi ndings can be used to track postoperative mortality rates and to test
preventative interventions at our institution and elsewhere.

risk factors
Postoperative mortality after inpatient surgery:
Incidence and risk factors.Karamarie Fecho,Anne T Lunney,Philip G Boysen,
Peter Rock,Edward A Norfleet. Therapeutics and Clinical Risk Management
0000:0(0) 1–8
• American Society of Anesthesiologists
physical status scores
• extremes of age,
• emergencies,
• perioperative adverse events
postoperative Intensive Care Unit admission

Risk prediction on line
• Risk prediction in surgery
[http://www.riskprediction.org.uk/p
pindex.php].

• This site has been developed to allow surgeons to estimate risk online for
their patients undergoing surgery. This service is provided for individual
use to help surgeons more fully consent their patients by giving mortality
and other surgical risk predictions based on relevant prognostic factors
including age, disease severity and co-morbidity. Risk adjusted operative
mortality can be used as an objective measure of outcome for monitoring
performance within a centre or between centres.

• ACPGBI CRC Model
ACPGBI Malignant Large Bowel Obstruction Model
ACPGBI Lymph Node Harvesting Model
St Mark's Lymph Node Positivity Model
The Cleveland Clinic Colorectal Laparoscopic Conversion The Cleveland Clinic Ileal Pouch Failure Model
CR-POSSUM P-POSSUM O-POSSUM
Vascular-POSSUM models
MUST screening tool (malnutrition)
ACPGBI CRC Model - Association of
Coloproctology of GB & I Colorectal Cancer

calculate a mortality risk online for
patients using the ACPGBI Colorectal
Cancer Model
• Calculate an ACP Score
• Choose a value in each category that matches your patient from the drop down
lists in both the physiological and operative parameters tables below. Default
values (the lowest score) are shown for each category. Simply submitting the form
as it is without changing the values (i.e. a young fit patient having a minor
operation) still gives a % risk for mortality. It is important to say in this model by
ticking the appropriate box whether or not the cancer was resected. The reason
for this is the value allocated to ASA status is dependent upon resection status.
• Parameters
– Age
– Cancer Resection Status cancer resected cancer NOT resected
– ASA Status C
– Cancer Staging :Duke’s
– Operative Urgency ;elective,urgent,emergency

Calculate a CR-POSSUM Score
• Choose a value in each category that matches
your patient from the drop down lists in both
the physiological and operative parameters
tables below. Default values (the lowest
score) are shown for each category. Simply
submitting the form as it is without changing
the values (i.e. a young fit patient having a
minor operation) still gives a v.small % risk for
mortality. The more 'risky' the procedure the
more accurate is the predicted risk calculated
below.

CR POSSUM
• Physiological Parameters
– Age
– Cardiac :No-mild/moderate Carcdiac failure/severe CF
– Systolic BP
– Pulse Rate
– Haemoglobin
– Urea
• If calculating risk in a preoperative patient you will need to estimate the
parameters below. You can return and modify the parameters post-operatively
if required.
– Operative Parameters
– Operation Type
• Peritoneal Contamination
• Malignancy Status
• CEPOD

Calculate a P-POSSUM Score
Choose a value in each category that matches your patient from the drop
down lists in both the physiological and operative parameters tables
below. Default values (the lowest score) are shown for each category.
Simply submitting the form as it is without changing the values (i.e. a
young fit patient having a minor operation) still gives a % risk for
morbidity and mortality. This illustrates that even in the modified P-POSSUM
formula used in this application still overestimates risk in low risk
groups. The more 'risky' the procedure the more accurate is the predicted
risk calculated below.

P-POSSUM score
Physiological Parameters
Age
Cardiac
Respiratory
ECG
Systolic BP
Pulse Rate
Haemoglobin
WBC
Urea
Sodium
Potassium
GCS I
f calculating risk in a preoperative patient you will need to estimate the
parameters below. You can return and modify the parameters post-operatively
if required.
Operative Parameters :Operation Type /Number of procedures/ Operative
Blood Loss/ Peritoneal Contamination/ Malignancy Status/ CEPOD

Calculate an O-POSSUM Score
• Choose a value in each category that matches your patient from the drop
down lists in both the physiological and operative parameters tables
below. You must enter the patients actual age as well as selecting the
age range otherwise an error will occur. Default values (the lowest score)
are shown for each category. Simply submitting the form as it is without
changing the values (i.e. a young fit patient having a minor operation) still
gives a % risk for mortality.

O-POSSUM Score
• Physiological Parameters
– Age Range
– * BOTH FIELDS MUST BE COMPLETED
– Actual Age * BOTH FIELDS MUST BE COMPLETED
– Cardiac
– Respiratory
– ECG
– Systolic BP
– Pulse Rate
– Haemoglobin
– WBC
– Urea
– Sodium
– Potassium
– GCS
– If calculating risk in a preoperative patient you will need to estimate the parameters below. You
can return and modify the parameters post-operatively if required.
• Operative Parameters :Operation Type/ Malignancy Status/ CEPOD

Malnutrition Universal Screening Tool (MUST
‘MUST’ is a five-step screening tool to identify adults, who are malnourished, at risk of
malnutrition, or obese. It also includes management guidelines which can be used
to develop a care plan. The tool is being used both in hospitals and in the
community. It is easy to use and can be used by all care workers.
• Full details of this tool can be found at the following:
• http://www.bapen.org.uk/the-must.htm
• Calculate Risk
• Use the form below to estimate the risk of malnutrition. Please note that the
figures entered for weight must be in kilograms and the figure entered for height
must be in centimetres. Conversion charts for Imperial units can be found here
(opens in a new window).
• Parameters Current weight (Kg) /Current height (cms) /Previous healthy weight*
/Is the patient acutely ill and there has been or is likely to be no nutritional intake
for >5 days? /
• * This is the patients' weight when they were healthy, or the weight prior to any
unplanned weight loss in the last 3-6 months

Application of Portsmouth modification of physiological and operative severity scoring
system for enumeration of morbidity and mortality (P-POSSUM) in pancreatic surgery
Appou Tamijmarane*, Chandra S Bhati, Darius F Mirza, Simon R Bramhall,
David A Mayer, Stephen J Wigmore and John AC Buckels.World Journal of Surgical
Oncology • 2008, 6:39 doi:10.1186/1477-7819-6-39 Abstract Background: Pancreatoduodenectomy (PD) is associated with high incidence of
morbidity and mortality. We have applied P-POSSUM in predicting the incidence of outcome
after PD to identify those who are at the highest risk of developing complications.
• Method: A prospective database of 241 consecutive patients who had PD from January
2002 to September 2005 was retrospectively updated and analysed. P-POSSUM score was
calculated for each patient and correlated with observed morbidity and mortality.
• Results: 30 days mortality was 7.8% and morbidity was 44.8%. Mean physiological score
was 16.07 ± 3.30. Mean operative score was 13.67 ± 3.42. Mean operative score rose to
20.28 ± 2.52 for the complex major operation (p < 0.001) with 2 fold increase in morbidity
and 3.5 fold increase in mortality. For groups of patients with a physiological score of (less
than or equal to) 18, the O:P
• (observed to Predicted) morbidity ratio was 1.3–1.4 and, with a physiological score of >18,
the O:P ratio was nearer to 1. Physiological score and white cell count were significant in a
multivariate model.
• Conclusion: P-POSSUM underestimated the mortality rate. While P-POSSUM analysis gave
a truer prediction of morbidity, underestimation of morbidity and potential for systematic
inaccuracy in prediction of complications at lower risk levels is a significant issue for
pancreatic surgery.

American Journal of Surgery - Volume 194, Issue 2 (August 2007) -
Estimation of physiologic ability and surgical stress (E-PASS) as a predictor of immediate
outcome after elective abdominal aortic aneurysm surgery
Tjun Tang,Stewart R. Walsh,Thomas R. Fanshawe, Jonathan H. Gillard,Umar Sadat,
Kevin Varty, Michael E. Gaunt, Jonathan R. Boyle.
• Haga et al [10] derived and validated the Estimation of Physiologic Ability and
Surgical Stress (E-PASS) scoring system for risk stratification of patients
undergoing elective general gastrointestinal (GI) surgery. Furthermore, it has been
externally validated in a different geographical setting from where it was
originally developed and has been shown to be reproducible in accurately
predicting outcome following elective GI surgery [11]. This system comprises a
pre-operative risk score (PRS), a surgical stress score (SSS), and a comprehensive
risk score (CRS), which is calculated from the PRS and SSS. E-PASS was based on
the premise that morbidity and mortality rates can be correlated with the
patient’s physiologic risk and the surgical stress applied. Surgical stress can be
estimated, in general, because tissue destruction, bleeding and ischemia caused
by basic surgical techniques produce inflammatory cytokines, which are thought
to be an underlying mechanism in the development of organ failure following a
surgical insult [12].

