Evaluation Of Perioperative Risk Research Articles

ESAIC focused guideline for the use of cardiac biomarkers in perioperative risk evaluation: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine.

The Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine endorses the clinical practice guideline "ESAIC focused guideline for the use of cardiac biomarkers in perioperative risk evaluation." The guideline can provide guidance to Nordic anaesthesiologists on the perioperative use of cardiac biomarkers in patients undergoing non-cardiac surgery.

Preoperative Echocardiogram Does Not Contribute to Surgical Risk Assessment in Patients With Large Curve Scoliosis and No Cardiac Risk Factors.

Severe scoliosis can affect thoracic organs, potentially leading to cardiovascular abnormalities. Thus, echocardiograms have been suggested for use in preoperative screening in patients with significant scoliosis. However, the utility of preoperative heart screenings in patients without known or suspected heart problems is not well understood. This study aims to find the incidence of cardiac findings in patients with severe scoliosis ≥90° without cardiac history. A single-institution retrospective chart review was performed. Inclusion criteria were scoliosis patients with curves ≥90 degrees and a screening echocardiogram performed within 6 months of spine surgery. Patients with a previous cardiac history, diagnosis associated with cardiac comorbidities (eg, connective tissue disease), or major coronal curves <90 degrees were excluded. Echocardiogram reports and perioperative clinical notes from involved services (including orthopaedics, cardiology, and anesthesia) were reviewed. Any postoperative use of vasopressors and reasons for their use were recorded. Overall, 50 patients met the inclusion criteria. The mean age at surgery was 14.0 ± 4.9 years old (range: 2 to 33). The mean major curve was 108 ± 19 degrees (range: 90 to 160 degrees). A normal echocardiogram was seen in 38 (76%), whereas 6 patients (12%) had mild dilation of the aortic sinus or root, 4 (8%) had mild valvular regurgitation, 1 patient had a small atrial septal defect, and 1 had a trace pericardial effusion. No patient had any changes made to their perioperative plan and one patient was advised to see a cardiologist postoperatively. Postoperatively, 8 patients (16%) received vasopressors to raise blood pressure to meet preset goal MAP, but only one of these 8 had a positive echocardiogram (mild valvular insufficiency), which was not seen as a contributing factor to the use of pressors. This study suggests that screening echocardiograms for patients without a cardiac history or related symptoms does not contribute to the evaluation of perioperative risk or anesthetic management. Creating clear, evidence-based guidelines for the utilization of perioperative testing, like echocardiograms, can reduce the social, time, and financial burdens on families. Such guidelines are vital for appropriate risk assessment and proper utilization of health care resources. Level III.

The role of cardiac biomarkers in perioperative risk evaluation of noncardiac surgery patients-A summary of the ESAIC guidelines 2023

The recently published ESAIC guidelines highlight the clinical value of cardiac troponins (cTn) and B‑type natriuretic peptides (BNP) for risk assessment in patients undergoing noncardiac surgery. Summary of the ESAIC guideline recommendations. The evidence for the recommendations was extracted from studies that investigated the perioperative role of cTn and BNP as prognostic factors, for risk prediction and for therapeutic guidance. To collate this evidence 12 relevant endpoints as well as risk benefit analyses of systematic screening were considered to issue the strength of the recommendations. The body of evidence for these guidelines was based on 115 studies. The evidence varied significantly across the 12predefined endpoints. Additionally, there was a gradient in evidence for the use of cTn and BNP as prognostic factors, for risk prediction and for therapeutic guidance. The guidelines issue aweak recommendation for the use of preoperative, postoperative and combined measurement of cTn as well as for preoperative BNP measurement to assess the prognosis. For risk prediction aweak recommendation was formulated for combined and postoperative cTn and preoperative BNP measurements. No recommendation could be given for the evidence on biomarkers as data were very limited. Both cTn and BNP can be used as prognostic factors or to predict the risk for selected endpoints. Therapeutic interventions should not be guided by cardiac biomarker levels.

ESAIC focused guideline for the use of cardiac biomarkers in perioperative risk evaluation.

