MRCS PART A ESSENTIAL REVISION NOTES BOOK 1 - PasTest

MRCS PART A ESSENTIALREVISION NOTESBOOK 1Edited byClaire Ritchie ChalmersBA PhD FRCSCatherine Parchment SmithBSc MBChB FRCS

Chapter 6Nigel W GummersonTraumaPart 2: musculoskeletal trauma 499Chapter 7 Evidence-based surgical practice 547Nerys ForesterChapter 8Sebastian Dawson-BowlingEthics, clinical governance and the medicolegalaspects of surgery 567Chapter 9 Orthopaedic Surgery 595Nigel W GummersonChapter 10 Paediatric surgery 793Stuart J O’Toole, Juliette Murray, Susan Picton and David CrabbeChapter 11 Plastic Surgery 853Stuart W WaterstonList of Abbreviations 873Bibliography 877Index 879iv

CHAPTER 1Perioperative CareTristan E McMillan1 Assessment of fitness for surgery 31.1 Preoperative assessment 41.2 Preoperative Laboratory testingand imaging 71.3 Preoperative consent andcounselling 101.4 Identification anddocumentation 141.5 Patient optimisation forelective surgery 141.6 Resuscitation of the emergencypatient 151.7 The role of prophylaxis 151.8 Preoperative marking 162 Preoperative management ofcoexisting disease 172.1 Preoperative medications 172.2 Preoperative management ofcardiovascular disease 202.3 Preoperative management ofrespiratory disease 242.4 Preoperative management ofendocrine disease 262.5 Preoperative management ofneurological disease 292.6 Preoperative management of liverdisease 302.7 Preoperative management ofrenal failure 322.8 Preoperative management ofrheumatoid disease 322.9 Preoperative assessment andmanagement of nutritionalstatus 332.10 Risk factors for surgery andscoring systems 383 Principles of anaesthesia 403.1 Local anaesthesia 403.2 Regional anaesthesia 433.3 Sedation 473.4 General anaesthesia 473.5 Complications of generalanaesthesia 524 Care of the patient in theatre 564.1 Pre-induction checks 564.2 Prevention of injury to theanaesthetised patient 564.3 Preserving patient dignity 571

SECTION 1Assessment of fitness for surgeryCHAPTER 1In a nutshell …Before considering surgical intervention itis necessary to prepare the patient as fullyas possible.The extent of pre-op preparationdepends on: Classification of surgery: Elective Scheduled Urgent Emergency Nature of the surgery (minor, major,major-plus) Location of the surgery (A&E,endoscopy, minor theatre, maintheatre) Facilities availableThe rationale for pre-op preparation is to: Determine a patient’s ‘fitness forsurgery’Anticipate difficultiesMake advanced preparation andorganise facilities, equipment andexpertiseEnhance patient safety and minimisechance of errorsAlleviate any relevant fear/anxietyperceived by the patientReduce morbidity and mortalityCommon factors resulting in cancellation ofsurgery include: Inadequate investigation and managementof existing medical conditions New acute medical conditionsClassification of surgery according to theNational Confidential Enquiry into PatientOutcome and Death (NCEPOD): Elective: mutually convenient timing Scheduled: (or semi-elective) earlysurgery under time limits (eg 3 weeks formalignancy) Urgent: as soon as possible after adequateresuscitation and within 24 hoursPatients may be: Emergency: admitted from A&E; admittedfrom clinic Elective: scheduled admission from home,usually following pre assessmentIn 2011 NCEPOD published Knowing the Risk: Areview of the perioperative care of surgical patientsin response to concerns that, although overallsurgical mortality rates are low, surgical mortalityin the high-risk patient in the UK is significantlyhigher than in similar patient populations in theUSA. They assessed over 19 000 surgical casesprospectively and identified four key areas forimprovement (see overleaf).3

