ANZCA Final Exam Resources

Structures & Approach

High Risk Patient

Issues

Confusing area as there are multiple guidelines with differing recommendations regarding the assessment of high risk patients undergoing non-cardiac surgery (AHA/ACC, ESC, etc)

⁠

Cardiovascular risk management in the peri‐operative setting⁠

(MJA 2023) provides an Australian narrative review which looks at the evidence for the various guides and provides some recommendations

⁠

Overall Approach

Pre-Op

Risk stratify

Determine severity of known disease (e.g. valvular lesion) and complications

Assess for unstable disease +/- consider deferral to fix the issue

Functional assessment (M-DASI-4Q)

Frailty (Clinical Frailty Scale)

Risk stratification tool (e.g. NSQIP, RCRI)

Investigate further

Not routinely

Exercise tolerance < 4 METs → consider formal CPET

Unclear risk → consider cardiac biomarkers (e.g. NT-proBNP) [high false positive rate but may be worth it to identify/optimise high risk patients]

Optimise

CV risk factors

Medications

Prehabilitation?

Intra-Op

Haemodynamic goals

Choice of anaesthetic modality

Impact of surgery on haemodynamics (e.g. pneumoperitoneum)

Lines and monitoring

Induction

Maintenance

Emergence

Post-Op

Safest environment

Analgesia and impact of poor pain control on haemodynamics

Need for MINS monitoring (daily troponin for 72 hours)

Specifics

M-DASI-4Q

Simplified version of the Duke Activity Status Index (DASI)

Shown to be equivalent to DASI in terms of predicting VO2 peak and anaerobic threshold

If a patient scores 4/4 then there is an 84% chance that their VO2 peak is > 16 mL/kg/min (4.5 METs)

Questions

Are you able to climb a flight of stairs or walk up a hill?

Are you able to do heavy work around the house (lifting and moving heavy furniture)?

Are you able to do yard work (raking leaves or pushing a power mower)?

Are you able to participate in strenuous sports (swimming, singles tennis, football, basketball or skiing)?

Clinical Frailty Scale (CFS)

Scoring system from 1 (very fit) to 9 (terminally ill)

Broadly seems to be stratified into three categories

Well (1-3: very fit, fit, managing well)

Variable dependence (4-6: very mild, mild, moderate frailty)

Complete dependence (7-9: severe, very severe frailty, terminally ill)

Linear relationship between CFS score and perioperative mortality

Patients with CFS score of 6+ are at significantly higher risk of postoperative complications

Delirium

Pneumonia

Arrhythmia

Prolonged hospital stay

Functional decline

Revised Cardiac Risk Index (RCRI)

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