Abstract
For many patients optimal perioperative care may require little or no additional medical management beyond that given by the anaesthetist and surgeon. However, the continued existence of a group of surgical patients at high risk for morbidity and mortality indicates an ongoing need to identify such patients and deliver optimal care throughout the perioperative period. A group of patients exists in whom the risk for death and serious complications after major surgery is in excess of 20%. The risk is related mainly to the patient's preoperative physiological condition and, in particular, the cardiovascular and respiratory reserves. Cardiovascular management of the high-risk surgical patient is of particular importance. Once the medical management of underlying disease has been optimized, two principal areas remain: the use of haemodynamic goals to guide fluid and inotropic therapy, and perioperative β blockade. A number of studies have shown that the use of goal-directed haemodynamic therapy during the perioperative period can result in large reductions in morbidity and mortality. Some patients may also benefit from perioperative β blockade, which in selected patients has also been shown to result in significant mortality reductions. In this review a pragmatic approach to perioperative management is described, giving guidance on the identification of the high-risk patient and on the use of goal-directed haemodynamic therapy and β blockade.
Highlights
For many patients optimal perioperative care may require little or no additional medical management beyond that given by the anaesthetist and surgeon
There is a select group of patients in whom the risk for death and serious complications following major surgery is in excess of 20%
The risk is not related to the surgery per se but mainly to the patient’s own preoperative physiological condition
Summary
For many patients optimal perioperative care may require little or no additional medical management beyond that given by the anaesthetist and surgeon. Wilson and colleagues [5] modified the ideas of previous investigators They randomly assigned 138 patients undergoing major elective surgery to receive conventional treatment or perioperative GDT and achieved very similar results to those of both previous studies. In a mixed group of general, gynaecology and urology patients, Doppler-guided fluid therapy resulted in improvement in cardiac index, reduced length of hospital stay and an earlier return to enteral feeding, suggesting a reduction in postoperative ileus [15]. An important aspect of these guidelines is the use of dobutamine stress echocardiography to identify patients at high risk for perioperative myocardial ischaemia This process of evaluation may indicate a patient in whom the risks for surgery are not justified by the potential benefits. Perioperative, peroperative or postoperative cardiac output monitoring is still recommended in this subgroup in order to ensure optimal fluid management
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