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Clinical pharmacology
Optimal medical management around the time of surgery
  1. Michiel T Voûte1,
  2. Tamara A Winkel1,
  3. Don Poldermans2
  1. 1Department of Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
  2. 2Department of Anesthesiology, Erasmus Medical Centre, Rotterdam, The Netherlands
  1. Correspondence to Professor Don Poldermans, Erasmus MC, Thoraxcentre, Room BD 373, PO BOX 2040, 3000 CA Rotterdam, The Netherlands; d.poldermans{at}erasmusmc.nl

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Undergoing surgery imposes certain risks on the patient, such as impaired wound heeling, bleeding complications, perforations, nerve damage, and infection. These are all well known points of attention when planning a surgical procedure. Apart from these apparent risks directly related to the target area of the surgical procedure, there are other surgery related factors contributing to the outcome, that tend to be overlooked by the treating physicians. Of all contributors to poor postoperative outcome, cardiac complications are the most important, including myocardial infarction, congestive heart failure, stroke, and arrhythmias. An estimated 10–40% of postoperative mortality is attributed to myocardial infarction. With over 230 million surgical procedures being performed worldwide each year, the perioperative period is also a “golden hour” to initiate secondary prevention. Identification of risk factors for perioperative cardiac adverse events and risk stratification of surgery patients are the pillars for reducing cardiovascular complication rates.

The overall theme for perioperative care is to find the balance between risk reduction strategies, with a potential delay of the index surgical procedures, and its impact on the operation—for example, how to handle the controversy between haemorrhagic control and prevention of thrombosis related complications, such as myocardial infarction and stroke. Patients receiving antiplatelet therapy represent a surgical challenge, in terms of bleeding risk, while withdrawal can increase the risk of coronary thrombosis.

In this paper we aim to provide a comprehensive overview of the optimal medical management around the time of surgery, shedding light on all key issues.

Pathophysiology of surgical risks

Surgery causes physiological changes, affecting many organs apart from the primary target of the procedure. These changes can increase myocardial oxygen demand and reduce supply because of thrombosis, both leading to (fatal) myocardial ischaemia. The most important contributors to these pathophysiological pathways will be outlined briefly.

Stress and the oxygen mismatch

In the perioperative period, surgical stress induces a catecholamine …

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