In recent years, there has been increasing focus on the use of cardiac biomarkers in patients undergoing noncardiac surgery. The aim of this focused guideline was to provide updated guidance regarding the pre-, post- and combined pre-and postoperative use of cardiac troponin and B-type natriuretic peptides in adult patients undergoing noncardiac surgery. The guidelines were prepared using Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology. This included the definition of critical outcomes, a systematic literature search, appraisal of certainty of evidence, evaluation of biomarker measurement in terms of the balance of desirable and undesirable effects including clinical outcomes, resource use, health inequality, stakeholder acceptance, and implementation. The panel differentiated between three different scopes of applications: cardiac biomarkers as prognostic factors, as tools for risk prediction, and for biomarker-enhanced management strategies. In a modified Delphi process, the task force defined 12 critical outcomes. The systematic literature search resulted in over 25,000 hits, of which 115 full-text articles formed the body of evidence for recommendations. The evidence appraisal indicated heterogeneity in the certainty of evidence across critical outcomes. Further, there was relevant gradient in the certainty of evidence across the three scopes of application. Recommendations were issued and if this was not possible due to limited evidence, clinical practice statements were produced. The ESAIC focused guidelines provide guidance on the perioperative use of cardiac troponin and B-type natriuretic peptides in patients undergoing noncardiac surgery, for three different scopes of application.

Would surgical Apgar score be useful to predict postoperative complications after proximal femoral fracture surgery? - A retrospective cohort study.

The surgical Apgar score (SAS) is a perioperative risk evaluation score, which considers intraoperative minimum heart rate, minimum mean arterial pressure and estimated blood loss. Although validated in multiple surgical fields, SAS remains quite controversial in the orthopedic one. The main purpose of this study was to investigate if SAS relates with the occurrence of complications during the first 30-days after proximal femoral fracture surgery. Retrospective study including all consecutive patients submitted to proximal femoral fracture surgery between January and July 2019. Patients with no information about SAS were excluded. Patients were divided in two groups, based on the occurrence of complications during the first 30 post-operative days and their SAS calculated. Receiver operating characteristic (ROC) curves were used to assess SAS power as a predictive model of complications. Forty-two percent (n=76) of the 181 patients included in the study developed complications during the first 30 postoperative days. Eight patients (4,4%) died during that period. The patient's mean age was 79 years and 30,9% (n=56) were men. Heart failure, pacemaker use, chronic kidney disease, chronic obstructive pulmonary disease and dementia were significantly associated with post-operative morbidity. There was no significant correlation between SAS and the occurrence of complications during the first 30 postoperative days. The AUC of SAS as a predictive model for postoperative complications after proximal femoral fracture surgery was 0,522, being insufficient to be considered an accepted model of prediction. Based on this study, we conclude that SAS is not predictive of the development of complications in the first 30 post-operative days in patients submitted to proximal femoral fracture surgery. However, other clinical factors have been identified as associated with postoperative morbidity. In the future, prospective-based studies with higher samples may better clarify the role of SAS in this context.

Natriuretic Peptides and Troponins to Predict Cardiovascular Events in Patients Undergoing Major Non-Cardiac Surgery.

Patients undergoing major surgery have a substantial risk of cardiovascular events during the perioperative period. Despite the introduction of several risk scores based on medical history, classical risk factors and non-invasive cardiac tests, the possibility of predicting cardiovascular events in patients undergoing non-cardiac surgery remains limited. The cardiac-specific biomarkers, natriuretic peptides (NPs) and cardiac troponins (cTn) have been proposed as additional tools for risk prediction in the perioperative period. This review paper aims to discuss the value of preoperative levels and perioperative changes in cardiac-specific biomarkers to predict adverse outcomes in patients undergoing major non-cardiac surgery. Based on several prospective observational studies and six meta-analyses, some guidelines recommended the measurement of NPs to refine perioperative cardiac risk estimation in patients undergoing non-cardiac surgery. More recently, several studies reported a higher mortality in surgical patients presenting an elevation in high-sensitivity cardiac troponin T and I, especially in elderly patients or those with comorbidities. This evidence should be considered in future international guidelines on the evaluation of perioperative risk in patients undergoing major non-cardiac surgery.

Періопераційна оцінка ризику розвитку серцевих ускладнень

Досягнення в галузі медичної допомоги, зокрема стратегій лікування гострого коронарного синдрому й раптової смерті, призвели до поліпшення виживаності пацієнтів із хронічними захворюваннями, такими як атеросклероз, гіпертонія та діабет. Одним із факторів, що призвели до такої позитивної динаміки, було широке використання оцінних шкал. Пацієнти, які мають серцеву недостатність, являють собою групу зі значним ризиком післяопераційних ускладнень, як і пацієнти з ішемічною хворобою серця, і повинні бути ретельно обстежені для гарантування переносимості операції і наркозу. Застосування нових методів, таких як вимір біомаркерів, дає можливість більш точно визначити ймовірність розвитку та перспективи прогнозу або ранньої діагностики серцевої недостатності у пацієнтів, які перенесли розширену операцію.

