Perioperative Monitoring

and Evaluation

Gabriel L. Martinez, MD, FPCS

Professor of Surgery
At the end of the session, the student should be able to:

1. Enumerate the various methods of

perioperative evaluation
2. Discuss the value of perioperative
evaluation
3. Apply the evaluation results to
prognosticate patient outcomes
4. Design a patient-centered
perioperative plan.
Monitor [Lat. Monere] “to warn or advise”
1. Provide advanced warning of impending
deterioration in the status of one or more organ
systems.
2. To allow the clinician to take appropriate actions in a
timely fashion and prevent or ameliorate any
physiologic derangement; Titrate therapeutic
interventions.
3. Assess clinically relevant parameters of tissue and
organ status to ensure that the flow of oxygenated
blood through the microcirculation is sufficient to
support aerobic metabolism at the cellular level.
Course Coverage
A. Systems Evaluation
1. Cardiovascular system
BP/PR/MAR
EKG
Measures of cardiac function
2. Respiratory/Pulmonary
system
ABG/Ventilation-Perfusion
Oximetry/Capnometry
3. Renal
Urine Output
Bladder pressure
4. Neurologic
Intracranial Pressure
Electroencephalography
Transcranial Ultrasound
5. Others (Hepatic, Hematologic,
Endocrinologic)
CT/BT/PT/PTT, LFT, FBS
B. Applications
1. NEWS/MEWS
2. MRA
Approach to Preoperative Evaluation
Organ Systems
• Co-morbid Factors
1. Cardiovascular
• 1. Age
2. Pulmonary
• 2. Functional status
3. Renal
• 3. Nutritional Status
4. Hepatobiliary
• 4. Obesity
5. Endocrine
• 5. Anesthesia risk
6. Immunologic
7. Hematologic
Common complications after non-cardiac
surgery that may be prevented by
enhanced perioperative care Pearse RM
Pneumonia and Respiratory failure
Superficial and deep wound infection
Myocardial infarction and Arrhythmias
Severe pain
Pulmonary embolism
Acute kidney injury
Stroke
Acute confusion or delirium
Cardiac arrest
Preoperative Preparation of the Patient
1. The need for Surgery

Guided by the pillars of Medical Ethics

Patient’s right to choose or refuse treatment (Autonomy)
Acting in the best interest of patient (Beneficence)
First do no harm/primum non nocere (non-maleficence)
Treated with respect (Dignity)
Informed consent and truth-telling (honesty and truthfulness)
Equitable use of health resources (Justice)
Open understandable communication sans Paternalism
Pathophysiologic correlation and prognostication
 Preoperative Preparation of the Patient

2. PeriOperative Decision-making

- timing of surgery
- site of surgical procedure
- type of anesthesia
- patient preparation
- support system
Preoperative Preparation of the Patient
3. PreOperative Evaluation

Guided by findings on the history and physical examination,

demographic or epidemiologic data or patterns of disease progression.

To identify and quantify any co-morbidity that may have an impact on

the outcome of the surgical procedure.

To uncover problem areas that may require further investigation or

optimization.
Goal of Hemodynamic Monitoring

To ensure that the flow of oxygenated blood through the

microcirculation is sufficient to support aerobic
metabolism at the cellular level (mitochondria).

May be influenced by cardiac output (HR x SV),

hemoglobin concentration of the blood or oxygen content
of arterial blood (O2 saturation)
 Physiologic Basis of CP Monitoring
Synthesis of ATP via TCA cycle, requires the continuous delivery of
oxygen (from pulmonary ventilation [DO2] to O2 diffusion from
hemoglobin in red blood cells) to the oxidative machinery within
the mitochondria (perfusion [VO2], O2 utilization).
DO2 is the function of RR, Hgb, BP, HR, QT
VO2 depends on mitochondrial functional integrity
When oxygen availability is inadequate [low O2 Sat],
oxygen utilization (VO2) becomes dependent upon oxygen
delivery (DO2) >>> inc HR (aerobic rate)
Physiologic Basis of CP
Monitoring Supply-dependent
oxygen consumption
Supply-independent
Oxygen consumption

In normoxemic state, homonal milieu

and mechanical workload of contractile

Oxygen Utilization (VO2)

tissues will affect aerobic metabolism
In the hypoxemic state, increased DO2
cannot compensate for the decrease in
VO2 (due to mitochondrial dysfunction)
and will reach the point of critical
oxygen delivery (DO2crit) >>> clinically,
the Maximum Aerobic Rate (MAR)

Hypoxemia Normoxemia
MAR=[220-age in yrs] x 0.75] Oxygen Delivery (DO2)
Arterial Blood Pressure – Non-invasive
A complex function of both cardiac output and vascular input impedance.

