Assessment of Operative and Anesthetic Risk

Scoring criteria

The surgical risk assessment system requires summing up points across three key factors: the patient's baseline status, surgical invasiveness, and the aggressiveness of anesthesia.

1. General condition of the patient

• 0.5 points: Satisfactory condition. The disease is strictly localized, with no systemic disorders or comorbid pathologies.
• 1 point: Moderate severity. Mild or moderate systemic disorders are present.
• 2 points: Severe condition. Pronounced systemic disorders caused by the underlying surgical or comorbid pathology.
• 4 points: Extremely severe condition. Life-threatening systemic disorders (independent of the surgery).
• 6 points: Terminal condition. Decompensation of vital organ functions. Extremely high probability of mortality on the operating table or within the first hours after intervention.

2. Extent and nature of the surgery

• 0.5 points: Minor purulent surgeries and superficial interventions.
• 1 point: More complex surface surgeries, interventions on internal organs, spine, peripheral nerves, and vessels.
• 1.5 points: Extensive and prolonged surgeries on internal organs, as well as in neurosurgery, oncology, urology, and traumatology.
• 2 points: Complex interventions on the heart and major vessels, extended oncological, reconstructive, and repeat surgeries.
• 2.5 points: Cardiac surgeries using cardiopulmonary bypass (CPB), organ transplantation.

3. Type of anesthesia The choice of pain management method is always strictly individualized. Neuroleptanalgesia (NLA) is generally preferred. For bronchial asthma and pulmonary diseases, halothane anesthesia is indicated, and for heart failure, a number of interventions are performed under local anesthesia.

• 0.5 points: Potentiated local anesthesia.
• 1 point: Intravenous, regional, spinal, epidural anesthesia, as well as mask inhalation anesthesia with spontaneous breathing.
• 1.5 points: Standard balanced endotracheal anesthesia (BETA).
• 2 points: BETA combined with artificial hypothermia, controlled arterial hypotension, cardiac pacing, or massive infusion therapy.
• 2.5 points: BETA combined with cardiopulmonary bypass (CPB), hyperbaric oxygenation, or intensive care and resuscitation methods.

Determination of the degree of risk

To determine the final degree of risk, the points for all three criteria are summed up. This allows surgeons and anesthesiologists to adjust the treatment plan, for example, by reducing the scope of surgery or choosing a more gentle method of anesthesia.

• Grade I (insignificant risk): 1.5 points.
• Grade II (moderate risk): 2–3 points.
• Grade III (significant risk): 3.5–5 points.
• Grade IV (high risk): 8.5–11 points.

Preoperative assessment and monitoring

It is impossible to reliably assess the risk without a thorough examination of the patient before surgery.

Anamnesis: It is critically important to assess the fluid balance and potential blood loss. The physician records the presence of thirst, the volume of fluid loss (e.g., from vomiting), and the estimated volume of blood lost during external hemorrhage or hematemesis. They also inquire about allergy history, tolerance to previous blood transfusions, the presence of liver and kidney diseases, and changes in diuresis.

Objective status (Status praesens):

• Skin and mucous membranes: dryness of the mucous membranes and collapse of superficial veins indicate dehydration and volume disorders. Skin mottling and fingertip cyanosis are markers of impaired microcirculation and respiratory failure.
• Hemodynamics and respiration: blood pressure and heart rate are measured, the presence of shortness of breath, depth and frequency of breathing are assessed, and lung auscultation and ECG are performed. Central venous pressure (CVP) measurement is mandatory for critically ill patients.

Assessment of homeostasis: Indicators are monitored dynamically, as the body's responses to trauma, infection, or hemorrhage are non-specific. The following are monitored:

1. Kidneys: relative urine density, daily and hourly diuresis.
2. Blood: hemoglobin (Hb), hematocrit (Ht).
3. Electrolytes and ABG: acid-base balance, levels of $Na^+$, $K^+$, $Ca^{2+}$, $Mg^{2+}$, $Cl^-$.
4. Hemodynamics: circulating blood volume (CBV).

Features in emergency surgery

In urgent conditions, the time for examination and preparation is strictly limited to avoid delaying the start of life-saving surgery.

• Emergency laboratory diagnostics: a complete blood count (Hb, Ht) is rapidly assessed to understand the severity of inflammation and blood loss, along with a urinalysis to monitor renal function. CBV and electrolytes are determined to select replacement or detoxification infusion.
• Sanation of infection foci: chronic foci (caries, tonsillitis, skin infections) under emergency indications are sanitized only as much as possible. For elective indications for surgery, the patient may be temporarily discharged for full treatment of inflammations.
• Extreme situations: in massive internal hemorrhage or cardiac injury, preoperative preparation is completely cancelled—the patient is immediately transported to the operating room.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Anesthetic features and drug selection in bronchial asthma
• Neuroleptanalgesia (NLA): pharmacodynamics and indications
• Measurement technique and clinical significance of CVP
• Principles of emergency infusion-transfusion therapy in blood loss
• Interpretation of acid-base balance (ABG) in surgery

Other topics in "CHAPTER 8. SURGICAL OPERATION"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.