Urine drug screen positive for cocaine and amphetamine is not an adverse risk factor for cardiovascular morbidity or mortality in trauma

BackgroundUrine drug screening (UDS) is a component of trauma workup and of perioperative risk evaluation. Illicit stimulant use has been associated with cardiovascular complications. This study investigates the impact of...

Validation of the Surgical Outcome Risk Tool (SORT) for Predicting Postoperative Mortality in Colorectal Cancer Patients Undergoing Surgery and Subgroup Analysis.

The accurate evaluation of perioperative risk is crucial to facilitate the shared decision-making process. Surgical outcome risk tool (SORT) has been developed to provide enhanced and more feasible identification of high-risk surgical patients. Nonetheless, SORT has not been validated for patients with colorectal cancer undergoing surgery. Our aim was to determine whether SORT can accurately predict mortality after surgery for colorectal cancer and to compare it with traditional risk models. 526 patients undergoing surgery performed by a colorectal surgical team in a single Greek tertiary hospital (2011-2019) were included. Five risk models were evaluated: (1) SORT, (2) Physiology and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM), (3) Portsmouth POSSUM (P-POSSUM), (4) Colorectal POSSUM (CR-POSSUM), and (5) the Association of Great Britain and Ireland (ACPGBI) score. Model accuracy was assessed by observed to expected (O:E) ratios, and area under Receiver Operating Characteristic curve (AUC). Ten patients (1.9%) died within 30days of surgery. SORT was associated with an excellent level of discrimination [AUC:0.81 (95% CI:0.68-0.94); p = 0.001] and provided the best performing calibration of all models in the entire dataset analysis (H-L:2.82; p = 0.83). Nonetheless, SORT underestimated mortality. SORT model demonstrated excellent discrimination and calibration predicting perioperative mortality in patients undergoing (1) open surgery, (2) emergency/acute surgery, and (3) in cases with colon-located cancer. SORT is an easily adopted risk-assessment tool, associated with enhanced accuracy, that could be implemented in the perioperative pathway of patients undergoing surgery for colorectal cancer.

Protocol for evaluation of perioperative risk in patients aged over 75\u2009years: Aged Patient Perioperative Longitudinal Evaluation\u2013Multidisciplinary Trial (APPLE-MDT study)

BackgroundWith the extended life expectancy of the Chinese population and improvements in surgery and anesthesia techniques, the number of aged patients undergoing surgery has been increasing annually. However, safety, effectiveness, and quality of life of aged patients undergoing surgery are facing major challenges. In order to standardize the perioperative assessment and procedures, we have developed a perioperative evaluation and auxiliary decision-making system named “Aged Patient Perioperative Longitudinal Evaluation–Multidisciplinary Trial (APPLE-MDT)”.MethodsWe will conduct a perioperative risk evaluation and targeted intervention, with follow-ups at 1, 3, and 6 months after surgery. The primary objective of the study is to evaluate the effectiveness of the “Aged Patient Perioperative Longitudinal Evaluation-Multiple Disciplinary Trial Path” (hereinafter referred to as the APPLE-MDT path) in surgical decision-making for aged patients (≥75 years) undergoing elective surgery under non-local anesthesia in the operating room. The secondary objectives of the study are to evaluate the postoperative outcome and health economics of the APPLE-MDT path applied to the surgical decision-making of aged patients (≥75 years) undergoing elective surgery under non-local anesthesia and to optimize intervention strategies for aged patients undergoing surgery to reduce the occurrence of postoperative complications and improve the quality of life after surgery.DiscussionIt is necessary to formulate a reliable, effective, and concise evaluation tool, which can effectively predict the perioperative complications and mortality of aged patients, support targeted intervention strategies, and allow for a more comprehensive risk and benefit analysis, thereby forming an effective senile perioperative surgery management path. It is expected that the implementation of this protocol can reduce the occurrence of postoperative complications, improve the postoperative quality of life, shorten hospital stay, reduce hospitalization expenses, reduce social burden, and allow the elderly to have a good quality of life after surgery.Trial registrationChiCTR, ChiCTR1800020363, Registered 15 December 2018.