Perioperative CareCHAPTER 11. Identification of the high-risk grouppreoperatively, eg scoring systems tohighlight those at high risk2. Improved pre-op assessment, triage andpreparation, proper preassessment systemswith full investigations and work-upfor elective patients and more rigorousassessment and preoperative managementof the emergency surgical patient, especiallyin terms of fluid management3. Improved intraoperative care: especiallyfluid management, invasive and cardiacoutput monitoring4. Improved use of postoperative resources:use of high-dependency beds and criticalcare facilities1.1 PreoperativeassessmentIn a nutshell …Preoperative preparation of a patientbefore admission may include: History Physical examination Investigations as indicated: Blood tests Urinalysis ECG Radiological investigations Microbiological investigations Special tests Consent and counsellingThe preassessment clinic is a useful toolfor performing some or all of these tasksbefore admission.Preassessment clinicsThe preassessment clinic aims to assess surgicalpatients 2–4 weeks preadmission for electivesurgery.Preassessment is timed so that the gap betweenassessment and surgery is: Long enough so that a suitable response canbe made to any problem highlighted Short enough so that new problems areunlikely to arise in the interimThe timing of the assessment also means that: Surgical team can identify current pre-opproblems High-risk patients can undergo earlyanaesthetic review Perioperative problems can be anticipatedand suitable arrangements made (egbook intensive therapy unit [ITU]/high-dependency unit [HDU] bed for thehigh-risk patient) Medications can be stopped or adapted (eganticoagulants, drugs that increase risk ofdeep vein thrombosis [DVT]) There is time for assessment by alliedspecialties (eg dietitian, stoma nurse,occupational therapist, social worker) The patient can be admitted to hospitalcloser to the time of surgery, therebyreducing hospital stayThe patient should be reviewed again onadmission for factors likely to influence prognosisand any changes in their pre-existing conditions(eg new chest infection, further weight loss).Preassessment is run most efficiently by followinga set protocol for the preoperative managementof each patient group. The protocol-led systemhas several advantages: The proforma is an aide-mémoire in clinic Gaps in pre-op work up are easily visible Reduces variability between clerking byjuniorsHowever, be wary of preordered situations becausethey can be dangerous and every instruction must4

Perioperative CareCHAPTER 15. Drug history and allergiesList of all drugs, dosages and times that they were taken. List allergies and nature of reactionsto alleged allergens. Ask directly about the oral contraceptive pill and antiplatelet medicationsuch as aspirin and clopidogrel which may have to be stopped preoperatively.6. Social historySmoking and drinking – how much and for how long. Recreational drug abuse. Who is athome with the patient? Who cares for them? Social Services input? Stairs or bungalow? Howmuch can they manage themselves?7. Family history8. Full review of non-relevant systemsThis includes all the systems not already covered in the history of the presenting complaint,eg respiratory, cardiovascular, neurological, endocrine and orthopaedic.Physical examinationDetailed descriptions of methods of physicalexamination can only really be learntby observation and practice. Don’t relyon the examination of others – surgicalsigns may change and others may missimportant pathologies. See MRCS Part BOSCEs: Essential Revision Notes for detailsof surgical examinations for each surgicalsystem.Physical examinationGeneral examination: is the patient well or in extremis? Are they in pain? Look foranaemia, cyanosis and jaundice, etc. Do they have characteristic facies or body habitus (egthyrotoxicosis, cushingoid, marfanoid)? Are they obese or cachectic? Look at the hands fornail clubbing, palmar erythema, etcCardiovascular examination: pulse, BP, jugular venous pressure (JVP), heart sounds andmurmurs. Vascular bruits (carotids, aortic, renal, femoral) and peripheral pulsesRespiratory examination: respiratory rate (RR), trachea, percussion, auscultation, use ofaccessory musclesAbdominal examination: scars from previous surgery, tenderness, organomegaly, mass,peritonism, rectal examinationCNS examination: particularly important in vascular patients pre-carotid surgery and inpatients with suspected spinal compressionMusculoskeletal examination: before orthopaedic surgery6

