Objective: To review the strategies for identification and subsequent management of high-risk patients that have been proposed to reduce perioperative morbidity and mortality.
Data sources: Articles and published reviews of studies on evaluation and management of patients to reduce perioperative morbidity and mortality.
Summary of review: Many strategies have been devised to evaluate the perioperative risk in elderly patients, particularly those who are about to undergo major intra-abdominal surgery. An assessment of cardiac and pulmonary responses to exercise-induced stress (i.e. cardiopulmonary exercise testing) using a bicycle ergometer, metabolic cart (to measure oxygen uptake and carbon dioxide excretion) and a 12 lead electrocardiograph has been found to be a non.invasive test that is quick, cheap, easy to perform and requires no special preparation. It has advantages over any other preoperative test by defining operative risk and allowing logical triage according to objective risk assessment. It is able to objectively evaluate the extent of any cardiac failure (by assessing the anaerobic threshold), myocardial ischaemia, provides insight into stroke index, the presence of pulmonary artery hypertension and defines obstructive and restrictive lung disease and ventilation perfusion inequality better than conventional preoperative respiratory function tests.
Conclusions: In patients who are about to undergo major intra-abdominal surgery, preoperative cardiopulmonary exercise testing is an excellent predictor of risk in the postoperative period. No other test is able to offer such a comprehensive preoperative risk evaluation for an operative patient.