Improved diagnostic accuracy of pathology with the implementation of a perioperative point-of-care ultrasound service: quality improvement initiative

IntroductionThe utility of perioperative point-of-care ultrasound (P-POCUS) is rapidly growing. The successful implementation of a comprehensive P-POCUS curriculum, Focused PeriOperative Risk Evaluation Sonography Involving Gastro-abdominal, Hemodynamic, and Trans-thoracic Ultrasound (FORESIGHT),...

The role of preoperative endocrine parameters in prediction of postoperative complication in adult patients undergoing elective heart surgery – Preliminary study

Introduction The correct cost-benefit estimation and the more accurately perioperative risk evaluation is one of the more difficult task in the perioperative medicine. We wanted to study more than the obvious parameters, so we looked for less studied predictors, such as different peripherial hormone levels. Every hormone molecule acts a complex pathway, so we truely believe that the insufficient function or decreased serum level of these mediators could be heavy influence for the perioperative adverse events. Methods Our single center prospective, observational study approved by the IRB and registered at clinicaltrials.gov (NCT03736499). We enrolled 89 patients between 25.01.2019 and 30.04.2019 who underwent elective cardiac surgical procedure. In the preoperative period we measured different hormone levels in serum (TSH, free T3 and T4, prolactine and testosterone) and collected the demographic parameters. We corrigated the normal hormone levels for age and gender. We recorded the length of postoperative intensive care unit stay, length of mechanical ventilation, dose of different vasopressor and inotropic agents, fluid balance, blood transfusion and bleeding. The adverse outcomes were also collected. The primary outcome was the all-cause mortality. Secondary outcome were the length of ICU stay, length of mechanical ventilation and the frequency of different adverse events. We performed descriptive statistics, chi square test and Mann-Whitney U test using the IBM-SPSS 22.0 statistic software. Results Median age was 66.0 years (IQR: 59.0-73.0), 64.04% of the patients were male, median of BMI was 28.22 (IQR: 25.44-31.44). The median of EuroSCOREII was 1.94 (IQR: 1.17-3.05). The mean follow up time was 52.8±20.68 days. 8 patients (8.98%) died during the follow up time, the median length of ICU stay was 45 hours (IQR: 22.0-92.0), the median length of mechanical ventilation was 9 hours (IQR: 5.0-19.0). In univariable Cox regression serum free T3 was correlated with all cause mortality (OR: 0.266, CI 95%: 0.096-0.735, p = 0.011) and the abnormal level of free T3 was associated with higher infection rate (OR: 6.052, CI 95%: 1.271-28.832, p = 0.024). Using nonparametric tests we found association between abnormal serum prolactine level and postoperative arrhythmias (p = 0.017) and between abnormal serum testosterone level and prolonged length of ICU stay (p = 0.002). Discussion The evaluation of serum hormone levels could help to make more precise estimation of perioperative risk in adult patients waiting heart surgery. Further examination should be performed, to establish stronger correlation between fine hormonal dysregulation and postoperation complications.

Collaboration Converts Cardiac Catastrophe During Living Donor Kidney Recipient Surgery to Long Term Success