Perioperative CareCHAPTER 1When to perform a preoperative U&EIn practice almost all surgical patientsget their U&Es tested but it is particularlyimportant in the following groups: All pre-op cases aged >65 Positive result from urinalysis(eg ketonuria) All patients with cardiopulmonarydisease, or taking diuretics, steroidsor drugs active on the cardiovascularsystem All patients with a history of renal/liverdisease or an abnormal nutritionalstate All patients with a history ofdiarrhoea/vomiting or other metabolic/endocrine disease All patients on an intravenous infusionfor >24 hoursAmylase Normal plasma amylase range varies withdifferent reference laboratories Perform in all adult emergency admissionswith abdominal pain, before considerationof surgery Inflammation surrounding the pancreaswill cause mild elevation of the amylase;dramatic elevation of the amylase resultsfrom pancreatitisWhen to perform an RBG Emergency admissions withabdominal pain, especially ifsuspecting pancreatitis Preoperative elective cases withdiabetes mellitus, malnutrition orobesity All elective pre-op cases aged >60years When glycosuria or ketonuria ispresent on urinalysisClotting testsProthrombin time (PT) 11–13 seconds Measures the functional components of theextrinsic pathway prolonged with warfarintherapy, in liver disease and disseminatedintravascular coagulation (DIC)Activated partial thromboplastin time(APTT)

Assessment of fitness for surgerySickle cell testDifferent hospitals have different protocols, butin general you would be wise to perform a sicklecell test in all black patients in whom surgeryis planned, and in anyone who has sicklecell disease in the family. Patients should becounselled before testing to facilitate informedconsent.Liver function tests (LFTs) Perform LFTs in all patients with upperabdominal pain, jaundice, known hepaticdysfunction or history of alcohol abuse Remember that clotting tests are the mostsensitive indicator of liver synthetic disorderand may be deranged before changes inthe LFTs. Decreased albumin levels are anindicator of chronic illness and sepsisGroup and save/cross-matchWhen to perform a group and save: Emergency pre-op cases likely to result insignificant surgical blood loss, especiallytrauma, acute abdomen, vascular cases If there is suspicion of blood loss, anaemia,haematopoietic disease, coagulation defects Procedures on pregnant femalesUrinalysisWhen to perform pre-op urinalysis: All emergency cases with abdominal orpelvic pain All elective cases with diabetes mellitus All pre-op cases with thoracic, abdominalor pelvic traumaA midstream urine (MSU) specimen should beconsidered before genitourinary operations andin pre-op patients with abdominal or loin pain.A urine pregnancy test should be performed inall women of childbearing age with abdominalsymptoms, or who need a radiograph.ElectrocardiographyA 12-lead electrocardiogram (ECG) is capableof detecting acute or long-standing pathologicalconditions affecting the heart, particularlychanges in rhythm, myocardial perfusion orprior infarction.Note that the resting ECG is not a sensitive testfor coronary heart disease, being normal in upto 50%. An exercise test is preferred.When to perform a 12-lead ECG: Patients with a history of heart disease,diabetes, hypertension or vascular disease,regardless of age Patients aged >60 with hypertension orother vascular disease Patients undergoing cardiothoracic surgery,taking cardiotoxic drugs or with an irregularpulse Any suspicion of hitherto undiagnosedcardiac diseaseRadiological investigationsRadiological investigations may include: Plain films: chest radiograph, plainabdominal film, lateral decubitus film, KUB(kidney, ureter, bladder) film, skeletal views Contrast studies and X-ray screening:Gastrografin, intravenous (IV) contrast Ultrasonography: abdominal, thoracic,peripheral vasculature Computed tomography (CT): intraabdominalor intrathoracic pathology Magnetic resonance imaging (MRI):particularly for orthopaedics, spinal cordcompression, liver pathologyCHAPTER 19

