The high-risk surgical patient and the role of preoperative management

Reducing the risk in high-risk surgical patients is a common effort of surgeons, anesthesiologists and internists. Several definitions of high-risk surgery exist and one should differentiate the risk for the development of shock and multiple organ dysfunction syndrome from explicitly cardiac risk. Insufficient tissue, especially splanchnic, perfusion can lead to a cascade with the liberation of cytokines and adhesion molecules. Ensuring adequate tissue perfusion is therefore of utmost importance. Assessing tissue perfusion and recognizing hypovolemia is, however, a difficult task using only standard clinical signs as blood pressure and heart rate. Several studies where high-risk surgical patients were treated preoperatively with fluid infusions and/or vasoactive drugs, mainly as determined by invasive monitoring, have shown a positive effect on outcome. On the other hand the value of beta-blockade, started preoperatively, in selected patients at high risk for cardiac complications is accumulating and convincing. The author therefore suggests to aim for targets of therapy based on multiple baseline values for each individual patient. The author also calls for stopping the practice, as is still the case in many hospitals, to leave the patients the night before surgery with an overnight fast, without an intravenous infusion with the appropriate amounts of fluids. However, it is concluded that the definition of 'appropriate' is currently still a matter of opinion and not facts.