• [10] Haga Y., Ikei S., Ogawa M.: Estimation of Physiologic Ability and
Surgical Stress (E-PASS) as a new prediction scoring system for post-operative
morbidity and mortality following gastrointestinal surgery.
Surg Today 29. 219-225.1999;
[11] Oka Y., Nishijima J., Oku K., et al: Usefulness of an Estimation of
Physiologic Ability and Surgical Stress (E-PASS) scoring system to predict
the incidence of postoperative complications in gastrointestinal surgery.
World J Surg 29. 1029-1033.2005;
[12] Ogawa M.: Mechanisms of the development of organ failure
following surgical insult: the “second attack” theory. Clin Intens
Care 7. 34-38.1996;
[13] Haga Y., Ikei S., Wada Y., et al: Evaluation of an Estimation of
Physiologic Ability and Surgical Stress (E-PASS) scoring system to predict
postoperative risk: a multicenter prospective study. Surg Today 31. 569-
574.2001;

Incidence of mortality and morbidity accordingto CRS. The graph appears to
demonstrate that patients in the ≥1.0 categoryare at particularly high risk
of mortality, and in the .5 to <1.0 and ≥1.0categories at particularly high risk
of morbidity. Bars show 95% confidence intervals Estimation of physiologic ability and
surgical stress (E-PASS) as a predictor of immediate outcome after elective abdominal aortic aneurysm
surgery

Estimation of physiologic ability and surgical stress (E-PASS) as a predictor of immediate outcome after
elective abdominal aortic aneurysm surgery

Estimation of physiologic ability and surgical stress (E-PASS) as a predictor of
immediate outcome after elective abdominal aortic aneurysm surgery
• Risk adjustment is important in comparative audit and in general, models of adverse outcome are
formed using logistic regression as the statistical technique. Unfortunately, the current scoring
systems that have been developed to assess postoperative mortality and morbidity involve collection
of numerous variables and therefore databases are likely to be incomplete [22], [23]. The Physiological and
Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) [24] has been
proposed as a predictor equation of complications and mortality taking into account differences in
case-mix. A major drawback of the POSSUM approach is that it requires up to 19 perioperative
physiologic data items per patient, which are not necessarily collected as part of routine clinical care.
Furthermore, it was criticized because it overpredicted the mortality rate of patients at low risk [25].
Portsmouth-POSSUM and Vascular-POSSUM, although more accurate predictors of death than
POSSUM in vascular patients, have not been shown to be robust in different geographic locations [26], [27].
E-PASS has also been compared to POSSUM and P-POSSUM in elective GI surgery, which revealed that
although both systems had significant correlations with the observed rates of postoperative
complications, the POSSUM equations overpredicted mortality [28].

Estimation of physiologic ability and surgical stress (E-PASS) as
a predictor of immediate outcome after elective abdominal
aortic aneurysm surgery
• We have started to prospectively compare E-PASS with the different POSSUM predictor
equations in vascular surgery to evaluate its usefulness in defining quality of care.
Undoubtedly, the practical logistics associated with collecting such a large dataset in the
POSSUM models have been one of the main factors inhibiting their universal adoption
by vascular surgeons. E-PASS uses far fewer variables and therefore has obvious
advantages over POSSUM in amount of data entry needed and the complexity of the
analysis. We have found that the CRS can be quickly calculated immediately after the
operation and the different parameters to calculate PRS and SSS were relatively easy to
collect, as demonstrated by the low number of cases excluded. The POSSUM scoring
system can only be used as a prediction guideline if the physiology-only equations are
used. Generally, the estimated mortality rates can be determined only after the
pathologic results are known [24]. Moreover POSSUM devised for exponential analysis
does not provide accurate predicted mortality rates for individual patients. The E-PASS
model was developed originally as a prediction guideline for decision-making and
therefore the estimated mortality rates can be computed easily after an operation. It
was previously reported that E-PASS was useful in estimating surgical costs in GI surgery
[29]. CRS had a significant positive correlation to the duration and costs of hospital stay.
They showed an equation for estimating surgical costs and compared a real to
estimated costs among hospitals, proposing a risk-based payment system because
hospitals that treat more high-risk patients would not only show higher mortality and
morbidity rates but also surgical costs of hospital stay. Although not performed in this

Estimation of physiologic ability and surgical stress (E-PASS) as a predictor of
immediate outcome after elective abdominal aortic aneurysm surgery
• The strong correlation between PRS and outcome (P < .0001 for mortality and
morbidity) may allow the vascular surgeon to predict risk in an individual patient
before surgery. Furthermore, this risk can be discussed confidently with both
patient and relatives while gaining informed consent. If the risk predicted by PRS is
too high for a patient, a less invasive procedure such as endovascular stenting or
conservative management may be considered. The fact that PRS, on an individual
basis, was extremely powerful in predicting mortality and morbidity ranges may
allow for the reduction of data required for a national vascular database without
compromising the statistical basis of comparative audit. Prytherch et al were able to
successfully model surgical outcomes in arterial surgery using a minimal dataset of
blood tests known as “VBHOM” (vascular biochemistry and hematology outcome
models) [3]. This has the advantage that it is universal in its application and does
not require operative data. Many models like POSSUM suffer from the same
weakness, which is, by definition, that they exclude patients who were either not
offered or refused surgery. The PRS component of E-PASS, in the future, may be
developed and validated like VBHOM to overcome this problem.

• Estimation of Physiologic Ability and
Surgical Stress (E-PASS) scoring
system:
• E-PASS=a pre-operative risk score (PRS), a
surgical stress score (SSS), and a
comprehensive risk score (CRS), which is
calculated from the PRS and SSS.
• CRS=PRS+SSS
• E-PASS=K*CRS

equations of the E-PASS scoring
system
• The equations of the E-PASS scoring system are as follows (data from Haga et al1):
(1) Estimation of physiologic ability and surgical stress (E-PASS)
as a predictor of immediate outcome after elective
abdominal aortic aneurysm surgery

equations of the E-PASS scoring system are as follows (data from
Haga et al1):
• (1) PRS = -0.0686 + 0.00345X1 +0.323X2
+0.205X3
+0.153X4 +0.148X5 +0.0666X6,
where X1 is age; X2, the presence (1) or absence
(0) of severe heart disease; X3, the presence (1)
or absence (0) of severe pulmonary disease; X4,
the presence (1) or absence (0) of diabetes
mellitus; X5, the performance status index
(range, 0-4); and X6, the American Society of
Anesthesiologists' physiological status
classification (range, 1-5).

• (1) PRS = -0.0686 + 0.00345X1 +0.323X2
+0.205X3
+0.153X4 +0.148X5 +0.0666X6,
dove: X1 è etò, X2,la presenza (1) o assenza (0)
di malattia cardiaca severa; X3
la presenza (1) o
assenza (0)di malattia polmonare severa; X4, la
presenza (1) o assenza (0) di diabete mellitus;
X5, il performance status index (range, 0-4); X6,
la classificazione di stato fisico della American
Society of Anesthesiologists (ASA Ps) (range, 1-
5).

• Severe heart disease is defined as heart failure of New York Heart
Association class III or IV or severe arrhythmia requiring mechanical
support.
• Severe pulmonary disease is defined as any condition with a percentage
vital capacity of less than 60% and/or a percentage forced expiratory
volume in 1 second of less than 50%.
• Diabetes mellitus is defined according to the World Health Organization
criteria.
• Performance status index is defined by the Japanese Society for Cancer
Therapy.

SSS:surgical stress core
• (2) SSS = -0.342 + 0.0139X1 +0.0392X2 +0.352X3,
where X1 is blood loss (in grams) divided by
body weight (in kilograms); X2, the operating
time (in hours); and X3, the extent of the skin
incision (0 indicates a minor incision for
laparoscopic or thoracoscopic surgery,
including laparoscopic- or thoracoscopic-assisted
surgery; 1, laparotomy or
thoracotomy alone; and 2, laparotomy and
thoracotomy).
(

• 2) SSS = -0.342 + 0.0139X1 +0.0392X2 +0.352X3,
dove X1 è la perdita ematica (in grammi) diviso
per il peso corporeo (in kg); X2, tempo
operatorio ( h); X3, l’estensione della incisione
cutanea: (0 indica una incisione minore
laparoscopica o toracoscopica; 1, laparotomia
o toracototomia da sole ; 2, laparotomia e
toracotomia

comprehensive risk score (CRS)
• 3) CRS = -0.328 + (0.936 x PRS) + (0.976 x SSS).

