Risk Stratification, Preoperative Testing, and Operative Planning

Abstract

March 2008

Section Elements of Contemporary Practice

6 Risk Stratification, Preoperative Testing, and Operative Planning

Cyrus J. Parsa, M.D.
Cardiothoracic Fellow, Duke University School of Medicine

Andrew E. Luckey, M.D.
Southern California Advanced Laparo-Endoscopic Surgery, Los Angeles

Nicolas V. Christou, M.D., F.A.C.S.
Professor of Surgery, McGill University Faculty of Medicine

Alden H. Harken, M.D., F.A.C.S.
Professor of Surgery and Chairman, UCSF-East Bay Surgery Program, University of California, San Francisco, School of Medicine

No one truly wants to undergo surgery, yet the results can be highly gratifying to both patient and surgeon when the right operation is performed accurately, expeditiously, and for the right reasons on the right patient at the right time. To this end, surgeons must balance the risks of surgery against the anticipated benefits. Assessment of surgical risk includes the use of classification systems such as that proposed by the American Society of Anesthesiologists (ASA); history and physical examination; selective preoperative testing; evaluation of factors affecting cardiac risk (e.g., previous or current cardiovascular disease, functional capacity, and type of procedure); specialized cardiac testing (exercise treadmill testing, ambulatory ECG, radionuclide ventriculography, echocardiography, thallium scintigraphy, and coronary angiography); and evaluation of factors affecting noncardiac risk (respiratory, nutritional, endocrine, and hematologic status). Assessment of the patient's physical and emotional happiness as a component of outcome is addressed. Strategies to reduce perioperative cardiac risk are also highlighted. A discussion of epidemiology of surgical risk and an evaluation of the cost-effectiveness of risk identification are included. This chapter contains 113 references.

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