Assessment of surgical and anaesthetic risks

As both surgery and anaesthesia pose potential risks to the patient, their objective assessment is very important. It helps determine the indications for surgery and choose the appropriate surgical and anaesthetic techniques, which, in turn, reduces the perioperative risks. To do this, the scoring system is frequently used. When assessing the anaesthetic risk, the three aspects should be considered, namely the patient's general condition, the extent and type of the surgery, the anaesthetic technique.

1. The patient's general condition:

a) satisfactory: the otherwise healthy patient- 0, 5 points;

b) fair: the patient with a mild systemic disease - 1 point;

c) severe: the patient with severe disease that limits activity but is not incapacitating - 2 points;

d) critical: the patient with an incapacitating disease that is life-threatening - 4 points;

e) terminal: moribund patient not expected to survive 24 hours with or without surgery - 6 points.

2. The extent and type of the surgery:

a) superficial operations and those for mild infections - 0, 5 points;

b) more complex superficial operations and the ones on the viscera, spine and peripheral nerves, and vessels - 1 point;

c) prolonged and invasive surgeries on the viscera in traumatology, urology, oncology, and neurosurgery - 1, 5 points;

d) cardiac and major vascular surgeries, major operations in oncology, repeated and reconstructive surgeries - 2 points;

e) complex cardiac surgeries using extracorporeal circulation technique (coronary artery bypass, cardiac transplantation) - 2, 5 points.

3. The anaesthetic technique:

a) local potentiated anaesthesia - 0, 5 points;

b) regional spinal, epidural, intravenous anaesthesia, inhalation mask anaesthesia with spontaneous breathing - 1 point;

c) standard combined endotracheal anaesthesia - 1, 5 points;

d) endotracheal anaesthesia combined with artificial hypothermia, controlled hypotension, massive infusion therapy, electric cardiac stimulation - 2 points;

e) endotracheal anaesthesia combined with extracorporeal circulation using a heart-lung machine (e.g. coronary artery bypass), hyperbaric oxygenation, intensive care and resuscitation - 2, 5 points.

Further, the risk is assessed based on the sum of points:

• degree 1 (minimal risk) - 1, 5 points;

• degree 2 (moderate risk) - from 2 to 3 points;

• degree 3 (high risk) - from 3, 5 to 5 points;

• degree 4 (extremely high risk) - from 8, 5 to 11 points.

In emergency, the preoperative period is very short (e.g. heart injuries, massive internal bleeding) with the patient being immediately admitted to the operating theatre. Preparation of the patient for elective surgery is started before he/she arrives at the surgical unit.The outpatient surgeon or physician is to promptly determine the preliminary indications for surgery, order the pertinent additional investigations to establish the diagnosis, and psychologically prepare the patient for the impending surgery.

Whatever vital function disorders (e.g. haemorrhage) require that the surgeon start emergent management - control of bleeding and giving vasopressor and/or vasodilator agents. These will be continued during the patient's transportation to the surgical unit and are considered the preoperative care.

Contraindications. The laboratory findings help assess the patient's general condition, reveal concurrent diseases and thus determine the contraindications, if any, for the operation.

The absolute contraindications include the following:

• shock (other than that resulting from sustained bleeding);

• acute myocardial infarction;

• stroke.

The relative contraindications involve as follows:

• congestive heart failure;

• cardiac arrhythmia;

• ischaemic heart disease;

• respiratory failure;

• bronchial asthma;

• chronic renal failure;

• hepatitis;

• anaemia;

• leukaemia;

• diabetes mellitus.

Assessing the contraindications for the operation the surgeon should take both the indications and the risk degree into consideration. Currently, each situation with absolute indications for surgery can virtually always be resolved.

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