RT Book, Section
A1 Chen, Robert
A1 Aucoin, Sylvie Y.
A1 Ali, Jameel
A2 Schmidt, Gregory A.
A2 Kress, John P.
A2 Douglas, Ivor S.
SR Print(0)
ID 1201810224
T1 Preoperative Assessment of the High-Risk Surgical Patient
T2 Hall, Schmidt and Wood’s Principles of Critical Care, 5<sup>th</sup> Edition
YR 2023
FD 2023
PB McGraw Hill
PP New York, NY
SN 9781264264353
LK accessanesthesiology.mhmedical.com/content.aspx?aid=1201810224
RD 2024/09/17
AB KEY  POINTSSurgical  stressors  include  the  proinflammatory  reaction  of  tissue  injury  and  associated  pain,  prothrombosis  that  puts  the  brain,  heart,  and  lungs  at  risk,  sodium  retention  leading  to  edema  in  all  organ  systems,  immune  dysfunction,  and  insulin  resistance.  Collectively,  this  complex  reaction  is  referred  to  as  the  surgical  stress  response.1Anesthesia  stressors  exclusive  of  surgical  stress  include  intubation  and  positive  pressure  ventilation  with  their  effects  on  the  cardiorespiratory  system.  Lung  injury  may  result  from  positive  pressure  ventilation  and  supplemental  oxygen.  Central  nervous  system  (CNS)  changes  from  anesthetics  coupled  with  perioperative  inflammation  can  lead  to  long-lasting  reduced  cognitive  function.Identification  of  risks  and  outcomes  other  than  death  and  communication  of  those  risks  is  an  essential  part  of  the  consent  process.  The  Paling  perspective  scale  (a  logarithmic  scale)  with  comparators2  may  be  useful.  The  risk  of  death  as  a  metric  can  be  problematic  as  many  patients  interpret  death  as  an  “all  or  none”  risk  with  death  versus  intact  survival  as  the  only  possibility.  Patients  may  not  appreciate  that  compared  to  death,  there  is  a  greater  risk  of  surviving  surgery  with  a  new  disability,  new  symptoms,  or  loss  of  independence  leading  to  discharge  to  nursing  home.During  consultation,  identification  of  surgical  and  anesthesia  risks  allows  patients  to  more  intelligently  examine  the  risks  of  surgery  versus  alternatives.  Identifying  higher  risk  patients  allows  the  possibility  of  preoperative  care  to  reduce  risk  by  altering  the  patient’s  current  medication,  through  presurgical  procedures  or  physiotherapy  and  exercise  therapy  to  reduce  frailty.Patients  with  little  physiologic  reserve  may  be  candidates  for  medical  management  or  alternative  surgical  and/or  anesthesia  modalities.  And,  identification  of  high-risk  patients  allows  for  planning  for  postoperative  resources  such  as  monitored  units  or  critical  care  areas.