1. Auscultation of the Korotkoff sounds

2. Detection of oscillations in the pressure within the bladder of the
cuff. The width of the cuff should be approximately 40% of its
circumference.
3. Doppler stethoscope (reappearance of the pulse produces an audible
amplified signal) or a pulse oximeter (reappearance of the pulse is
indicated by flashing of a light-emitting diode).
4. Photoplethysmography uses the transmission of infrared light to
estimate the amount of hemoglobin (directly related to the volume of
blood) in a finger placed under a servo-controlled inflatable cuff.
Arterial Blood Pressure – Pulse Pressure
PP = sysBP – BPdia
Wide PP may indicate change in
cardiac function or structure
Normal = 40-60 mmHg
-valvular regurgitation
-aortic stiffening
Narrow PP can be a sign of a
poorly functioning heart -severe iron deficiency
anemia
-hyperthyroidism
-increased risk for atrial
fibrillation and coronary
artery disease
Determinants of Cardiac Performance
Preload - the stretch of ventricular myocardial tissue at the
end of diastole just prior to the next contraction
determined by the end-diastolic volume (EDV)

For the RV, central venous pressure (CVP) approximates

RV end-diastolic pressure (EDP). For the LV, pulmonary
artery occlusion pressure (PAOP) approximates LV end-
diastolic pressure
Determinants of Cardiac Performance Hemodynamic Measurements
Afterload - the force resisting fiber shortening SVR – systemic vascular resistance
once systole begins; the amount of Normal – 9-20 mmHg-min/L
resistance the heart must overcome to SVR = MAP/QT
open the aortic valve and push the MAP = BPdia + ([BPsys – BPdia ]/3)
blood volume out into the systemic
circulation approximated by calculating QT = HR x Stroke Volume (cardiac output)

Normal = 4-8L/min
systemic vascular resistance, divided by
cardiac output (QT) SV = End-diastolic volume (EDV)
minus End-systolic volume (ESV
Normal = 70ml
Contractility - the inotropic state of the
myocardium CI – cardiac index
= QT /BSA
Arterial Blood Pressure –Invasive
A complex function of both cardiac output and vascular input impedance.

Intra-arterial pressure monitoring (via Radial Artery)

complications: distal ischemia, thrombosis, infection, air
embolism, thromboembolism
Pulmonary Artery Catheterization (PAC)
complications: wrong placement, rupture of pulmonary
vessel, air embolism
Determines Cardiac Output (QT), Mixed Venous Oximetry
 Electrocardiographic Monitoring
Detects abnormalities in Rate (tachy/
bradycardia) and Rhythm
(dysrhythmias) or combinations
thereof
ECG patterns of interest include repetitive
changes in the morphology of the T-
wave [T-wave alternans (TWA)] and
heart rate variability
Precordial lead V4 is the most sensitive for
detecting perioperative ischemia and
infarction
Choosing Wisely®
No risk factors* for
heart disease or
symptoms suggesting
possible heart disease
→ No need for ECG
* Age≥40 yrs., smoking history,
lifestyle, diet, alcohol intake, stress,
blood pressure, Diabetes mellitus,
obesity, hyperlipidemia,
 Cardiovascular Preoperative Assessment
Risk of Cardiac Death and Nonfatal Myocardial Infarction for
Non-cardiac Surgical Procedures

Risk of procedure
High (> 5%) Aortic and major vascular surgery,
peripheral vascular surgery

Intermediate Intraperitoneal or intrathoracic surgery,

5%) carotid endarterectomy, head and neck
surgery, orthopedic surgery, prostate
surgery

