How do you determine perioperative risk in a patient in the family practice setting?

Perioperative Risk Assessment in Family Practice

The most effective approach to determining perioperative risk in family practice is to use validated risk prediction tools combined with assessment of functional capacity and surgery-specific risk factors to guide clinical decision-making and optimize patient outcomes. 1

Risk Assessment Framework

• Begin with classifying the surgical procedure by risk level (low, intermediate, or high-risk) based on invasiveness and hemodynamic stress, noting that emergency procedures carry 2-5 times higher risk than elective surgeries 1
• Use the Revised Cardiac Risk Index (RCRI) as a primary screening tool for cardiac risk assessment, which assigns 1 point for each of 6 predictors of major cardiac complications 2, 1
• Consider the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) risk calculator for superior predictive discrimination compared to RCRI 2, 1
• Evaluate functional capacity using the Duke Activity Status Index (DASI), as poor functional capacity (inability to achieve 4 METs) indicates increased perioperative risk 1
• Assess ASA physical status classification, which has been shown to correlate significantly with postoperative complications and mortality 3, 4

Patient-Specific Risk Factors

Cardiovascular Risk Factors

• Screen for unstable coronary syndromes, decompensated heart failure, significant arrhythmias, and severe valvular disease as high-risk conditions 1
• Evaluate history of coronary artery disease, compensated heart failure, cerebrovascular disease, diabetes mellitus, and renal insufficiency 1
• Consider measuring B-type natriuretic peptide (BNP) levels before surgery as an additional risk stratification factor 1
• For patients with congenital heart disease, assess complexity and severity of the disease, with single-ventricle patients and those with unrepaired or palliated cyanotic CHD at elevated risk 2

Other Risk Factors

• Age-related physiological decline, multi-morbidity, and frailty are independently associated with increased perioperative risk 1
• Screen for modifiable risk factors including smoking, alcohol usage, undiagnosed hypertension, diabetes, anemia, and nutritional status 1
• Evaluate for obstructive sleep apnea using a validated screening tool, as OSA increases perioperative risk of complications 2
• Assess for risk of postoperative delirium, particularly in elderly patients, with key risk factors including age, ASA physical status >2, and Charlson Comorbidity Index ≥2 2

Antithrombotic Management Assessment

• Estimate the risk for arterial thromboembolism (ATE) for patients with atrial fibrillation or mechanical heart valves and risk for recurrent VTE for patients with history of VTE 2
• Classify patients according to estimated risk for ATE (high risk: >10%/year; intermediate risk: 4%-10%/year; low risk: <4%/year) and estimated risk for VTE (high risk: >10%/month; intermediate risk: 4%-10%/month; low risk: <2%/month) 2
• Consider individual patient characteristics that may override the standard risk classification, such as history of perioperative stroke 2

Surgical Risk Stratification

• Categorize surgical procedures as low risk (<1% risk of MACE) or elevated risk (≥1% risk of MACE) based on combined surgical and patient characteristics 2
• Define surgical timing as emergency (immediate threat to life or limb, <2h), urgent (threat to life or limb, ≥2 to <24h), time-sensitive (can be delayed up to 3 months), or elective (can be delayed for complete evaluation) 2
• For patients with low risk of perioperative MACE, further cardiac testing is not recommended before the planned operation 2

Special Considerations

Elderly Patients

• Perform multidisciplinary assessment with early involvement of geriatricians and anesthesiologists 1
• Evaluate minimum criteria for adequate pre-operative geriatric assessment specific to anesthesia 1
• Consider age-related physiological changes that may affect perioperative risk 1

High-Risk Patients (ASA 4)

• Recognize that ASA 4 classification is independently associated with increased perioperative mortality and morbidity, with cardiac complications being among the most common adverse outcomes 5
• Be aware that ASA 4 patients have MACE rates exceeding 5% for major cardiac complications 5
• Consider preoperative optimization and more intensive perioperative monitoring for these patients 5

Common Pitfalls and Caveats

• Risk scores have poorer discrimination in patients undergoing vascular surgery, likely due to underestimation of MI risk 1
• Avoid relying solely on age as a risk factor; greater risks are associated with urgency and significant cardiac, pulmonary, and renal disease 1
• Underestimation of MACE risk in ASA 4 patients can lead to inadequate perioperative monitoring and management 5
• The ASA classification alone is not a predictor of operative risk; operative risk is a combination of patient physical status, physiological derangement from the procedure, operator skill, anesthetic factors, and perioperative support 3