Esempio di di EPass
• 70 anni
• Copd
• Iperteso
• Gastrtect 5 h,perdite 800 ml stimate…….
• PRS = -0.0686 + 0.00345*70+0.323*0
+0.205*1 +0.153X4
+0.148*??X5 +0.0666*3,assumiamo X5=1…
• PRS=3,49
• SSS =0,4345
• CRS = -0.328 + (3,26) + (0,4240).=3,35 ,cioè mortalità
0-5%,morbilità 44%

Quality Assessment in High-Acuity Surgery
Volume and Mortality Are Not Enough
Charles M. Vollmer, Jr, MD; Wande Pratt, BA; Tsafrir Vanounou, MD, MBA;
Shishir K. Maithel, MD; Mark P. Callery, MD
• Expected Morbidity
• Expected morbidity was predicted for each of the 296 consecutive
• patients in the following manner. In accordance with
• POSSUM, 12 physiologic and 6 operative variables were prospectively
• recorded for each patient undergoing pancreatic resection.
• 16 Physiologic variables included patient age, Glasgow
• coma score, the presence of cardiac and respiratory symptoms,
• vital signs (systolic blood pressure and pulse), serum biochemistry
• evaluation (urea nitrogen, sodium, and potassium
• levels), hematologic investigation (white blood cell count and
• hemoglobin level), and electrocardiographic and chest radiographic
• findings. Operative variables included the magnitude
• of the operation, the number of operations performed within
• 30 days, intraoperative blood loss, the degree of peritoneal contamination,
• the presence or absence of malignancy, and the timing

The value of Modified Early Warning Score (MEWS) in surgical in-patients: a
prospective observational study J GARDNER-THORPE1, N LOVE2, J
WRIGHTSON2, S WALSH1, N KEELING2
• 1Department of Surgery, Addenbrooke’s Hospital, Cambridge, UK
• 2Department of Surgery, West Suffolk Hospital, Bury St Edmunds, UK
• INTRODUCTION The Modified Early Warning Score (MEWS) is a simple, physiological
score that may allow improvement in the quality and safety of management
provided to surgical ward patients. The primary purpose is to prevent delay in
intervention or
• transfer of critically ill patients.
• PATIENTS AND METHODS A total of 334 consecutive ward patients were
prospectively studied. MEWS were recorded on all patients and the primary end-point
was transfer to ITU or HDU.
• RESULTS Fifty-seven (17%) ward patients triggered the call-out algorithm by scoring
four or more on MEWS. Emergency patients were more likely to trigger the system
than elective patients. Sixteen (5% of the total) patients were admitted to the ITU or
• HDU. MEWS with a threshold of four or more was 75% sensitive and 83% specific for
patients who required transfer to ITU or HDU.
• CONCLUSIONS The MEWS in association with a call-r

Faraday, Nauder M.D. *; Martinez, Elizabeth A. M.D. +; Scharpf, Robert B. M.S. ++; Kasch-Semenza,
Laura M.S. [S]; Dorman, Todd M.D. *; Pronovost, Peter J. M.D., Ph.D. *; Perler, Bruce M.D. [//];
Gerstenblith, Gary M.D. #; Bray, Paul F. M.D. **; Fleisher, Lee A. M.D. ++ Platelet Gene Polymorphisms
and Cardiac Risk Assessment in Vascular Surgical Patients. Anesthesiology. 101(6):1291-1297,
December 2004.
• Abstract
• Background: Current perioperative cardiac risk assessment tools use historic
and surgical factors to stratify patient risk. Polymorphisms in platelet
glycoprotein (GP) IIIa and GPIb[alpha] are associated with myocardial ischemic
risk in nonsurgical settings, but their relation to perioperative ischemia is
unclear. The authors hypothesized that platelet genotype would be an
independent predictor of postoperative myocardial ischemia and would
improve risk assessment when added to clinical factors.
• Methods: One hundred ninety-six patients who underwent infrainguinal,
abdominal aortic, or thoracoabdominal vascular surgery were evaluated for
clinical and genetic factors that might predict the development of
postoperative myocardial ischemia. Genomic DNA was genotyped for the
Leu33Pro polymorphism of GPIIIa and the Thr145Met polymorphism of
GPIb[alpha]. Myocardial ischemic outcome was determined by review of the
medical record for cardiac death or myocardial infarction and by surveillance
troponin I and automated continuous 12-lead electrocardiographic analysis.

Faraday, Nauder M.D. *; Martinez, Elizabeth A. M.D. +; Scharpf, Robert B. M.S. ++;
Kasch-Semenza, Laura M.S. [S]; Dorman, Todd M.D. *; Pronovost, Peter J. M.D.,
Ph.D. *; Perler, Bruce M.D. [//]; Gerstenblith, Gary M.D. #; Bray, Paul F. M.D. **;
Fleisher, Lee A. M.D. ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment
in Vascular Surgical Patients. Anesthesiology. 101(6):1291-1297, December 2004.
• Results: Sixty-five patients (33%) experienced one or more ischemic
endpoints (2% death, 5% myocardial infarction, 20% troponin+, 22%
electrocardiogram+). The Pro33 (adjusted odds ratio [OR], 2.4 [95%
confidence interval, 1.2–6.2]) and Met145 (OR 3.4 [1.4–9.3]) genotypes
were independent predictors of composite ischemic outcome by
multivariate regression, as were diabetes mellitus (OR 4.0 [1.7–12.5]),
abdominal aortic surgery (OR 4.1 [1.7–14.4]), and thoracoabdominal
aortic surgery (OR 6.4 [2.7–23.8]). The addition of platelet gene
polymorphisms to clinical factors improved fit (likelihood ratio testing chi-square
= 13.5, P < 0.001) of an ischemia prediction model. The derived risk
assessment tool had a receiver operator characteristic curve of 0.73
(0.65–0.81) compared with 0.64 (0.57–0.74) for a model excluding genetic
factors (P = 0.04). A significant relation between the GPIb[alpha]
polymorphism and ischemic outcome remained after excluding
electrocardiographic ischemia from the composite endpoint.

Szekely, Andrea MD, PhD, DEAA; Balog, Piroska PhD; Benko, Erzsebet MD; Breuer,
Tamas MD; Szekely, Judit MD; Kertai, Miklos D. MD, PhD; Horkay, Ferenc MD, PhD;
Kopp, Maria S. MD, PhD; Thayer, Julian F. PhD Anxiety Predicts Mortality and
Morbidity After Coronary Artery and Valve Surgery-A 4-Year Follow-Up Study.
Psychosomatic Medicine. 69(7):625-631, September 2007
• . Objective: To explore the long-term effect of anxiety and depression on outcome
after cardiac surgery. To date, the relationship between psychosocial factors and
future cardiac events has been investigated mainly in population-based studies, in
patients after cardiac catheterization or myocardial infarction.
• Methods: In total, 180 patients who underwent cardiac surgery using
cardiopulmonary bypass were prospectively studied and followed up for 4 years.
Anxiety (Spielberger State-Trait Anxiety Inventory, STAI-S/STAI-T), depression
(Beck Depression Inventory, BDI), living alone, and education level along with
clinical risk factors and perioperative characteristics were assessed. Psychological
self-report questionnaires were completed preoperatively and 6, 12, 24, 36, and
48 months after discharge. Clinical end-points were mortality and cardiac events
requiring hospitalization during follow-up.
• Results: Average preoperative STAI-T score was 44.6 +/- 10. Kaplan-Meier analysis
showed a significant effect of preoperative STAI-T >45 points (p = .008) on
mortality. In multivariate models, postoperative congestive heart failure (OR: 10.8;
95% confidence interval [CI]:2.9-40.1; p = .009) and preoperative STAI-T (score OR:
1.07; 95% CI: 1.01-1.15; p = .05) were independently associated with mortality.
The occurrence of cardiovascular hospitalization was independently associated
with postoperative intensive care unit days (OR: 1.41; 95% CI: 1.01-1.96; p = .045)

BAYRAM, AHMET SAMI; CANDAN, TARIK; GEBITEKIN, CENGIZ Preoperative maximal
exercise oxygen consumption test predicts postoperative pulmonary morbidity
following major lung resection. Respirology. 12(4):505-510, July 2007
• Background and objective: Pulmonary resection carries a significant morbidity and
mortality. The utility of maximal oxygen uptake test (VO2max) to predict
cardiopulmonary complications following major pulmonary resection was
evaluated.
• Methods: Following standard preoperative work-up and VO2max testing, 55
patients (49 male; mean age 59 years, range 20-74) underwent major pulmonary
surgery: lobectomy (n = 31), bilobectomy (n = 6) and pneumonectomy (n = 18). An
investigator blinded to the preoperative assessment prospectively collected data
on postoperative cardiopulmonary complications. Patients were divided into two
groups according to preoperative VO2max and also according to FEV1. The
frequency of postoperative complications in the groups was compared.
• Results: Complications were observed in 19 (34.5%) patients, 11 of which were
pulmonary (20%). There were two deaths (3.6%), both due to respiratory failure.
Preoperative FEV1 failed to predict postoperative respiratory complications. Five of
36 patients with a preoperative FEV1 > 2 L suffered pulmonary complications,
compared with six of 19 patients with FEV1 < 2 L. Cardiopulmonary complications

• Max VO2 < 15 ml/kg indica aumento di
morbilità dopo interv.sul polmone

Wei, A. C. 1; Poon, R. Tung-Ping 2; Fan, S.-T. 2; Wong, J. 2 Risk
factors for perioperative morbidity and mortality after extended
hepatectomy for hepatocellular carcinoma. British Journal of
Surgery. 90(1):33-41, January 2003.
• Background: Extended hepatectomy with resection of more than four segments is a
high-risk operation, especially in patients with hepatocellular carcinoma (HCC)
associated with chronic liver disease. This study evaluated the risk factors for morbidity
and mortality following extended hepatectomy for HCC.
• Methods: Preoperative and intraoperative variables of 155 patients who underwent
extended hepatectomy for HCC were analysed to identify risk factors for postoperative
morbidity and mortality.
• Results: The overall morbidity rate was 55[middle dot]5 per cent (n = 86). Most
morbidity was due to ascites or pleural effusion. Significant life-threatening
complications occurred in 20[middle dot]0 per cent (n = 31). The perioperative mortality
rate was 8[middle dot]4 per cent (n = 13). Multivariate analysis found that portal
clamping (P = 0[middle dot]023) and perioperative blood transfusion (P < 0[middle
dot]001) were risk factors for morbidity, whereas perioperative blood transfusion (P <
0[middle dot]001) was the only risk factor for significant morbidity. Co-morbid illness (P
= 0[middle dot]019) and perioperative blood transfusion (P = 0[middle dot]004) were
risk factors for perioperative mortality.
• Conclusion: Meticulous operative techniques to minimize blood loss and transfusion,
while avoiding a prolonged Pringle manoeuvre, may help reduce postoperative
morbidity. Avoidance of perioperative blood transfusion and careful preoperative