Perioperative CareCHAPTER 1Chest radiographWhen to perform a pre-op chest radiograph: All elective pre-op cases aged >60 years All cases of cervical, thoracic or abdominaltrauma Acute respiratory symptoms or signs Previous cardiorespiratory disease and norecent chest radiograph Thoracic surgery Patients with malignancy Suspicion of perforated intra-abdominalviscus Recent history of tuberculosis (TB) Recent immigrants from areas with a highprevalence of TB Thyroid enlargement (retrosternal extension)Investigating special casesCoexisting disease A chest radiograph for patients with severerheumatoid arthritis (they are at risk ofdisease of the odontoid peg, causingsubluxation and danger to the cervicalspinal cord under anaesthesia) Specialised cardiac investigations (egechocardiography, cardiac stress testing,MUGA scan) used to assess pre-op cardiacreserve and are increasingly used routinelybefore major surgery Specialised respiratory investigations (egspirometry) to assess pulmonary functionand reservePlain abdominal filmPlain abdominal films should be performedwhen there is: Suspicion of obstruction Suspicion of perforated intra-abdominalviscus Suspicion of peritonitisThe role of radiological investigation in diagnosisand planning is discussed further in Chapter 2,Surgical technique and technology.Microbiological investigationsThe use and collection of microbiologicalspecimens is discussed in Surgical microbiology.Investigations relating to the organin question Angiography or duplex scanning in arterialdisease before bypass Renal perfusion or renal isotope imaging orliver biopsy before transplant Colonoscopy, barium enema or CTcolonography (CTC) before bowel resectionfor cancer1.3 Preoperative consentand counsellingDeciding to operateIt is often said that the best surgeon knows whennot to operate. The decision to undertake surgerymust be based on all available information froma thorough history, examination and investigativetests. All treatment options, includingnon-surgical management, and the risks andpotential outcomes of each course of action mustbe discussed fully with the patient in order to10

Assessment of fitness for surgeryObtaining consentThe General Medical Council gives the followingguidelines (GMC 2008).Ask patients whether they have understood theinformation and whether they would like morebefore making a decision. Sometimes asking thepatient to explain back to you, in his or her ownwords, what you have just said clarifies areasthat the patient does not really understand andmay need more explanation.The legal right to consentThe ability to give informed consent for differentpatient ages and groups is discussed fully inChapter 8, Ethics, Clinical Governance and theMedicolegal Aspects of Surgery.CHAPTER 1Obtaining consentProvide sufficient information: Details of diagnosis Prognosis if the condition is left untreated and if the condition is treated Options for further investigations if diagnosis is uncertain Options for treatment or management of the condition The option not to treat The purpose of the proposed investigation or treatment Details of the procedure, including subsidiary treatment such as pain relief How the patient should prepare for the procedure Common and serious side effects Likely benefits and probabilities of success Discussion of any serious or frequently occurring risks Lifestyle changes that may result from the treatment Advice on whether any part of the proposed treatment is experimental How and when the patient’s condition will be monitored and reassessed The name of the doctor who has overall responsibility for the treatment Whether doctors in training or students will be involved A reminder that patients can change their minds about a decision at any time A reminder that patients have a right to seek a second opinion Explain how decisions are made about whether to move from one stage of treatment toanother (eg chemotherapy) Explain that there may be different teams of doctors involved (eg anaesthetists) Seek consent to treat any problems that might arise and need to be dealt with while thepatient is unconscious or otherwise unable to make a decision Ascertain whether there are any procedures to which a patient would object (eg bloodtransfusions)13