Low (< 1%) Ambulatory surgery, breast surgery,

endoscopic procedures,
superficial procedures,
cataract surgery
 Cardiovascular Risk Predictors (RCRI)

Estimates the patient’s risk for perioperative cardiac

complications. Derived from Goldman’s Criteria
 ASA PS Classification
Glance LG, et al. Ann Surg 2012;255:696-702

ASA PS Definition

I A normal healthy patient

II A patient with mild systemic disease
III A patient with severe systemic disease
IV A patient with severe systemic disease
that is a constant threat to life
V A moribund patient who is not expected
to survive without the operation
.
S-MPM* Scoring System for Estimating Risk of
30-Day Mortality After Non-cardiac Surgery
S-MPM Class Levels and Associated
Risk of Mortality

Class Point Total Mortality

I 0-4 <0.50%
II 5-6 1.5%-4.0%
III 7-9 >10%
Glance LG, et al. Ann Surg 2012;255:696-702.

*Surgical Mortality Probability Model

Pulmonary Risk Predictors
• 1. Increasing age
• 2. Lower albumin level,
• 3. Dependent functional status
• 4. Significant weight loss
• 5. Obesity
• 6. Concurrent comorbid conditions such as impaired sensorium,
previous stroke, congestive heart failure, acute renal failure,
chronic steroid use, and blood transfusion.
• 7. Specific pulmonary risk factors include COPD, smoking,
preoperative sputum production, pneumonia, dyspnea, and
obstructive sleep apnea.
Respiratory Monitoring

1. Gas exchange (ABGs)

Acid-Base Balance
Respiratory Failure
2. Oxygen delivery
3. Pulse oximetry
4. Pulse CO-Oximetry
5. Capnometry
Respiratory Monitoring
Pulse Oximetry provides
continuous non-invasive monitoring of
the oxygen saturation of arterial blood
(SaO2); especially useful in the titration
of FiO2 and PEEP for mechanically
ventilated patients
Pulse CO-oximetry provides
continuous non-invasive measurement
of oxidative states of hemoglobin to
obviate serial blood draws, potential
postsurgical hemorrhage and more
judicious use of blood transfusion
Capnometry is the measurement of
CO2 in the airway throughout the
respiratory cycle; measures the partial
pressure of CO2 in arterial blood
(PaCO2)
Capnography allows the
confirmation of endotracheal
intubation and continuous
assessment of ventilation,
integrity of the airway, operation
of the ventilator and CP function
Renal Risk Predictors
• Preoperative creatinine level ≥2.0 mg/dl
is an independent risk factor
for cardiac complications.

• Dehydration and electrolyte

abnormalities

• Associated diabetic nephropathy

Renal Monitoring
Urine Output
a gross indicator of renal
perfusion, with patent Foley
catheter
Normal output is 0.5ml/kg/hr in
adults; 1-2ml/kg/hr in pediatric
patients
May reflect hypotension,
hypovolemia or low QT
Bladder Pressure
Measures intra-abdominal
pressure (IAP)
Abdominal Compartment
Syndrome – triad of oliguria,
elevated peak airway pressure
and elevated IAP impairing
perfusion of kidneys and
viscera; IAP>20mmHg
 Hepatobiliary Risk Predictors
• Liver insufficiency – spider Child-Pugh Scoring System
angiomas, caput medusa, ascites,
POINTS 1 2 3
palmar erythema, hepatomegaly, Encephalopathy None Stage I or II Stage III or IV
encephalopathy, cachexia Ascites Absent Slight (controlled) Moderate
despite
• Liver function tests – albumin, diuretics
prothrombin time/activity, Bilirubin (mg/dL) <2 2-3 >3
Albumin (g/L) >3.5 2.8-3.5 <2.8
bilirubins PT (prolonged seconds) <4 4-6 >6
• Elevations in hepatocellular INR <1.7 1.7-2.3 >2.3