Lobo, Suzana M. A. MD; Salgado, Paula F. MD; Castillo, Vania G. T. RN; Borim,
Aldenis A. MD; Polachini, Carlos A. MD; Palchetti, Jose C. MD; Brienzi, Sergio
L. A. MD; de Oliveira, Granville G. PhD Effects of maximizing oxygen delivery
on morbidity and mortality in high-risk surgical patients. Critical Care
Medicine. 28(10):3396-3404, October 2000
• Objective: To evaluate the effects of maximizing the oxygen delivery on
morbidity and mortality in patients >60 yrs of age and/or with chronic
diseases of vital organs who underwent major elective surgery.
• Design: Prospective, randomized, controlled trial.
• Setting: A 24-bed general intensive care unit of a teaching hospital.
• Patients: Thirty-seven high-risk patients who underwent major surgery.
• Interventions: The hemodynamic and oxygen transport variables and
outcomes in 18 patients (control group) treated to maintain normal values
of oxygen delivery were compared with 19 patients (protocol group)
treated to maintain "supranormal" values. Therapy in both groups
consisted of volume expansion and, when necessary, dobutamine to
reach target values, during the surgery and 24 hrs postoperatively.
• Measurements and Main Results: We interrupted the study because of a
significant difference in the 60-day mortality rate. The mortality rate in
the control group was significantly higher when compared with the
protocol group (9/18 [50%] vs. 3/19 [15.7%], p < .05). The prevalence of
clinical and infectious complications was higher in the control group than

• Massimizzazione del traspoprto di O2 con
dobutamina migliora la prognosi nell’anziano

Klotz, H. P.; Candinas, D.; Platz, A.; Horvath, A.; Dindo, D.; Schlumpf,
R.; Largiader, F. Preoperative risk assessment in elective general
surgery. British Journal of Surgery. 83(12):1788-1791, December
1996.
• Despite improved surgical techniques there is still a risk of mortality in
elective general surgery. In a prospective study preoperative data from
3250 patients were collected and compared with postoperative systemic
complications, using univariate chi squared analysis. Highly significant (P <
0.00001) variables were subjected to stepwise logistic regression analysis.
The severity of operative procedure, higher American Society of
Anesthesiologists (ASA) grade, symptoms of respiratory disease and
malignancy were found to be significant risk factors predicting
postoperative morbidity (P < 0.05). Using these four variables, a simple
preoperative risk scoring system has been defined. Class A (up to 5 points)
was defined as a low-risk group (systemic complication rate 5.0 per cent),
class B (5-7 points) was intermediate risk (systemic complication rate 17.9
per cent) and class C (8-10 points) was high risk (systemic complication
rate 33.3 per cent). Patients at high risk for perioperative and
postoperative complications are more likely to be identified by this
analysis than by using the ASA classification alone

Fattori di rischio
Klotz, H. P.; Candinas, D.; Platz, A.; Horvath, A.; Dindo, D.; Schlumpf, R.; Largiader, F. Preoperative
risk assessment in elective general surgery. British Journal of Surgery. 83(12):1788-1791, December
1996
• La severità dell’intervento
• ASA
• Sintomi di malattia respiratoria
• Tumore
– Classe A:< 5 punti,basso rischio complicazioni sistemiche
5%
– Classe B:5-7 punti,rischio intermedio,complicazioni
sistemiche 17.9%
– Classe C:8-10 punti ,alto rischio,complicazioni sistemiche
33.3%

• usinSchouten, Olaf MD a; Poldermans, Don MD, PhD b; Visser, Loes MD b;
Kertai, Miklos D. MD c; Klein, Jan MD, PhD b; van Urk, Hero MD, PhD a;
Simoons, Maarten L. MD, PhD c; van de Ven, Louis L. MD, PhD c;
Vermeulen, Maarten MSc c; Bax, Jeroen J. MD, PhD d; Lameris, Thomas
W. MD, PhD c; Boersma, Eric PhD c Fluvastatin and bisoprolol for the
reduction of perioperative cardiac mortality and morbidity in high-risk
patients undergoing non-cardiac surgery: Rationale and design of the
DECREASE-IV study. American Heart Journal. 148(6):1047-1052,
December 2004

Eur J Vasc Endovasc Surg. 2004 Oct;28(4):343-52. Links
A combination of statins and beta-blockers is independently associated with a reduction in
the incidence of perioperative mortality and nonfatal myocardial infarction in patients
undergoing abdominal aortic aneurysm surgery.
Kertai MD, Boersma E, Westerhout CM, Klein J, Van Urk H, Bax JJ, Roelandt JR, Poldermans D
.
• Department of Cardiology, Erasmus MC,
Rotterdam, The Netherlands.
• OBJECTIVE: To investigate the combined
beneficial effect of statin and beta-blocker use
on perioperative mortality and myocardial
infarction (MI) in patients undergoing
abdominal aortic aneurysm surgery (AAA).
BACKGROUND: Patients undergoing elective
AAA-surgery identified by clinical risk factors
and dobutamine stress echocardiography
(DSE) as being at high-risk often have

Eur J Vasc Endovasc Surg. 2004 Oct;28(4):343-52. Links
A combination of statins and beta-blockers is independently associated with a
reduction in the incidence of perioperative mortality and nonfatal myocardial
infarction in patients undergoing abdominal aortic aneurysm surgery.
Kertai MD, Boersma E, Westerhout CM, Klein J, Van Urk H, Bax JJ, Roelandt JR,
Poldermans D.
• 570 pazienti sottoposti a chirurgic dell’aorta addominale
• Perioperative mortality or MI occurred in 51 (8.9%) patients.
• Perioperative mortality or MI significantly lower in statin users compared
to nonusers (3.7% vs. 11.0%; crude odds ratio (OR): 0.31, 95% confidence
interval (CI): 0.13-0.74; p=0.01).
• Beta-blocker use was also associated with a significant reduction in the
composite endpoint (OR: 0.24, 95% CI: 0.11-0.54).
• Patients using a combination of statins and beta-blockers appeared to be
at lower risk for the composite endpoint across multiple cardiac risk strata;
particularly patients with 3 or more risk factors experienced
significantly lower perioperative events. CONCLUSIONS: A
combination of statin and beta-blocker use in patients with AAA-surgery is
associated with a reduced incidence of perioperative mortality and
nonfatal MI particularly in patients at the highest risk.
•

PhD; Eaton, Charles B. MD; Poses, Roy M. MD; Uttley, Georgette
RN; Sharma, Satish C. MD; Vezeridis, Michael MD; Khuri, Shukri F.
MD; Friedmann, Peter D. MD Preoperative Hematocrit Levels and
Postoperative Outcomes in Older Patients Undergoing Noncardiac
Surgery. JAMA. 297(22):2481-2488, June 13, 2007 • . Context: Elderly patients are at high risk of both abnormal hematocrit values and cardiovascular
complications of noncardiac surgery. Despite nearly universal screening of patients for abnormal
preoperative hematocrit levels, limited evidence demonstrates the adverse effects of preoperative
anemia or polycythemia.
• Objective: To evaluate the prevalence of preoperative anemia and polycythemia and their effects on
30-day postoperative outcomes in elderly veterans undergoing major noncardiac surgery.
• Design: Retrospective cohort study using the VA National Surgical Quality Improvement Program
database. Based on preoperative hematocrit levels, we stratified patients into standard categories of
anemia (hematocrit <39.0%), normal hematocrit (39.0%-53.9%), and polycythemia (hematocrit
>=54%). We then estimated increases in 30-day postoperative cardiac event and mortality risks in
relation to each hematocrit point deviation from the normal category.
• Setting and Patients: A total of 310 311 veterans aged 65 years or older who
underwent major noncardiac surgery between 1997 and 2004 in 132 Veterans'
Affairs medical centers across the United States.

Wu, Wen-Chih MD; Schifftner, Tracy L. MS; Henderson, William G. PhD; Eaton, Charles
B. MD; Poses, Roy M. MD; Uttley, Georgette RN; Sharma, Satish C. MD; Vezeridis,
Michael MD; Khuri, Shukri F. MD; Friedmann, Peter D. MD Preoperative Hematocrit
Levels and Postoperative Outcomes in Older Patients Undergoing Noncardiac Surgery.
JAMA. 297(22):2481-2488, June 13, 2007
• Main Outcome Measures: The primary outcome measure was 30-day
postoperative mortality; a secondary outcome measure was composite 30-
day postoperative mortality or cardiac events (cardiac arrest or Q-wave
myocardial infarction).
• Results: Thirty-day mortality and cardiac event rates increased
monotonically, with either positive or negative deviations from normal
hematocrit levels. We found a 1.6% (95% confidence interval, 1.1%-2.2%)
increase in 30-day postoperative mortality associated with every
percentage-point increase or decrease in the hematocrit value from the
normal range. Additional analyses suggest that the adjusted risk of 30-day
postoperative mortality and cardiac morbidity begins to rise when
hematocrit levels decrease to less than 39% or exceed 51%.
• Conclusions: Even mild degrees of preoperative anemia or polycythemia
were associated with an increased risk of 30-day postoperative mortality
and cardiac events in older, mostly male veterans undergoing major
noncardiac surgery. Future studies should determine whether these findings
are reproducible in other populations and if preoperative management of

Wu, Wen-Chih MD; Schifftner, Tracy L. MS; Henderson, William G. PhD; Eaton, Charles
B. MD; Poses, Roy M. MD; Uttley, Georgette RN; Sharma, Satish C. MD; Vezeridis,
Michael MD; Khuri, Shukri F. MD; Friedmann, Peter D. MD Preoperative Hematocrit
Levels and Postoperative Outcomes in Older Patients Undergoing Noncardiac Surgery.
JAMA. 297(22):2481-2488, June 13, 2007
• Anche piccole deviazioni da un HCT normale
influenzano morbilità e mortalità nel paz
anziano……….

