Perioperative Medicine and Preoperative Assessment Flashcards

According to the Revised Cardiac Risk Index (Lee Index), which of the following is NOT one of the six independent risk factors for major perioperative cardiac events?

Answer: Obesity (BMI > 35 kg/m²)

The six RCRI predictors are: (1) high-risk surgery, (2) history of ischaemic heart disease, (3) history of congestive heart failure, (4) history of cerebrovascular disease, (5) preoperative insulin therapy, and (6) preoperative creatinine > 177 µmol/L. Obesity is not an independent RCRI variable, although it contributes to other risk factors.

A patient scheduled for elective infrainguinal vascular surgery has an RCRI score of 3. Which approximate risk of major adverse cardiac events (MACE) does this correspond to?

Answer: ~11%

In the original Lee validation cohort: RCRI 0 = 0.4%, 1 = 0.9%, 2 = 6.6%, 3 = 11%. An RCRI of 3 therefore carries approximately 11% MACE risk, placing this patient in the high-risk category where further preoperative evaluation and optimisation should be considered before elective major surgery.

The ESC 2022 guidelines on cardiovascular assessment before non-cardiac surgery recommend using functional capacity as a key determinant of further cardiac testing. A patient who can climb one flight of stairs without symptoms is estimated to have a functional capacity of approximately:

Answer: ≥ 4 METs (adequate functional capacity)

Climbing one flight of stairs without symptoms is a widely used surrogate for ≥ 4 METs — the threshold for 'adequate' functional capacity. Patients achieving ≥ 4 METs generally do not require further non-invasive cardiac stress testing before intermediate- or high-risk surgery. Inability to achieve 4 METs warrants consideration of further assessment.

According to current ESAIC/ESA fasting guidelines for elective surgery in adults, what is the minimum recommended fasting time for clear fluids (water, black tea, black coffee)?

Answer: 2 hours

Current evidence-based guidelines (ESAIC, ERAS, ASA) recommend a minimum of 2 hours fasting for clear fluids and 6 hours for solids and milk in healthy adults undergoing elective surgery. Clear fluids empty rapidly from the stomach; prolonged fasting beyond 2 hours for fluids is unnecessary and associated with increased patient discomfort, dehydration, and insulin resistance.

Which of the following chronic medications should routinely be CONTINUED on the morning of elective non-cardiac surgery?

Answer: Chronically prescribed beta-blockers

Chronically prescribed beta-blockers must be continued perioperatively; abrupt withdrawal risks rebound hypertension, tachycardia, and myocardial ischaemia. Metformin is typically withheld ≥ 24–48 hours before major surgery due to lactic acidosis risk in the setting of haemodynamic instability. ACE inhibitors/ARBs are generally withheld on the morning of surgery to reduce the risk of refractory intraoperative hypotension. Warfarin requires bridging or cessation based on thrombotic and haemorrhagic risk assessment.

A 70-year-old patient with stable heart failure (EF 35%) is scheduled for elective total hip replacement. According to ESC 2022 perioperative guidelines, which investigation adds the most diagnostic value for preoperative cardiac risk stratification in this scenario?

Answer: Echocardiography to reassess ventricular function if no echo in the past 12 months

In a patient with known heart failure scheduled for intermediate-risk surgery, reassessing ventricular function with echocardiography is appropriate if there has been a recent clinical change or no recent echo is available (within approximately 12 months). This guides anaesthetic planning (choice of agent, haemodynamic targets, need for invasive monitoring). CPEX is indicated for high-risk or uncertain functional capacity cases. Routine coronary angiography and troponin are not first-line for preoperative evaluation in stable heart failure.