enzyme levels Class A = 5-6 points; Class B = 7-9 points; Class C = 10-15 points

• AST/ALT ratio >2 INR, international normalized ratio; PT, prothrombin time.
• Child-Pugh Classification
 Neurologic Monitoring
Intracranial Pressure Continuous EEG permits
Monitoring using ventriculostomy ongoing evaluation of cortical
catheter; recommended in patients activity and to monitor therapy for
with traumatic brain injury (TBI) status epilepticus.
[GCS≤8 with abnormal CT scan] or
[normal CT scan with 2 or more of
the following: age>40, unilateral or Transcranial Doppler UTZ to
bilateral motor posturing, systolic evaluate cerebral hemodynamics; an
BP<90mmhg independent predictor of vasospasm
after subarachnoid hemorrhage.
The goal is to ensure that cerebral
perfusion pressure is adequate to
support perfusion of the brain
Endocrinologic Risk
DM – FBS, Post-prandial glucose, HbA1c
watch out for retinopathy, neuropathy and nephropathy

Thyroid function – tachycardia/palpitations and palmar sweating

Adrenal insufficiency – patients who have taken more than 5mg of

prednisone per day for more than 3 weeks within the past year
are considered at risk

Pheochromocytoma – malignant/labile hypertension

Immunologic Predictors
To optimize immunologic function preoperatively to minimize infection
risk and wound breakdown

Absolute Neutrophil Count (ANC) to assess risk of developing

opportunistic infections
ANC = 10 x WBC count in 1000s x (%PMN + % Bands)
Neutropenia is ANC < 1500 cells/cumm
Hematologic and Bleeding Predictors

CBC and reticulocyte count to initially assess anemia

Estimate allowable blood loss (ABL)

ABL= (Hcts- HctA) x (Blood Vol/Hcts)
Blood Vol = 0.07L/kg x weight in Kg

Clotting Time, Bleeding Time, Partial Thromboplastin

Time, Prothrombin Time/Activity
Co-morbid Factors
Age An independent risk factor
≥3 of the following → 50%
postop delirium
Co-existing local or systemic disease
1. ≥ 70 yrs of age
Comprehensive Geriatric Assessment 2. self-reported alcohol abuse
3. poor cognitive status
Functional Capacity and Frailty Index 4. poor functional status
5. abnormal electrolytes/glucose
6. non-cardiac thoracic surgery
Charlson Co-morbidity Index 7. aortic aneurysm surgery
Predicts 10-year survival based on
many factors
PERFORMANCE INDICES
Grade ECOG Score Karnofsky Scale Zubrod
Toxicity and Response Criteria of the Performance Status Activity Level
Eastern Cooperative Oncology Group
0 Fully active, able to carry on all pre-disease 100 Normal, no complaints; no evidence of 0 Normal activity
Performance without restriction disease
90 Able to carry out normal activity;
Minor signs of disease
1 Restricted in physically strenuous activity 80 Normal activity with effort, some signs or 1 Symptomatic and ambulatory;
but ambulatory and able to carry out work symptoms of disease capable of self-care
of a light or sedentary nature, e.g. light 70 Cares for self but unable to carry on
housework, office work normal activity or do active work
2 Ambulatory and capable of all self-care but 60 Requires occasional assistance but is 2 Ambulatory>50% of the time;
unable to carry out any work activities. Up unable to care for most of personal needs occasional assistance
and about more than 50% of waking hours
50 Requires considerable assistance and 3 Ambulatory <50% of the time;
frequent medical care nursing care needed
3 Capable of only limited self-care, confined 40 Disabled; requires special care and
to bed or chair more than 50% of waking assistance
hours 30 Severely disabled; hospitalization is
indicated although death not imminent
4 Completely disabled. Cannot carry on any 20 Very ill; hospitalization and active 4 Bedridden
self-care. Totally confined to bed or chair supportive care necessary
10 Moribund
5 Dead 0 Dead
Frailty Scale – guides physician on morbidity and mortality risks and the need
for extended care

Scoring Parameters (1pt each) Interpretation

• Unintentional weight loss >4.5kgs in the past
year
Healthy person score 0
• <20th population centile for grip strength Very frail person score 4-5
(poor grip strength)
worse outcomes
• Self-reported exhaustion
20x likely to end up in nursing home
• Low physical activity such that person rarely
undertake short walk Intermediate Frailty score 2-3
• Slowed walking speed (lowest population 2x likely to have complications
quartile on 4 minute walking test) 50% more time in the hospital
will likely need extended care
Domains of Comprehensive Geriatric Assessment (CGA)
Domain Measures