Murray, P. 1,*; Whiting, P. 1; Hutchinson, S. P. 1; Ackroyd, R. 2;
Stoddard, C. J. 2; Billings, C. 3 Preoperative shuttle walking
testing and outcome after oesophagogastrectomy. BJA: British
Journal of Anaesthesia. 99(6):809-811, December 2007.
• Background: Objective assessment of cardiorespiratory reserve has been
recommended before major surgery to identify patients with impaired oxygen
delivery who may be at increased operative risk. Access to formal
cardiopulmonary exercise (CPX) testing is limited outside larger centres. Following
a previous audit of morbidity and mortality after oesophagectomy, we decided to
add a simpler form of exercise test to our preoperative screen and review the
outcomes.
• Methods: Fifty-one patients who had surgical resection of an oesophageal cancer
in our unit between April 2002 and April 2005 carried out an incremental shuttle
walk exercise test before operation. Thirty-day outcome data were collected for
each patient.
• Results: Overall mortality in the group was 10%. No patient who walked 350 m or
more died within 30 days. Five of the eight patients who could not achieve this
distance died and two others remained in the critical care unit at 30 days.
• Conclusion: Preoperative shuttle walk testing using a standard protocol appears to
be a sensitive indicator of operative risk in this group of patients. The apparent
threshold value of 350 m is consistent with previously reported measures of
functional capacity obtained using formal CPX testing

Murray, P. 1,*; Whiting, P. 1; Hutchinson, S. P. 1; Ackroyd, R. 2;
Stoddard, C. J. 2; Billings, C. 3 Preoperative shuttle walking
testing and outcome after oesophagogastrectomy. BJA: British
Journal of Anaesthesia. 99(6):809-811, December 2007.
• Mortalità e ricoveri prolungati nei pazienti
candidati ad esofagectomia che non
camminano > 350 m.

• Dillioglugil, Ozdal; Leibman, Bryan D.;
Leibman, Neville S.; Kattan, Michael W.;
Rosas, Alejandro L.; Scardino, Peter T. Risk
Factors for Complications and Morbidity After
Radical Retropubic Prostatectomy. Journal of
Urology. 157(5):1760-1767, May 1997.
Purpose: With recognition of the efficacy of
surgical therapy for prostate cancer, there has
been a marked increase in the number of
radical prostatectomies performed, and
substantial changes in surgical technique and

Prostatectomia radicale retropubica:
Dillioglugil, Ozdal; Leibman, Bryan D.; Leibman, Neville S.; Kattan, Michael W.; Rosas, Alejandro L.;
Scardino, Peter T. Risk Factors for Complications and Morbidity After Radical Retropubic Prostatectomy.
Journal of Urology. 157(5):1760-1767, May 1997
• Complicanze maggiori e mortalità
associate con:
• ASA
• Perdite ematiche intraop

Bennett-Guerrero, Elliott M.D. *; Panah, Michael H. M.D. +; Robin Barclay, G.
Ph.D. ++; Bodian, Carol A. Dr.P.H. [S]; Winfree, Wanda J. B.S.N. [//]; Andres,
Lewis A. B.S. #; Reich, David L. M.D. **; Mythen, Michael G. M.D. ++
Decreased Endotoxin Immunity Is Associated with Greater Mortality and/or
Prolonged Hospitalization after Surgery. Anesthesiology. 94(6):992-998, June
2001
• Background: Patients undergoing noncardiac surgery often develop postoperative
morbidity, potentially attributable to endotoxemia and the systemic inflammatory response
syndrome. Endogenous antibodies to endotoxin may confer protection from endotoxin-mediated
toxicity. The authors sought to determine the association of preoperative
antiendotoxin immunity and death or prolonged hospitalization in a broad population of
general surgical patients undergoing major surgery.
• Methods: To test the hypothesis that low preoperative serum antiendotoxin core antibody
(EndoCAb) concentration is an independent predictor of adverse outcome after general
surgery, 1,056 patients undergoing routine noncardiac surgery were enrolled into a
prospective, blinded, cohort study. Immunoglobulin M EndoCAb, immunoglobulin G
EndoCAb, total immunoglobulin M, and immunoglobulin G concentrations were measured in
serum obtained preoperatively. A physiologic risk score using the established POSSUM
criteria was assigned preoperatively to each patient. The primary predefined composite end
point (postoperative complication) was either in-hospital death or postoperative length of
stay greater than 10 days. Multivariate logistic regression was used to test the study
hypothesis.

Bennett-Guerrero, Elliott M.D. *; Panah, Michael H. M.D. +; Robin Barclay, G. Ph.D. ++;
Bodian, Carol A. Dr.P.H. [S]; Winfree, Wanda J. B.S.N. [//]; Andres, Lewis A. B.S. #;
Reich, David L. M.D. **; Mythen, Michael G. M.D. ++ Decreased Endotoxin Immunity Is
Associated with Greater Mortality and/or Prolonged Hospitalization after Surgery.
Anesthesiology. 94(6):992-998, June 2001
• Results: Overall, postoperative complication occurred in 234 of the 1,056
patients (22.1%). Lower immunoglobulin M EndoCAb concentration (P =
0.006) predicted increased risk of postoperative complication
independent of POSSUM physiologic risk score (P < 0.001). In contrast,
total immunoglobulin M and total immunoglobulin G concentrations did
not predict adverse outcome. Complications involved multiple organ
systems and were generally unrelated to the type or site of surgery,
consistent with the systemic inflammatory response syndrome.
• Conclusions: Adverse outcome after routine noncardiac surgery is
common and is predicted in part by low concentrations of EndoCAb. The
authors' findings suggest that endotoxemia may be a cause of
postoperative morbidity after routine noncardiac surgery

Bennett-Guerrero, Elliott M.D. *; Panah, Michael H. M.D. +; Robin Barclay, G. Ph.D. ++;
Bodian, Carol A. Dr.P.H. [S]; Winfree, Wanda J. B.S.N. [//]; Andres, Lewis A. B.S. #;
Reich, David L. M.D. **; Mythen, Michael G. M.D. ++ Decreased Endotoxin Immunity Is
Associated with Greater Mortality and/or Prolonged Hospitalization after Surgery.
Anesthesiology. 94(6):992-998, June 2001
• low preoperative serum antiendotoxin core
antibody (EndoCAb) concentration is an
independent predictor of adverse outcome

• Lower immunoglobulin M EndoCAb
concentration (P = 0.006) predicted increased
risk of postoperative complication independent
of POSSUM physiologic risk score (P < 0.001). In
contrast, total immunoglobulin M and total
immunoglobulin G concentrations did not
predict adverse outcome. Complications
involved multiple organ systems and were
generally unrelated to the type or site of
surgery, consistent with the systemic
inflammatory response syndrome.

• BERLAUK, JON F. M.D. *; ABRAMS, JEROME H.
M.D. +; GILMOUR, IAN J. M.D. *; O'CONNOR,
S. RHIANNON M.D. *; KNIGHTON, DAVID R.
M.D. +; CERRA, FRANK B. M.D. + Preoperative
Optimization of Cardiovascular
Hemodynamics Improves Outcome in
Peripheral Vascular Surgery. Annals of
Surgery. 214(3):289-299, September 1991.
The hypothesis that optimizing hemodynamics
using pulmonary artery (PA) catheter
(preoperative 'tune-up') would improve

BERLAUK, JON F. M.D. *; ABRAMS, JEROME H. M.D. +; GILMOUR, IAN J. M.D. *;
O'CONNOR, S. RHIANNON M.D. *; KNIGHTON, DAVID R. M.D. +; CERRA, FRANK B.
M.D. + Preoperative Optimization of Cardiovascular Hemodynamics Improves
Outcome in Peripheral Vascular Surgery. Annals of Surgery. 214(3):289-299,
September 1991
Ottimizzazione dell’emodinamica(tune up invasivo con PA
catetere,ottenuto con riduzione del postcarico,miglioramento
inotropico e riempimento volemico , in pazienti candidati a
chirurgia vascolare degli arti inferiori riduceva :
• eventi avversi intraop
• morbiditò postop
• l’incidenza di trombosi dei graft.
La mortalità generale era del 3.4%, ,ma del 9.5% nel gruppo di controllo e
dell’ 1.5% nel gruppo trattato .

• PA catheter improves outcome……….

