Perioperative Considerations for Surgical Emergencies
Emergent perioperative care is strikingly different from all other surgical environments. This period requires coordination of care from the unpredictable pre-hospital environment to the sterile conditions of the operating room (OR). In this fluid environ
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J. Davis Yonge and Patricia Ayoung-Chee
Emergent perioperative care is strikingly different from all other surgical environments. This period requires coordination of care from the unpredictable pre-hospital environment to the sterile conditions of the operating room (OR). In this fluid environment, the acute care surgeon must effectively risk-stratify a potential operative candidate. The following chapter will discuss the appropriate perioperative management of the emergent general surgery patient. Three surgical time frames define this period: emergent, urgent, and timesensitive. An emergent diagnosis requires operative intervention within 6 h of surgical consultation [1]. Urgent situations require operative intervention within 6–24 h, and time-sensitive situations require surgical management within 1–6 weeks [1]. The critical step for maneuvering through the perioperative period is attention to detail. From resuscitation to OR preparation, the surgical team is responsible for managing all aspects of patient care and careful planning cannot be underestimated in this situation. The primary surgical assessment begins with the history and physical examination. Initial questioning of the patient or family member will provide valuable information regarding functional capability and physiologic reserve. This encounter will identify all medications, with specific attention paid to anticoagulant and cardiac medications. It will give insight into the patient’s mental status and guide a “goals of care” discussion. It will, at times, be integral in determining surgical futility. The accurate assessment and appropriate patient management during this initial phase of care is as important as the intended operative procedure.
Perioperative Cardiovascular Assessment Patients undergoing emergent noncardiac surgery have increased morbidity and mortality compared to the elective surgical population (odds ratio (OR) 1.39; 95 % confidence interval (CI) 1.30–1.48) [2, 3]. The purpose of a focused cardiac assessment is early identification of factors associated with increased morbidity and mortality, including cardiac irregularities and classification of functional status. Functional status, as measured in metabolic equivalents (METs), ranges from 1 to greater than 10 METs (Table 3.1). As a patient’s functional status increases, there is a reduction in postoperative complications [4, 5]; Girish et al. reported an 89 % “postoperative cardiopulmonary complication rate” in patients who cannot climb 1 flight of stairs prior to highrisk surgery [6]. The American Society of Anesthesiologists (ASA) classification adds to the surgical team’s global assessment of patient health. Originally developed in 1941 [7, 8] and subsequently revised and validated in 1962, this 5-tiered system by the American Society of Anesthesiologists is not intended to determine operative risk, but to evaluate a patient’s physiological reserve prior to surgery [9–11]: 1. 2. 3. 4. 5.
Healthy Patienta Mild systemic diseasea Severe systemic diseasea Incapacitating systemic
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