Perioperative CareCHAPTER 11.4 Identification anddocumentationPatient identificationPatient identification is essential. All patientsshould be given an identity wristband onadmission to hospital, which should state clearlyand legibly the patient’s name, date of birth,ward and consultant. He or she should also begiven a separate red wristband documentingallergies. Patient identification is checked by thenursing team on admission to theatre.DocumentationMedical documents (medical notes, drug andfluid charts, consent forms and operation notes)are legal documents. All entries to the notesshould be written clearly and legibly. Alwayswrite the date and time and your name andposition at the beginning of each entry.1.5 Patient optimisationfor elective surgeryMorbidity and mortality increase in patientswith comorbidity.Optimising the patient’s condition gives themthe best possible chance of a good surgicaloutcome. Do not forget that this includesnutrition.In patients with severe comorbidity thenNCEPOD recommend the following: Discussion between surgeon andanaesthetist before theatre Adequate preoperative investigation Optimisation of surgery by ensuring: An appropriate grade of surgeon (tominimise operative time and blood loss) Adequate preoperative resuscitation Provision of on-table monitoring Critical-care facilities are availableDocumentation often starts with clerking. Recordas much information as possible in the formatdescribed above for history and examination.The source of information should also be stated(eg from patient, relative, old notes, clinic letter,GP).Accurate documentation should continue foreach episode of patient contact, includinginvestigations, procedures, ward rounds andconversations with the patient about diagnosisor treatment.File documents in the notes yourself; otherwisethey will get lost. This is important to protect boththe patient and yourself. From a medicolegalpoint of view, if it is not documented then itdidn’t happen.Optimisation of patients forelective surgeryControl underlying comorbidity: specialistadvice on the management of underlyingcomorbidities (cardiovascular, respiratory,renal, endocrinological) should be sought.Individual comorbidities are discussed later inthe chapter. Optimisation should be undertakenin a timely fashion as an outpatient for electivesurgery, although some may occasionallyrequire inpatient care and intervention beforescheduling an elective procedure.Nutrition: good nutrition is essential for goodwound healing. Malnourished patients dobadly and a period of preoperative dietaryimprovement (eg build-up drinks, enteralfeeding, total parenteral nutrition or TPN)improves outcome.14

Assessment of fitness for surgery1.6 Resuscitation of theemergency patientIt is essential that the acutely ill surgical patientis adequately resuscitated and stabilisedbefore theatre. In extreme and life-threateningconditions this may not be possible (eg rupturedabdominal aortic aneurysm or AAA, trauma)and resuscitation should not delay definitivetreatment.Most emergency patients fall into one oftwo categories: haemorrhage or sepsis. Themanagement of haemorrhage and sepsis aredealt with in detail in the Chapters 3 and 4 ofthis book respectively.General principles of resuscitation are: Optimise circulating volume: Correct dehydration: many acute surgicalpatients require IV fluids to correctdehydration and restore electrolytebalance. Establish good IV access.Insertion of a urinary catheter is vital tomonitor fluid balance carefully with hourlymeasurements. Severe renal impairmentmay require dialysis before theatre.Dehydrated patients may exhibit profounddrops in blood pressure on anaestheticinduction and aggressive preoperative fluidmanagement is often required Correct anaemia: anaemia compromisescardiac and respiratory function and isnot well tolerated in patients with poorcardiac reserve. The anaemia may beacute (acute bleed) or chronic (underlyingpathology). If anaemia is acute, transfuseto reasonable Hb and correct clotting.Consider the effects of massive transfusionand order and replace clotting factorssimultaneously. Chronic anaemia is bettertolerated but may also require correctionbefore theatreTreat pain: pain results in the release ofadrenaline and can cause tachycardiaand hypertension. Pain control beforeanaesthesia reduces cardiac workloadGive appropriate antibiotics early asrequired in sepsis. These may need to beempirical until antimicrobial treatment canbe guided by blood and pus culturesDecompress the stomach: insert anasogastric (NG) tube to decompress thestomach because this reduces the risk ofaspiration on anaesthetic induction1.7 The role of prophylaxisProphylaxis essentially refers to the reductionor prevention of a known risk. Preoperativelyprophylaxis should include: Stopping potentially harmful factors: Stopping medications (eg the oralcontraceptive pill for a month, aspirin orclopidogrel for 2 weeks before surgery) Stopping smoking: improves respiratoryfunction even if the patient can only stopfor 24 hours Prescribing drugs known to reduce risks: Heparin to reduce the risk of DVT Cardiac medications (eg preoperativeblockers, statins or angiotensinconvertingenzyme [ACE] inhibitors) toreduce cardiovascular riskCHAPTER 115