Wiklund, Richard A. MD Preoperative preparation of patients
with advanced liver disease. Critical Care Medicine. CRITICAL
SURGICAL ILLNESS: PREOPERATIVE ASSESSMENT AND
PLANNING. 32(4) Supplement:S106-S115, April 2004.
• Objective: To review the characteristic features of patients with advanced
liver disease that may lead to increased perioperative morbidity and
mortality rates.
• Design: Literature review.
• Results: Patients with end-stage liver disease are at high risk of major
complications and death following surgery. The most common
complications are secondary to acute liver failure and include severe
coagulopathy, encephalopathy, adult respiratory distress syndrome, acute
renal failure, and sepsis. The degree of malnutrition, control of ascites,
level of encephalopathy, prothrombin time, concentration of serum
albumin, and concentration of serum bilirubin predict the risk of
complications and death following surgery. Other determinants of
adverse outcome include emergency surgery, advanced age, and
cardiovascular disease. Portal hypertension is a prominent feature of
advanced liver disease, and it predisposes the patient to variceal
hemorrhage, hepatorenal syndrome, hepatopulmonary syndrome, and
uncontrolled ascites. Portal hypertension can be ameliorated by

Fattori di rischio nei pazienti con
malattia epatica avanzata
• degree of malnutrition
• control of ascites
• level of encephalopathy
• prothrombin time
• concentration of serum albumin
• and concentration of serum bilirubin
• emergency surgery
• advanced age
• cardiovascular disease.

• Risk Assessment for and Strategies To
Reduce Perioperative Pulmonary
Complications for Patients Undergoing
Noncardiothoracic Surgery: A Guideline from
the American College of Physicians
• Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Annals of Internal medicine 18 April 2006 |
Volume 144 Issue 8 | Pages 575-580

• Vedi le considerazioni finali del mio
scritto………..

Relazione fra ASA PS e complicanze
polmonari

• Multivariate analysis found that portal
clamping (P = 0[middle dot]023) and
perioperative blood transfusion (P < 0[middle
dot]001) were risk factors for morbidity,
whereas perioperative blood transfusion (P <
0[middle dot]001) was the only risk factor for
significant morbidity. Co-morbid illness (P =
0[middle dot]019) and perioperative blood
transfusion (P = 0[middle dot]004) were risk
factors for perioperative mortality

Strategie tese alla riduzione delle complicanze postop
• Lawrence VA, Cornell JE, Smetana GW. Strategies to reduce postoperative
pulmonary complications after noncardiothoracic surgery: systematic review for
the American College of Physicians. Ann Intern Med. 2005;144:596-608.
• Tutte le tecniche di espansione polmonare :
– spirometria incentiva
– terapia fisica
– provocazione della tosse
– drenaggio posturale
– percussione e vibrazione
– Aspirazione
– Deambulazione
– IPPB
– CPAP
• hanno dimostrato superiorità rispetto ai controlli dopo chirurgia addominale.
• Non differenze fra le diverse modalità di espansione ,né dalla loro combinazione.

decompressione nasogastrica selettiva
• effettuata nei pazienti con PONV ,incapaci di assumere nutrizione orale o con
distensione addominale
– diminuisce la frequenza di polmonite ed atelettasia
nei confronti della decompression econ sondino
routinaria ,finche cioè non ritorni la motilità
gastrointestinale.
– Cheatham ML, Chapman WC, Key SP, Sawyers JL. A meta-analysis of selective
versus routine nasogastric decompression after elective laparotomy. Ann Surg.
1995;221:469-76.
– Nelson R, Tse B, Edwards S. Systematic review of prophylactic nasogastric
decompression after abdominal operations. Br J Surg. 2005;92:673-80.
– Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after
abdominal surgery. Cochrane Database Syst Rev. 2005.

Introduction
Selection of high-risk surgical patients for preoperative and perioperative
admission to an intensive therapy unit (ITU) for enhancement of oxygen
delivery may reduce postoperative morbidity and mortality rates. Limited
resources may prevent admission of all suitable patients. This study
examined whether it is possible to select patients most at risk and thus
reduce surgical morbidity and mortality rates when ITU services are
limited. Comparison of outcome after colorectal resection among
different surgeons is difficult. Crude rates of morbidity and mortality can
be misleading because such rates make no allowance for differences in
case mix and fitness of patients. Direct comparison of individual surgeon's
performance based on crude rates of morbidity and mortality can be
misleading. Risk-adjusted analysis allows more meaningful comparisons

Valutazione del rischio cardiaco
in chirurgia non cardiaca
C.Melloni
Libero professionista
Consulente di anestesia per Villa Torri,Villa
Chiara,Poliambulatorio Gynepro
Bologna

Revised cardiac index
. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF,
Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L:
Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac
Risk of Major Noncardiac Surgery. Circulation 1999; 100: 1043-1049
• • High risk surgery
• – intraperitoneal, intrathoracic or
suprainguinal vascular procedures
• • Ischemic heart disease
• • H/O CHF
• • H/O Cerebrovascular disease
• • Insulin therapy for DM
• • Preop Cr>2.0mg/dl

• Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA,
Fleischmann KE, Fleisher LA, Froehlich JB, Gusberg RJ,
Leppo JA, Ryan T, Schlant RC, Winters WL, Jr., Gibbons
RJ, Antman EM, Alpert JS,Faxon DP, Fuster V,
Gregoratos G, Jacobs AK, Hiratzka LF, Russell RO, Smith
SC, Jr.: 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). Circulation 2002;105: 1257-67

Weksler N, Klein M, Szendro G, Rozentsveig V, Schily M, Brill S,
Tarnopolski A, Ovadia L, Gurman GM: The dilemma of
immediate preoperative hypertension: to treat and operate, or
to postpone surgery? J Clin Anesth 2003; 15: 179-83
• There is a great deal of debate regarding a trigger to delay or cancel a
surgical procedure in a patient with poorly or untreated hypertension
• In the absence of end-organ changes, such as renal
insufficiency or left ventricular hypertrophy with strain, it
would seem appropriate to proceed with surgery.
• A randomized trial of treated hypertensive patients without known
CAD who presented the morning of surgery with an elevated diastolic
blood pressure was unable to demonstrate any difference in
outcome between those who were actively treated versus those in
whom surgery was delayed.
• In contrast, a patient with a markedly elevated blood pressure and the new
onset of a headache should have surgery delayed for further evaluation and
potential treatment..

Howell SJ, Sear YM, Yeates D, Goldacre M, Sear JW, Foëx P.
Hypertension, admission blood pressure and perioperative
cardiovascular risk. Anaesthesia 1996;51:1000-1004.
• A retrospective case-controlled study which
found that a history of hypertension was an
important predictor for perioperative cardiac
death but not admission blood pressure.
• The study implies that end-organ damage
resulting from hypertension is the likely villain
in this group of patients.

• Importance of Surgical Procedure
• The surgical procedure influences the extent of the preoperative
evaluation required by determining the potential range of changes
in perioperative management. There is little hard data to define the
surgery specific incidence of complications, and the rate may be
very institution depedendent. Eagle et. al. published data on the
incidence of perioperative myocardial infarction and mortality by
procedure for patients enrolled in the coronary artery surgery study
(CASS).6 Higher risk procedures for which coronary artery bypass
grafting reduced the risk of noncardiac surgery compared to
medical therapy include major vascular, abdominal, thoracic, and
orthopedic surgery. Ambulatory procedures denote low risk.
Vascular surgery represents a unique group of patients in whom
there is extensive evidence regarding preoperative testing and
perioperative interventions.

• Importance of exercise tolerance
• Exercise tolerance is one of the most important determinants of
perioperative risk and the need for invasive monitoring. If a patient
can walk a mile without becoming short of breath, than the
probability of extensive coronary artery disease is small.
Alternatively, if patients become dyspneic associated with chest
pain during minimal exertion, then the probability of extensive
coronary artery disease is high. Reilly and colleagues demonstrated
that the likelihood of a serious complication occurring was inversely
related to the number of blocks that could be walked or flights of
stairs that could be climbed.7 Exercise tolerance can be assessed
with formal treadmill testing or with a questionnaire that assesses
activities of daily living.

• Reilly DF, McNeely MJ, Doerner D, Greenberg
DL, Staiger TO, Geist MJ, Vedovatti PA, Coffey
JE, Mora MW, Johnson TR, Guray ED, Van
Norman GA, Fihn SD: Self-reported exercise
tolerance and the risk of serious perioperative
complications. Arch Intern Med 1999; 159:
2185-92

• Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman
WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jr., Jacobs AK,
Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF,
Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B: ACC/AHA 2006 guideline
update on perioperative cardiovascular evaluation for noncardiac surgery: focused
update on perioperative beta-blocker therapy: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines (Writing
Committee to Update the 2002 Guidelines on Perioperative Cardiovascular
Evaluation for Noncardiac Surgery): developed in collaboration with the American
Society of Echocardiography, American Society of Nuclear Cardiology, Heart
Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for
Cardiovascular Angiography and Interventions, and Society for Vascular Medicine
and Biology. Circulation 2006; 113: 2662-74.

