What is the recommended approach for cardiopulmonary (cardiovascular and pulmonary) evaluation in emergency surgery?

Cardiopulmonary Evaluation in Emergency Surgery

In emergency surgery, limit preoperative cardiopulmonary evaluation to rapid assessment of cardiovascular vital signs, volume status, hematocrit, electrolytes, renal function, urinalysis, and ECG—only the most essential tests are appropriate until the acute surgical emergency is resolved. 1

Emergency Surgery Context

Emergency surgery fundamentally changes the evaluation paradigm because the urgency of the surgical condition supersedes extensive preoperative testing. 1

• Emergency surgery inherently increases cardiac risk regardless of baseline risk stratification scores, and the focus must shift from comprehensive evaluation to immediate perioperative medical optimization. 2
• The ACC/AHA guidelines explicitly state that when acute surgical emergency exists, preoperative evaluation must be limited to simple and critical tests only. 1
• A more thorough cardiopulmonary evaluation should be conducted after surgery when the patient is stabilized. 1

Essential Rapid Assessment Components

Cardiovascular Assessment

• Obtain rapid assessment of cardiovascular vital signs including heart rate, blood pressure, and rhythm. 1
• Perform 12-lead ECG immediately to identify acute ischemia, arrhythmias, conduction abnormalities, or QT prolongation. 1, 3
• Assess volume status clinically through examination of jugular venous pressure, peripheral perfusion, and capillary refill. 1

Laboratory Evaluation

• Measure hematocrit to assess oxygen-carrying capacity and identify acute blood loss. 1
• Check electrolytes (particularly potassium and magnesium) as abnormalities increase perioperative arrhythmia risk. 1
• Assess renal function (creatinine/BUN) as this is a component of the Revised Cardiac Risk Index and affects perioperative management. 1, 2
• Obtain urinalysis to identify infection or other acute processes. 1

What NOT to Do in Emergency Surgery

Do not delay emergency surgery for:

• Stress testing or noninvasive cardiac imaging 1, 3
• Echocardiography unless there is acute hemodynamic instability requiring immediate diagnosis (e.g., suspected tamponade, acute valvular rupture, or massive pulmonary embolism) 1
• Cardiology consultation for "clearance" 1
• Coronary angiography 2
• Cardiopulmonary exercise testing 4, 5

Risk Stratification in Emergency Surgery

While formal risk stratification tools like RCRI are valuable in elective surgery, their utility is limited in emergency settings. 2

• The RCRI can be calculated rapidly using six factors: ischemic heart disease, heart failure, cerebrovascular disease, insulin-dependent diabetes, chronic renal dysfunction (creatinine >2 mg/dL), and high-risk surgery. 1, 2
• However, emergency surgery designation itself elevates risk regardless of RCRI score, so the score primarily informs postoperative monitoring intensity rather than surgical decision-making. 1, 2

Perioperative Monitoring Strategy

Based on the rapid assessment, determine appropriate intraoperative and postoperative monitoring:

Standard Monitoring (All Emergency Surgery Patients)

• Continuous ECG monitoring 1
• Invasive arterial blood pressure monitoring for major procedures 1
• Central venous access for volume resuscitation and medication administration 1

Enhanced Monitoring (High-Risk Patients)

• Pulmonary artery catheter placement is NOT routinely recommended even in high-risk emergency surgery patients. 6, 3
• PAC may be considered only when hemodynamic abnormalities cannot be adequately characterized non-invasively AND the information would directly alter intraoperative management. 6
• Consider less invasive cardiac output monitoring alternatives (e.g., arterial waveform analysis, esophageal Doppler) when available. 6

Active Cardiac Conditions Requiring Immediate Management

Even in emergency surgery, certain active cardiac conditions require simultaneous evaluation and treatment:

• Unstable coronary syndromes (acute MI, unstable angina): Coordinate with cardiology for medical management; consider coronary intervention only if it would not significantly delay life-saving surgery. 3
• Decompensated heart failure: Optimize volume status and consider inotropic support if time permits. 3
• Significant arrhythmias: Treat hemodynamically significant arrhythmias or high-grade AV block before surgery. 3
• Severe valvular disease: Document with point-of-care echocardiography if suspected and adjust anesthetic management accordingly. 3

Postoperative Cardiac Surveillance

For emergency surgery patients with RCRI ≥2, measure troponin at 48-72 hours postoperatively to detect myocardial injury. 2

• Postoperative troponin elevation identifies patients requiring intensified cardiac monitoring and medical management. 2
• This surveillance strategy is more appropriate than extensive preoperative testing in the emergency setting. 2

Common Pitfalls to Avoid

• Do not request cardiology consultation for "clearance"—this is an inappropriate use of consultation and delays necessary surgery. 1
• Do not order stress tests or advanced imaging in emergency surgery—these tests are designed for risk stratification in elective surgery and have no role when surgery cannot be delayed. 1, 3
• Do not assume that "optimizing" cardiac status will improve outcomes if it delays necessary emergency surgery—the surgical emergency itself is the primary threat to mortality. 1
• Do not place pulmonary artery catheters routinely—multiple trials show no benefit and potential harm in unselected high-risk surgical patients. 6