Perioperative CareCHAPTER 11.8 Preoperative markingThis should be performed after consent andbefore the patient has received premedication.Marking is essential to help avoid mistakes intheatre. Marking while the patient is consciousis important to minimise error. Preoperativemarking is especially important if the patient ishaving: A unilateral procedure (eg on a limb or thegroin) A lesion excised A tender or symptomatic area operated on(eg an epigastric hernia) A stomaMarking for surgery Explain to the patient that you aregoing to mark the site for surgery Confirm the procedure and the site(including left or right) with the notes,patient and consent form Position the patient appropriately (egstanding for marking varicose veins,supine for abdominal surgery) Use a surgical marker that will notcome off during skin preparation Clearly identify the surgical site usinga large arrow16

SECTION 2Preoperative management ofcoexisting diseaseCHAPTER 12.1 PreoperativemedicationsReview pre-existingmedicationIn a nutshell …If a patient is having surgery: Review pre-existing medication: Document preoperativemedications Decide which drugs need to bestopped preoperatively Decide on alternative formulations Prescribe preoperative medication: Prescribe prophylactic medication Prescribe medication related to thesurgery Prescribe premed if needed Be aware of problems with specificdrugs: Steroids and immunosuppressants Anticoagulants and fibrinolyticsPerioperative management ofpre-existing medicationDocument preoperative medicationsDecide whether any drugs need to bestopped before surgery Stop oral contraceptive (OCP) ortamoxifen 4 weeks before major orlimb surgery – risk of thrombosis Stop monoamine oxidase inhibitor(MAOI) antidepressants – they interactwith anaesthetic drugs, with cardiacrisk Stop antiplatelet drugs 7–14 dayspreoperatively – risk of haemorrhageDecide on alternative formulations forthe perioperative period For example, IV rather than oral,heparin rather than warfarin17

Perioperative CareCHAPTER 1Regular medications should generally be given– even on the day of surgery (with a sip of clearfluid only). If in doubt ask the anaesthetist. Thisis important, especially for cardiac medication.There are some essential medications (eganti-rejection therapy in transplant recipients)that may be withheld for 24 hours in thesurgical period but this should only be under thedirection of a specialist in the field.Prescribe preoperativemedicationMedication for the preoperativeperiodPre-existing medication (see above forthose drugs that should be excluded)Prophylactic medication For example, DVT prophylaxis For example, antibiotic prophylaxisMedication related to the surgery For example, laxatives to clear thebowel before resection For example, methylene blue toaid surgical identification of theparathyroidsAnaesthetic premedication (to reduceanxiety, reduce secretions, etc)Be aware of problems withspecific drugsSteroids and immunosuppressionIndications for perioperativecorticosteroid coverThis includes patients: With pituitary–adrenal insufficiency onsteroids Undergoing pituitary or adrenal surgery On systemic steroid therapy of >7.5 mg for>1 week before surgery Who received a course of steroids for>1 month in the previous 6 monthsComplications of steroid therapy in theperioperative period Poor wound healing Increased risk of infection Side effects of steroid therapy (eg impairedglucose tolerance, osteoporosis, musclewasting, fragile skin and veins, pepticulceration) Mineralocorticoid effects (sodium and waterretention, potassium loss and metabolicalkalosis) Masking of sepsis/peritonism Glucocorticoid deficiency in the perioperativeperiod (may present as increasingcardiac failure which is unresponsive tocatecholamines, or addisonian crisis withvomiting and cardiovascular collapse)Management of patients on pre-opsteroid therapyThis depends on the nature of the surgery to beperformed and the level of previous steroid use. Minor use: 50 mg hydrocortisone intramuscularly/intravenouslyIM/IV preoperatively Intermediate use: 50 mg hydrocortisoneIM/IV with premed and 50 mg hydrocortisoneevery 6 h for 24 h Major use: 100 mg hydrocortisone IM/IVwith premed and 100 mg hydrocortisoneevery 6 h for at least 72 h after surgeryEquivalent doses of steroid therapy: hydrocortisone100 mg, prednisolone 25 mg,dexamethasone 4 mg.18