Background Cardiovascular disease is more common in CKD and evaluation of perioperative risk for potential kidney transplant recipients is essential to reduce adverse postoperative complications. Collaborative work between multiple disciplines better prepares recipients for surgery and can mitigate adverse outcomes. A case presenting multidisciplinary teamwork to offset cardiac complications in setting of living donor (LD) recipient surgery is presented. Case 44 y/o man with diabetes mellitus type 1 and ESRD on hemodialysis for 1 year is evaluated for LD kidney transplant. He has history of myocardial infarct 5 years earlier s/p stent and stroke 5 years ago without sequelae. He has no symptoms of cardiovascular disease. Preoperative Echo shows EF 55% without pulmonary hypertension. Cardiolite nuclear medicine stress test reveals small fixed apical lateral defect suggestive of infarct without ischemia. Cardiac catheterization demonstrates left anterior descending (LAD) mid 80% stenosis, circumflex with 70-80% narrowing and right coronary artery (RCA) with proximal widely patent stent and distal 20-30% lesion. He had stents placed in LAD and circumflex (bare metal). He is cleared for LD transplant. He is taken to surgery 4 months later; undergoing successful anesthesia induction and the living donor kidney is anastomosed to recipient vein followed by sudden drop in BP, not responding to fluids. TEE shows EF 10%. The living donor kidney is detached from recipient vein, flushed and packaged per UNOS protocol. The team decides to notify the donor after anesthesia recovery and discuss option of offering the kdiney to the deceased donor list (subsequently donor concurred with this plan). Cardiology is consulted. Transplant Surgery closes wound. Recipient is emergently taken from operating room to heart cath lab (with Anesthesia in attendance) where an occluded LAD is found in addition to distal 90% circumflex and 75-80% RCA lesions. LAD occlusion is restented (bare metal stent) and IABP is placed. Patient is taken to intensive care unit where Critical Care Service provides support and stabilizes recipient. A huddle between Critical Care, Cardiology, Transplant Surgery, Anesthesia and Transplant Nephrology discussed options, relaying these to donor and recipient families. In the morning IABP is removed and recipient is cleared for transplant (repeat EF is 30%). Living donor kidney is successfully placed with slow but persistent fall in creatinine without need for dialysis on discharge. 10 years later, his Cr is 1.7mg/dl with measured iothalmate clearance of 58 ml/min and 490 mg proteinuria. Discussion Despite careful evaluation, unexpected postoperative complications may adversely affect kidney transplant surgery. Quick teamwork to address the problem mitigates risk. The framework of multidisciplinary care in this example of a cardiac complication during recipient surgery of a living donor kidney transplant enabled successful transplant and long term success.

Risk Assessment in Surgical Patients: American Society of Anesthesiologist’s (ASA) Classification vs Intraoperative Therapeutic and Diagnostic Interventions (I-ITS)

Background: In this prospective study of 859 surgical patients in a tertiary research hospital, we examined the association between ASA physical status classification and Intraoperative Therapeutic Intervention Score (I-TIS). Methodology: All patients were assigned by ASA classification before the operation and received a value of 1-4 points for I-TIS score during surgical procedures. Surgical complexity was also classified and correlation with I-TIS was examined. Results: The correlation coefficient of the ASA with I-TIS was r=0.55 (p25 and surgical complexity of major plus were admitted to the intensive care unit. Two of them were followed up six hours and the other three stayed more than 24 hours in the intensive care unit. Conclusions: It’s concluded that I-TIS score may be validated for our surgical patients but this assessment may show variability among institutions. The ASA classification is the most valued and widely used scoring system for evaluation of perioperative risk in surgical patients. It is simple, easy and also a useful tool to assist descriptions of workload and ‘anesthetic risk’ for analysis and research purposes.

Perioperative risk

The high-risk surgical patient is a growing challenge to modern health care. This cohort, although comprising only 10-15% of surgical procedures, accounts for approximately 80% of postoperative deaths and suffers a high rate of postoperative morbidity. Developing robust systems to help identify and better manage this patient group should be a priority. Risk stratification has become a valuable clinical tool for shared decision-making and the development of individualized care plans. Methods for stratifying individual risk include assessment tools, measures of functional capacity and plasma biomarker assays. Routine evaluation of perioperative risk is central to the delivery of high quality, appropriate surgical care.

The Prevalence of Congenital Heart Disease in Nonsyndromic Cleft Lip and/or Palate: A Systematic Review of the Literature.

Life-threatening anomalies, such as congenital heart disease (CHD) must be identified in patients with cleft lip and/or palate (CL/P) to minimize perioperative risk. Nevertheless, screening practices vary highly among cleft teams and programs, and little is known about the prevalence and clinical significance of CHD in nonsyndromic CL/P patients. Through a systematic literature review, this study examines the demographics and severity of CHD in the nonsyndromic CL/P population. The implications of concomitant CHD in providing safe and comprehensive cleft care both in the United States and abroad are discussed. A systematic review of PubMed literature from 1980 to September 2015 was performed following PRISMA guidelines. Studies describing rates of CHD and severity of lesions specifically in nonsyndromic and all CL/P patients were included. Analysis of cumulative data was performed according to nonsyndromic status and cleft type. Twelve studies were found to meet inclusion criteria. Of the 4055 nonsyndromic CL/P patients who met inclusion criteria, 7.42% (n=301) had CHD, which was significantly greater than the general population (~1%; odds ratio [OR], 7.94; P<0.0001). Congenital heart disease was significantly more common in cleft palate (CP) (OR, 15.1), combined CL and palate (CL+P) (OR, 13.5), and CL (OR, 4.23) compared with the general population. Palatal clefts (CP and CL+P) had significantly increased odds of CHD compared with CL (OR, 3.58 and 3.19, respectively, both P<0.0001). The most common forms of CHD were atrial or ventricular septal defects (n=210, 74.2%), which typically do not require surgical intervention in the general population. Clinical significance of these CHD lesions in CL/P patients is not fully known. Cleft management programs aim to maximize the number of patients receiving care while maintaining patient safety. Appropriate evaluation of perioperative risk necessitates understanding the prevalence of CHD in CL/P patients and the severity of those lesions. Patients with CL/P, particularly patients with palatal clefts, have significantly higher odds of having CHD than the general population. Congenital heart disease is most likely to present as atrial or ventricular septal defects, which are lesions that are unlikely to impact safety during cleft repair surgery.

