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operation. Surgery usually within 3 weeks.

Elective

Surgery to suit both patient and surgeon.

From [7], with permission.

Cardiac risk

Certain cardiovascular factors have been found to correlate with cardiac complications after non-cardiac surgery. They constitute a useful risk index (Table 2.6).

The mortality following a perioperative myocardial infarction is between 40% and 60%. The risk of developing a perioperative myocardial infarction is exponentially related to the interval between a previous myocardial infarction [8], if there was one, and surgery (Table 2.7). It is therefore advisable to delay non-urgent surgery until at least 3 and preferably 6 months after a myocardial infarction. Patients who require surgery sooner should be considered individually and managed appropriately.

In men with coronary artery disease or who are at high risk of it, that is:

• current smoking;

diabetes mellitus;

• sedentary lifestyle;

hypertension.

Early postoperative myocardial ischaemia can occur in up to 40%, with up to a 2.8-fold increase in the odds of an adverse cardiac outcome [9]. Clearly, these patients require special management.

High-risk surgical patients

Certain factors are associated with a particularly high mortality in the perioperative period, often related to the development of multiple organ failure [10]:

• previous severe cardiorespiratory illness (acute myocar-dial infraction, stroke, chronic obstructive airway disease (COAD));

• extensive ablative surgery planned for carcinoma (oesophagectomy, gastrectomy, cystectomy);

• severe multiple trauma (>3 organs or >2 systems);

• age >70 years with evidence of limited physiologic reserve in one or more vital organs;

• septicaemia (positive blood cultures or septic focus);

• respiratory failure (PaO2 < 8kPa (60mmHg), on an FiO2 > 0.4, or mechanical ventilation >48h);

• acute abdominal catastrophe with haemodynamic instability (pancreatitis, peritonitis, perforation, gastrointestinal haemorrhage);

• acute renal failure (urea >20 mmol/l, creatinine >250 mmol/l);

• late stage vascular disease involving the aorta.

These patients probably benefit from special anaesthetic and intensive care management, which is beyond the scope of this book.

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