Peri-op
THE BELLFLOWER PERIOPERATIVE POCKET MANUAL
Maracus Magallanes, MD 2001
Chapter 3 - SURGICAL
CONSIDERATIONS
STRESS OF
SURGERY
CARDIAC RISK STRATIFICATION FOR NONCARDIAC SURGERY:
(American College of Cardiology/American Heart Association, 1996)
HIGH (>5% incidence of combined cardiac death and nonfatal MI)
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-Emergent major operations, particularly in elderly patients
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-Aortic and other major vascular/peripheral vascular procedures
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-Prolonged surgical procedures associated with large fluid shifts/blood loss
INTERMEDIATE (<5%)
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-Carotid endarterectomy
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-Head and neck procedures
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-Intraperitoneal/intrathoracic procedures
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-Orthopedic procedures
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-Prostate surgery
LOW (<1%)
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-Endoscopy
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-Cataract
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-Breast
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-Superficial procedures
ESTIMATES OF SURGICAL STRESS FOR COMMON SURGICAL PROCEDURES:
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Ophthalmologic surgery-LOW
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Arthroscopy-LOW
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AV fistula-LOW
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Appendectomy-LOW to MODERATE
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Breast surgery-LOW to MODERATE
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TURP-LOW to MODERATE
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Hernia-LOW to MODERATE (depending on size,
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location, presence of incarceration/strangulation)
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Gallbladder-LOW if laparascopic, MODERATE if open,
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SEVERE if complicated biliary procedure
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C-section-MODERATE
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Amputation of extremity-MODERATE
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Carotid endarterectomy-MODERATE
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Femoral-popliteal bypass-MODERATE
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Small bowel surgery-MODERATE
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Radical prostatectomy-MODERATE
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Pulmonary lobectomy-MODERATE to SEVERE
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Hysterectomy-MODERATE (simple hysterectomy) to
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SEVERE (radical hysterectomy)
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Hip fracture ORIF/Hip or Knee replacement-
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MODERATE to SEVERE
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Colorectal surgery-MODERATE (if uncomplicated) to
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SEVERE (if emergency/complicated)
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Nephrectomy-MODERATE to SEVERE
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Gastrectomy-MODERATE to SEVERE
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Abdominal aortic aneurysm/Aorto-femoral bypass-
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SEVERE (aortic crossclamping during procedure)
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Pancreatic surgery (including Whipple)-SEVERE
URGENCY OF
SURGERY
*This is the key controlling factor in determining what can be done for medical
problems preoperatively. The two extremes are easy: emergency surgery is
immediate and no delay is possible, despite underlying medical conditions;
elective surgery is always elective and whatever needs to be done preoperatively
to optimize the patient should be done. The majority of cases fall in between
these two extremes, even among inpatients.
If there is ever any question as to the necessary timeframe for performing
surgery, ASK THE SURGEON! If the case is not emergent and you need to optimize
the patient preoperatively, specifically ask the surgeon how much time you
can allot to do this without adversely impacting the patient's overall prognosis.
On the flip side, the surgeon will want to know how long you think it will
take to medically optimize a non-emergent case for surgery.
Peri-op