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KEY POINTS

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  • Perioperative risk assessment by careful history, physical examination, and selective investigation is essential for directing therapy in the high-risk surgical patient.

  • To decrease mortality and morbidity, major medical illnesses must be identified and appropriately managed.

  • Delirium is a common postoperative complication that can be anticipated given risk factors.

  • Perioperative cardiac morbidity can be minimized with preemptive medical management which includes the perioperative administration of β-blockers in very select patients.

  • Postoperative pulmonary complications can be reduced by aggressive pre- and postoperative care.

  • Diabetes mellitus and steroid dependence must be completely managed to significantly influence perioperative morbidity and mortality.

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As indicated in Chap. 110, surgery and anesthesia trigger a host of physiologic responses. Anesthesiologists have described elective surgery as “planned trauma.” Thus they prepare for all the traumatic sequelae that will occur such as blood loss and fluid shifts, increased myocardial oxygen demands, respiratory changes caused by intubation and ventilation with supplemental oxygen, increased plasma cortisol of the stress response, and coagulopathy to name a few. In the average otherwise healthy patient, these responses result in no major untoward postoperative events. However, in the medically compromised patient, the additional burden of surgical stress can prove to be very challenging and sometimes insurmountable. Such patients frequently require detailed evaluation and monitoring in the preoperative as well as postoperative periods in the intensive care unit (ICU). Careful planning, preoperative assessment, and management of identified abnormalities in these patients are crucial to optimize chances of a good postoperative outcome. A major component of this planning involves the assessment of risks for intraoperative and postoperative morbidity. Patients with cardiac, respiratory, and renal abnormalities pose special risks for postoperative complications. In this chapter, we present guidelines for identifying and managing patients at risk of developing postoperative morbidity.

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PREOPERATIVE SCREENING

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Table 111-1 is a system of perioperative screening for patients at St Michael’s Hospital in Toronto, Canada. Patients identified preoperatively with severe disease (Table 111-1) or gravid patients for nonobstetric surgery should be seen by an anesthesiologist in an outpatient clinic where there is time for preoperative risk stratification and disease optimization if possible. If conditions are found that warrant a delay in surgery, early identification minimizes the impact of other scheduled surgeries. At that juncture, additional advice from Internal Medicine or medical subspecialties is sought as necessary for postoperative management.

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TABLE 111-1

Considerations for Preoperative Anesthesia Assessment

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