Preoperative management of coexisting diseaseAnticoagulants and fibrinolyticsConsider the risk of thrombosis (augmented bypostsurgical state itself) vs risk of haemorrhage.Warfarin Inhibits vitamin K-dependent coagulationfactors (II, VII, IX and X) as well as protein Cand its cofactor, protein S Illness and drug interactions may haveunpredictable effects on the level ofanticoagulation Anticoagulative effects can be reversedby vitamin K (10 mg IV; takes 24 h foradequate synthesis of inhibited factors) andfresh frozen plasma (15 ml/kg; immediatereplacement of missing factors) Stop 3–5 days before surgery and replacewith heparin; depends on indication foranticoagulation (eg metal heart valve is anabsolute indication, but atrial fibrillation[AF] is a relative one) INR should be

Perioperative CareCHAPTER 1Fibrinolytics Examples include streptokinase andalteplase Act by activating plasminogen to plasmin,which undertakes clot fibrinolysis Used in acute MI, extensive DVT and PE Contraindicated if the patient had undergonerecent surgery, trauma, recent haemorrhage,pancreatitis, aortic dissection, etcFor discussions of the management of immunosuppressionin the perioperative period seeTransplantation in Book 2. DVT prophylaxis inthe perioperative period is covered in Chapter 3,section 1.2, Surgical haematology.2.2 Preoperativemanagement ofcardiovascular diseaseIn a nutshell …Cardiac comorbidity increases surgicalmortality (includes ischaemic heartdisease, hypertension, valvular disease,arrhythmias and cardiac failure).Special care must be taken withpacemakers and implantabledefibrillators. In general it is necessary to: Avoid changes in heart rate (especiallytachycardia) Avoid changes in BP Avoid pain Avoid anaemia Avoid hypoxia (give supplementaloxygen)In addition, the details of preoperativeassessment before cardiac surgery iscovered in Book 2.The European Society of Cardiology haspublished guidelines (2009) to cover thepreoperative risk assessment and perioperativemanagement of patients with cardiovasculardisease. Patient-specific factors are moreimportant in determining risk than the type ofsurgery but, with regard to cardiac risk, surgicalinterventions can be divided into low-risk,intermediate-risk and high-risk groups: Low risk (cardiac event rate 1%): mostbreast, eye, dental, minor orthopaedics,minor urological and gynaecologicalprocedures Medium risk (cardiac event rate 1–5%):abdominal surgery, orthopaedic andneurological surgery, transplantationsurgery, minor vascular surgery andendovascular repair High risk (cardiac event rate >5%): majorvascular surgeryLaparoscopic surgery has a similar cardiac riskto open procedures because the raised intraabdominalpressure results in reduced venousreturn with decreased cardiac output anddecreased systemic vascular resistance, andshould therefore be risk assessed accordingly.The Lee Index is a predictor of individual cardiac riskand contains six independent clinical determinantsof major perioperative cardiac events: A history of ischaemic heart disease (IHD) A history of cerebrovascular disease Heart failure Type 1 diabetes mellitus Impaired renal function High-risk surgeryThe presence of each factor scores 1 point.Patients with an index of 0, 1, 2 and 3 pointscorrespond to an incidence of major cardiaccomplications of 0.4%, 0.9%, 7% and 11%respectively.20