From the Guidelines
For ARISCAT and RCRI risk assessment tools, tracheostomy is considered an intrathoracic procedure, while PEG insertion is considered an intraperitoneal procedure. Tracheostomy involves creating an opening in the anterior neck into the trachea, which is located in the thoracic cavity, making it an intrathoracic procedure for risk stratification purposes 1. PEG insertion requires penetration of the peritoneum to place a feeding tube into the stomach, classifying it as an intraperitoneal procedure. These classifications are important because both tools use the anatomical location of surgery as a risk factor for postoperative complications. Intrathoracic and intraperitoneal procedures generally carry higher risk scores in these assessment tools compared to more superficial surgeries, reflecting the increased risk of respiratory complications with thoracic procedures and cardiac complications with intraperitoneal procedures, as outlined in the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1. When using these risk assessment tools for preoperative evaluation, correctly categorizing these procedures ensures appropriate risk stratification and perioperative management planning. Key points to consider include:
- The RCRI is a simple, validated, and accepted tool to assess perioperative risk of major cardiac complications, with 6 predictors of risk, including undergoing suprainguinal vascular, intraperitoneal, or intrathoracic surgery 1.
- The American College of Surgeons NSQIP MICA risk-prediction rule and Surgical Risk Calculator provide additional tools for assessing perioperative risk, including procedure-specific risk assessment for a diverse group of outcomes 1.
- The anatomical location of surgery is a critical factor in determining the risk of postoperative complications, with intrathoracic and intraperitoneal procedures generally carrying higher risk scores than more superficial surgeries 1.
From the Research
Tracheostomy and PEG Insertion in ARISCAT and RCRI
- Tracheostomy is considered an intrathoracic procedure, as it involves the creation of an airway in the trachea, which is located in the thoracic cavity 2, 3.
- PEG (Percutaneous Endoscopic Gastrostomy) insertion, on the other hand, is considered an intraperitoneal procedure, as it involves the placement of a tube through the abdominal wall and into the stomach, which is located in the peritoneal cavity 4, 5.
Classification in ARISCAT and RCRI
- The ARISCAT (Assess Respiratory Risk in Surgical Patients in CATalog) and RCRI (Revised Cardiac Risk Index) scores are used to assess the risk of respiratory and cardiac complications in surgical patients, respectively.
- Tracheostomy and PEG insertion are both considered intermediate-risk procedures in the ARISCAT score, as they involve invasion of the thoracic and peritoneal cavities, respectively 6.
- The RCRI score also considers tracheostomy and PEG insertion as intermediate-risk procedures, as they may involve bleeding, infection, and other complications that can affect cardiac function 4, 5.