• Yang H, Raymer K, Butler R, Parlow J, Roberts R: The effects of perioperative beta-blockade:
results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized
controlled trial. Am Heart J 2006; 152: 983-90
• Juul AB, Wetterslev J, Gluud C, Kofoed-Enevoldsen A, Jensen G, Callesen T, Norgaard P,
Fruergaard K, Bestle M, Vedelsdal R, Miran A, Jacobsen J, Roed J, Mortensen MB,
Jorgensen L, Jorgensen J, Rovsing ML, Petersen PL, Pott F, Haas M, Albret R, Nielsen LL,
Johansson G, Stjernholm P, Molgaard Y, Foss NB, Elkjaer J, Dehlie B, Boysen K, Zaric D,
Munksgaard A, Madsen JB, Oberg B, Khanykin B, Blemmer T, Yndgaard S, Perko G, Wang
LP, Winkel P, Hilden J, Jensen P, Salas N: Effect of perioperative beta blockade in patients
with diabetes undergoing major non-cardiac surgery: randomised placebo controlled,
blinded multicentre trial. Bmj 2006; 332: 1482
• Wallace AW, Galindez D, Salahieh A, Layug EL, Lazo EA, Haratonik KA, Boisvert DM,
Kardatzke D: Effect of clonidine on cardiovascular morbidity and mortality after
noncardiac surgery. Anesthesiology 2004; 101: 284-93.
• Hindler K, Shaw AD, Samuels J, Fulton S, Collard CD, Riedel B: Improved postoperative
outcomes associated with preoperative statin therapy. Anesthesiology 2006; 105: 1260-
72.
Durazzo AE, Machado FS, Ikeoka DT, De Bernoche C, Monachini MC, Puech-Leao P,
Caramelli B: Reduction in cardiovascular events after vascular surgery with atorvastatin:

• (http://www.acc.org/qualityandscience/clinic
al/topic/topic.htm).

Key words
• perioperative risk
• cardiac risk,
• noncardiac surgery,
• intraoperative risk,
• postoperative risk,
• risk stratification,
• cardiac complication,
• cardiac evaluation,
• perioperative care,
• preoperative evaluation,
• preoperative assessment
• intraoperative complications.

Scopi della valutazione cardiaca preop
• 1)identificazione dei pazienti con rischio
cardiaco troppo alto,non accettabile
• 2)identificazione dei paz con malattia cardiaca
che possono essere migliorati o curati preop.
• 3)identificazione dei pazienti che possono
beneficiare di intervento di CABG

Come può la visita preop modificare il
trattamento?

Fattori che determinano il rischio
cardiaco periop
• Marcatori clinici
• Capacità funzionale
• Intervento chirurgico

• The overriding theme of this document is that intervention is rarely
necessary to simply lower the risk of surgery unless such
intervention is indicated irrespective of the preoperative context.
• The purpose of preoperative evaluation is not to give medical
clearance but rather to perform an evaluation of the patient’s
current medical status; make recommendations concerning the
evaluation, management, and risk of cardiac problems over the
entire perioperative period; and provide a clinical risk profile that
the patient, primary physician, and nonphysician caregivers,
anesthesiologist, and surgeon can use in making treatment
decisions that may influence short- and long-term cardiac
outcomes.
• No test should be performed unless it is likely to influence patient
treatment.
• The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per
complicanze cardiovascolari
perioperatorie
• Presenza dei fattori predittivi di aumentato
rischio cardiovascolare periop
• Scarsa capacità funzionale(<4 MET)
• Chirurgia ad alto rischio (rischio
cardiovascolare periop > 5%)

Active Cardiac Conditions for Which the Patient
Should Undergo Evaluation and Treatment Before
Noncardiac Surgery (Class I, Level of Evidence: B):major
clinical predictors

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active
clinical conditions, known cardiovascular disease,
or cardiac risk factors for patients 50 years of age or greater. *

• See Table 2 for active clinical conditions.
• †See Table 3 for estimated MET level equivalent.
‡Clinical risk factors include ischemic heart disease,
compensated or prior HF, diabetes mellitus, renal
insufficiency, and cerebrovascular disease. §Consider
perioperative beta blockade (see Table 11) for
populations in which this has been
shown to reduce cardiac morbidity/mortality.
ACC/AHA indicates American College of
Cardiology/American Heart Association; HR,
heart rate; LOE, level of evidence; and MET,
metabolic equivalent

Cardiac Risk* Stratification for Noncardiac
Surgical Procedures

Scopi dei test aggiuntivi
cardiovascolari
• Fornire una misura obbiettiva di capacità
funzionale
• Identificare una ischemia preop miocardica
importante
• Diagnosticare aritmie cardiache rilevanti
• Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio
• the presence of a redistribution defect on
dipyridamole thallium imaging in patients
undergoing peripheral vascular surgery is
predictive of postoperative cardiac events. In
order to increase the predictive value of the
test, several strategies have been suggested.
Lung uptake, left ventricular cavity dilation,
and redistribution defect size have all been
shown to be predictive of subsequent
morbidity.10

Dobutamine stress test
• Dobutamine stress echocardiography has been suggested as the best
preoperative test in several recent meta-analyses.11 The appearance of
new or worsened regional wall motion
abnormalities is considered a positive test. The
advantage of this test is that it is a dynamic assessment of ventricular
function. Dobutamine echocardiography has also been studied and was
found to have among the best positive and negative predictive values.
Poldermans et al. demonstrated that the group at greatest risk were those
who demonstrated regional wall motion abnormalities at low heart rates.12
The presence of 5 or more segments of new regional wall motion
abnormalities denotes a high risk group who did not benefit from
perioperative beta blockade in one trial.13 Beattie and colleagues
performed a meta-analysis of stress echocardiography versus thallium
imaging and demonstrate that stress echocardiography has better negative
predicative characteristics.11 A moderate-to-large perfusion defect by
either test predicted postoperative MI and death

Noninvasive Stress Testing
Recommendations for Noninvasive Stress Testing Before
Noncardiac Surgery
• CLASS I
• 1. Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should
be evaluated and treated per ACC/AHA guidelines† before noncardiac surgery. (Level of Evidence: B)
• CLASS IIa
• 1. Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional
capacity (less than 4 METs) who require vascular surgery‡ is reasonable if it will change management.
(Level of Evidence: B)
• CLASS IIb
• 1. Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors
and poor functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it
will change management. (Level of Evidence: B)
• 2. Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors
and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery.
(Level of Evidence: B)
• CLASS III
• 1. Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk
noncardiac surgery. (Level of Evidence: C)
• 2. Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery. (Level of
Evidence: C)

Razionale dei test non invasivi preop
nella valutazione del rischio
Test non invasivi Paz con valori del
test anormali
Valori predittivi per morte o MI periop
Positivo : negativo
Monitoraggio ECG
ambulat
9-39% 4-15 1-16
Esercizio con
monitoraggio ECG
16-70% 5-25 90-100
Dipiridamolo-tallio
Chir vasc 22-69 4-20 95-100
Chir non vasc 23-47 8-27 98-100
Eco cardio grafia
23-50 7-23 93-100
stress dobutamina

EF preop e outcome cardiaco postop.
(Franco et al,J Vasc Surg 10;656:1989)
EF>55%
EF 35-55%
N=50
N=20
EF 20-35%
N=15
MI 19% 15% 20%
Morte 0 0 13%

Chir vasc dopo
precedente
rivascolarizzazio
ne
Chir vascolare
senza prec
edente
rivascolarizzazio
ne
Complicazioni % Mortalità % Complicazioni % Mortalità %
angiografia 0.2-0.5 0.1-0.5 - -
PTCA/CABG 3-13 1-5.5 - -
Chir vasc 0.3-2 0.3-0.4 0.6-11.7 0.6-10
Rischio globale 3.5-10.5 1.4-12.4 0.6-11.7 0.8-10
Ma…….. Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate
Diminuiscono il rischio
cardiovascolare a lungo termine
Aumentano il rischio cardiaco a
lungo termine
Rischio globale a
lungo termine ??
??
Sono comparabili??
??

Outcome cardiaco per chirurgia
maggiore non cardiaca Eagle et al,Circulation 1997 96
1892-7
N=395
N=582
N=964

Cardiac outcome in low risk
surgery:n=1297

Incidenza di mortalità periop in
pazienti con CAD(n=1632) Eagle et al
High risk surgery >=4% Low risk surgery<=4%
Abdominal 4% Urologic 1.8
Vascolare 11.3 Orthopedic 1.2
Thoracic 7.7 Skin 0
Head neck 7.3 Miscellaneous 3

Cardiac outcome in noncardiac surgery
following CABG

Class I indications for preop coronary
angiography in non cardiac surgery
• High risk results during non invasive testing
• Amgina pectoris unresponsive to adequate
medical therapy
• Most patients with unstable angina pectoris
• Nondiagnostic or equivocal noninvasive test
result in a high risk patient undergoing a high
risk noncardiac surgical procedure

Proposed approach to the management of patients with
previous percutaneous coronary intervention (PCI) who
require noncardiac surgery, based on expert opinion

