A 60 year old woman is posted for an elective laparoscopic cholecystectomy under general anaesthesia. She is a known diabetic on Insulin and under fair control. She is also a known hypertensive on Amlodipine (Norvasc) for controlling her pressure. She complains of mild chest discomfort on severe exertion. Her preoperative assessment indicates good exercise tolerance on a treadmill test and good control of blood pressure and sugars.

Question (1)   The single most important predictor of her post operative risk in this case would be

(a)    Her anginal symptoms
(b)   Her diabetes mellitus
(c)    Her hypertension
(d)   Her age

 Answer: The answer is (a). Her anginal symptoms put her in an intermediate cardiac risk and this increases her risk of unstable angina, MI and sudden cardiac death in the perioperative period. The diabetes, hypertension and her increased age are also risk factors but do not pose her to an immediate perioperative risk.

Question (2)   One preventive measure taken preoperatively can dramatically modify her perioperative risk.

(a)    Performing a coronary angiogram and if needed an angioplasty
(b)   Starting her on a good dose of long acting nitrates
(c)    Doing her surgery under spinal block
(d)   Starting her on bisoprolol 2 weeks before surgery

Answer: The answer is (d). In one study when bisoprolol was started 7 days preoperatively, titrated to a resting heart rate of 60 beats per minute and continued for 30 days postoperatively, a 90% reduction in perioperative mortality and MI was observed.

There are several postoperative pulmonary complications associated with major surgeries such as laparotomy and major orthopaedic surgeries. These include pneumonia, bronchospasm, respiratory failure and atelectasis. Many times this leads to intubation and mechanical ventilation and its associated complications. While evaluating patients for these post operative pulmonary complications some important points have to be borne in mind.

Question (3)   The modifiable risk factors for post operative pulmonary complications include all except

(a)    Smoking
(b)   Uncontrolled COPD
(c)    Uncontrolled Asthma
(d)   Age 

Answer: The answer is (d). Cessation of smoking at least 8 weeks before surgery considerably reduces the risk of postoperative pulmonary complications. Aggressive medical treatment of COPD and Asthma preoperatively can reduce the risk of postoperative complications. The only risk, which cannot be modified, is age.