Preoperative risk evaluation in patients over 75 years candidates to non-cardiac and cardiac surgery.

In the 24th and 25thof June 2016, 80 national experts were invited to Rome from The Italian Society of Geriatric Cardiology and the Italian Association of Cardiovascular Prevention and Rehabilitation to revise the current knowledge on the perioperative risk in the elderly. Cardiologists, geriatricians, heart and general surgeons and anesthesiologists discussed the topic with the objective of reaching a consensus and to launch observational research and registries in the field of perioperative risk evaluation in the elderly. The introduction of objective measures of frailty on top of traditional cardiac evaluation in the different surgical contexts could allow for a more precise definition of "surgical risk", appropriate perioperative management and postoperative outcome.

Impact assessment of perioperative point-of-care ultrasound training on anesthesiology residents.

The perioperative surgical home model highlights the need for trainees to include modalities that are focused on the entire perioperative experience. The focus of this study was to design, introduce, and evaluate the integration of a whole-body point-of-care (POC) ultrasound curriculum (Focused periOperative Risk Evaluation Sonography Involving Gastroabdominal Hemodynamic and Transthoracic ultrasound) into residency training. For 2 yr, anesthesiology residents (n = 42) received lectures using a model/simulation design and half were also randomly assigned to receive pathology assessment training. Posttraining performance was assessed through Kirkpatrick levels 1 to 4 outcomes based on the resident satisfaction surveys, multiple-choice tests, pathologic image evaluation, human model testing, and assessment of clinical impact via review of clinical examination data. Evaluation of the curriculum demonstrated high satisfaction scores (n = 30), improved content test scores (n = 37) for all tested categories (48 ± 16 to 69 ± 17%, P < 0.002), and improvement on human model examinations. Residents randomized to receive pathology training (n = 18) also showed higher scores compared with those who did not (n = 19) (9.1 ± 2.5 vs. 17.4 ± 3.1, P < 0.05). Clinical examinations performed in the organization after the study (n = 224) showed that POC ultrasound affected clinical management at a rate of 76% and detected new pathology at a rate of 31%. Results suggest that a whole-body POC ultrasound curriculum can be effectively taught to anesthesiology residents and that this training may provide clinical benefit. These results should be evaluated within the context of the perioperative surgical home.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

The role of the internal medicine specialist in the management of infective complications in general surgical wards

BACKGROUND Internal medicine specialists are often asked to evaluate a patient before surgery. Perioperative risk evaluation for elderly patients is important, because complications increase with age. The increasing age of the general population increases the probabilities of surgery in the older patients. The manifestation of a surgical problem, is more likely to be severe and complicated in the elderly patients. In fact, emergency surgery treatment occurs more frequently in the elderly (e.g., it is much more common to see intestinal obstruction complicating colorectal cancer in the elderly compared with a younger population). Old age is an independent factor for long hospital stay after surgery. The role of the preoperative medical consultant is to identify and evaluate a patient’s current medical status and provide a clinical risk profile, in order to decide whether further tests are indicated prior to surgery, and to optimise the patient’s medical condition in the attempt of reducing the risk of complications. The medical consultant must know which medical condition could eventually influence the surgery, achieve a good contact and communication between the medical and surgical team, in order to obtain the best management planning. AIM OF THE STUDY This paper focuses on the rational use of antibiotic prophylaxis and on the treatment of the complications of post-surgery infections (e.g., pulmonary complication, peritonitis, intra-abdominal infection). Specific aspects of pre-operative risk evaluation and peri and post-operative management are discussed. CONCLUSIONS The internal medicin specialist in collaboration with the surgical team is necessary in the peri and post-surgery management.