Perioperative Beta-Blocker Therapy
Recommendations for Beta-Blocker Medical Therapy
• CLASS I
• 1. Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina,
symptomatic arrhythmias, hypertension, or other ACC/AHA class I guideline indications. (Level of Evidence: C)
• 2. Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the
finding of ischemia on preoperative testing. (Level of Evidence: B)
• CLASS IIa
• 1. Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative
assessment identifies CHD. (Level of Evidence: B)
• 2. Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery
identifies high cardiac risk, as defined by the presence of more than 1 clinical risk factor.* (Level of Evidence: B)
• 3. Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high
cardiac risk, as defined by the presence of more than 1 clinical risk factor,* who are undergoing intermediate-risk or
vascular surgery. (Level of Evidence: B)
• CLASS IIb
• 1. The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or
vascular surgery, in whom preoperative assessment identifies a single clinical risk factor.* (Level of Evidence: C)
• 2. The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who
are not currently taking beta blockers. (Level of Evidence: B)
• CLASS III
• 1. Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta
blockade. (Level of Evidence: C)

Indicazioni ai beta bloccanti
• i betabloccanti devono essere continuati nel periop per coloro che li assumono
per indicazione di angina,aritmie sitomatiche,ipertensione o altre indicazioni
delle linee guida ACC/AHA di classe I.
• i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad
alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza
B).
• I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia
vascolare nei quali la valutazione preop identifichi coronaropatia e/o un elevato
rischio cardiaco ,definito come la presenza di più di 1 fattore di rischio clinico
,anche se vanno incontro a chirurgia classificata come rischio intermedio .
• l’utilità dei betabloccanti rimane incerta in pazienti candidati a chirurgia di
rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di
evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non
stanno assumendo i farmaci( Livello di evidenza B).
• Ovviamente i betabloccanti non devono essere somministrati a coloro che
presentano controindicazioni assolute al loro impiego.
• In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in
pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac
outcome Poldermans et al NEJM 1999;341;1789-94
Bisoprolol n=59 Standard care n=53
Cardiac death 2(3,4%) 9(17%) *
Non fatal MI 0 9(17%) **
Total 2(3.4%) 18(34%) **
*=p<0.02 **=p<0.01

Beta blockers
• 1. Beta blockers should be continued in patients undergoing surgery who are
receiving beta blockers to treat angina, symptomatic arrhythmias, hypertension,
or other ACC/AHA class I guideline indications. (Level of Evidence: C)
• 2. Beta blockers should be given to patients undergoing vascular surgery who are
at high cardiac risk owing to the finding of ischemia on preoperative testing. (Level
of Evidence: B)
• CLASS IIa
• 1. Beta blockers are probably recommended for patients undergoing vascular
surgery in whom preoperative assessment identifies CHD. (Level of Evidence: B)
• 2. Beta blockers are probably recommended for patients in whom preoperative
assessment for vascular surgery identifies high cardiac risk, as defined by the
presence of more than 1 clinical risk factor.* (Level of Evidence: B)
• 3. Beta blockers are probably recommended for patients in whom preoperative
assessment identifies CHD or high cardiac risk, as defined by the presence of more
than 1 clinical risk factor,* who are undergoing intermediate-risk or vascular
surgery. (Level of Evidence: B)
• CLASS IIb
• 1. The usefulness of beta blockers is uncertain for patients who are undergoing

• In the absence of major contraindications
therapeutic dosages of beta adrenergic
antagonists should be given to patients with
an intermediate or high risk of cardiac
complications

Periop statin therapy
• Recommendations for Statin Therapy
• CLASS I
• 1. For patients currently taking statins and scheduled for
noncardiac surgery, statins should be continued. (Level of
Evidence: B)
• CLASS IIa
• 1. For patients undergoing vascular surgery with or without
clinical risk factors, statin use is reasonable. (Level of
Evidence: B)
• CLASS IIb
• 1. For patients with at least 1 clinical risk factor who are
undergoing intermediate-risk procedures, statins may be
considered. (Level of Evidence: C)

terapia preoperatoria con statine
• La terapia preoperatoria con statine deve
essere continuata per coloro che le assumono
già (livello di evidenza B);
• la loro somministrazione è ragionevole per i
candidati a chirurgia vascolare con o senza
fattori di rischio clinici (livello di evidenza B):
• Le statine possono essere prese in
considerazione per i pazienti con almeno 1
fattore di rischio clinico candidati a chirurgia di
rischio intermedio (livello di evidenza C)

Levels of Thromboembolism Risk in Surgical Patients
Without Prophylaxis

Livelli di rischio tromboembolico in pazienti senza profilassi
(Goertz et al 114 AHA/ACC
DVT PE
Livello di rischio polpa
ccio
prossimale Evento
clinico
fatale Strategia di
prevenzione con
successo
Basso:
Chir minore in paz <40 anni senza fattori
di rischio
2 0.4 0.2 <0.01 No
profilassi,deambulazio
ne precoce,aggressiva
Moderata:
Chir minore in paz con fattori di rischio
aggiuntivi;
Chir in paz 40-60 anni senza fattori di
rischio aggiuntivi
10-20 2-4 1-2 0.2-
0.4
Hep(ogni 12 h),LMWH
<3400,GCS,IPC
Alta:
chir in paz>60 a tra 40-60 con
FRA(VTE,cancro,ipercoagulabilità
molecolare)
20-40 4-8 2-4 0.4-1 HEP ogni 8
h,LMWH>3400,Ipc
Altissima:
Chir in paz con fattori di rischio multipli
Artroprotesi anca ,ginocchio
Frattura anca
Trauma maggiore
Trauma midollare spinale
40-80 10-20 4-10 0.2-5 LMWH>3400,fondapar
inux,Vit K antag p
os(INR 2-3),IPC o
GCS+LMWH o Hep
FRA:fattori di rischio aggiuntivi :
IPC;cpmpressione penumatica intermittente,

Choice of Anesthetic Technique and
Agent
• Recommendations for Use of Volatile
Anesthetic Agents
• CLASS Iia 1. It can be beneficial to use volatile
anesthetic agents during noncardiac surgery
for the maintenance of general anesthesia in
hemodynamically stable patients at risk for
myocardial ischemia. (Level of Evidence: B)

Perioperative Control of Blood Glucose
Concentration
• Recommendations for Perioperative Control of Blood
• Glucose Concentration
• CLASS IIa
• 1. It is reasonable that blood glucose concentration be controlled ¶
during the perioperative period in patients with diabetes mellitus or
acute hyperglycemia who are at high risk for myocardial ischemia
or who are undergoing vascular and major noncardiac surgical
procedures with planned ICU admission. (Level of Evidence: B)
• CLASS IIb
• 1. The usefulness of strict control of blood glucose concentration¶
during the perioperative period is uncertain in patients with
diabetes mellitus or acute hyperglycemia who are undergoing
noncardiac surgical procedures without planned ICU admission.
Level of Evidence: C)

Blood glucose control and mortality
• Poor intraoperative control of blood glucose
was an independent predictor of severe
morbidity; mortality rate was increased in
patients with poorly controlled glucose (11.4%)
vs those with tightly controlled glucose (2.4%).

Mortality % in diabetic patients with or without glucose
control
Glucose controlled Not controlled
van den Berghe et al
(496), 2001
4,6 8
Ouattara et al (500),
2005
2,4 11.4
McGirt et al (501),
2006
2.8-, 4.3-, and 3.3-fold increases in risk
of stroke/TIA, MI, or death
Gandhi et al (502),
2005
A 20-mg/dL increase in mean intraoperative glucose associated
with a 30% increase in adverse events.
Krinsley (505), 2003 42.5%
among patients with mean glucose values
in excess of 300 mg/dL.
Finney et al (499),
2003
Increased administration of insulin was an independent
predictor of ICU mortality; regression models demonstrated
a mortality benefit if blood glucose was maintained
< 144 to 200 mg/dL.
Furnary et al (506),
2003
Continuous iv insulin was an
independent predictor of survival.
McAlister et al (508),
2003
Hyperglycemia was an independent
predictor of adverse outcomes.

a preoperative risk index for
predicting postoperative respiratory
failure (PRF).

Ahsan M. Arozullah, MD, MPH,* Jennifer Daley, MD,† William G. Henderson, PhD,‡
and Shukri F. Khuri, MD,§ for the National Veterans Administration Surgical Quality
Improvement Program Multifactorial Risk Index for Predicting Postoperative
Respiratory Failure in Men After Major Noncardiac Surgery. ANNALS OF SURGERY
Vol. • Objective 232, No. 2, 242–253
• To develop and validate a preoperative risk index for
predicting postoperative respiratory failure (PRF).
• prospective cohort study
• 44 Veterans Affairs Medical Centers (n 5 81,719) were used to
develop the models. Cases from 132 Veterans Affairs Medical
Centers (n 5 99,390) were used as a validation sample.
• PRF was defined as mechanical ventilation for more than 48
hours after surgery or reintubation and mechanical
ventilation after postoperative extubation.
• Ventilator-dependent, comatose, do not,resuscitate, and
female patients were excluded.
• respiratory care.

Multifactorial Risk Index for Predicting Postoperative
Respiratory Failure in Men After Major Noncardiac
Surgery
• Results
• PRF developed in 2,746 patients (3.4%).
• The respiratory failure risk index was developed from a simplified logistic
regression model and included:
– abdominal aortic aneurysm repair,
– thoracic surgery,
– neurosurgery,
– upper abdominal surgery,
– Peripheral vascular surgery,
– neck surgery
– emergency surgery,
– albumin level l< than 30 g/L,
– blood urea nitrogen level >than 30 mg/dL,
– dependent functional status,
– chronic obstructive pulmonary disease,
– age>60

Cardiac asessment risk compatible 2008-2009

Cardiac asessment risk compatible 2008-2009

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