Functional Status Karnofsky Index, ECOG (physician/patient-rated), Zubrod

Activities of Daily Living (ADL) & Instrumental ADL (IADL)
Timed Up and Go (Frailty, Gait & Balance)
Number of Falls in the last six months

Co-morbidity Charlson’s Co-morbidity Index (predicts 10-yr survival based on age + other factors)

Cognition Blessed Orientation-Memory-Concentration Index

Level of Dementia

Psychological Hospital Anxiety and Depression Scale; Fears, Moods

Social Functioning Medical Outcomes Study Social Activity Limitation Measure

Social Support Emotional/Information & Tangible Subscale

Informal support from family and friends; social network

Nutrition Body Mass Index (BMI)

Percent unintentional weight loss in the last 3 months
 Nutritional Status as predictor

History of unintentional weight loss greater

than 10% of body weight over a 6-month
period or 5% over a month

Low albumin, transferrin or prealbumin levels

Temporal wasting, cachexia, sarcopenia,

ascites, edema

Subjective Global Assessment/NRS 2002

Nutritional Risk Screening (NRS 2002)
Obesity as Risk Predictor
The perioperative mortality rate is
significantly increased in patients with
clinically severe obesity (BMI>40 kg/sqm or
BMI >35 kg/sqm with significant co-morbid
conditions)

Clinically severe obesity is associated with

essential hypertension, pulmonary
hypertension, LVH, CHF, and ischemic heart
disease. Patients with ≥2 risk factors should
undergo noninvasive cardiac testing
Preoperative Checklist

1. Medical Risk Assessment

2. Antibiotic prophylaxis – consult CPGs
3. Mechanical Bowel Cleansing for bowel surgery
4. Review of home meds – cardiac drugs, anticoagulants, NSAIDS,
Herbal meds for drug interactions
5. NPO – solids for at least 6 hrs and clear liquids for 2 hrs
 Intraoperative Factors

The right procedure to the right

patient at the right time by the
right professional
Meticulous technique and
careful hemostasis
“be kind to the tissues and
they will be kind to you”
“don’t trouble trouble if
trouble does not trouble you lest
you get into trouble”
Postoperative Monitoring
1. National Early Warning Score
(NEWS) 5. Bleeding
2. Modified Early Warning Score
(MEWS) 6. Pain management

3. Fluid and electrolyte balance; 7. Engage Family

Acid-base balance

8. System-based medicine
4. Signs of Airway Obstruction
 A score of ≥5 is linked to
an increased likelihood of
death or ICU admission

Alert – fully awake, opens eyes, obeys

commands, motor functions ok
GCS 15
Verbal – responds to voice prompt
GCS 12
Pain – responds to squeeze/sternal rub
GCS 8
Unresponsive GCS 3
Key Points
• 1. Proficiency and patient safety should be maintained by updating
knowledge and understanding
• 2. All vital signs, observations and assessments performed must be
documented and tracked
• 3. Using evidence-based tools can make a stressful situation calmer
and more controlled
• 4. Patient-centered care and system-based medicine should be
utilized
• 5. Patient engagement and education prevents postoperative
complications
Physiologic Basis of CP
Monitoring

In the hypoxemic state, increased DO2

cannot compensate for the decrease in
VO2 (due to mitochondrial dysfunction)
and will reach the point of critical
oxygen delivery (DO2crit) >>> clinically,
the Maximum Aerobic Rate (MAR)

MAR=[220-age in yrs] x 0.75]

 The Law of Mass Action

H2O + CO2 ↔ H2CO3 ↔ H+ + HCO3-

Po2=80-100 mmHg HCO3=22-26 mmHg
O2Sat=94-100% pH=7.35-7.45
Pco2=35-45 mmHg BE= ±2

• pH will change whenever either or both Pco2 or HCO3-

change such that the 40:24 ratio is lost.