Key points

• Perioperative cardiac complications are the most serious risk to delineate and ­ pre-emptively manage

• Discussions between anaesthetist, surgeon and cardiologist are frequently required on a case-by-case basis

• Critical care is an essential and rapidly developing support to many surgical procedures

Introduction

‘Good surgeons know how to operate, better surgeons know when to operate, and the best surgeons know when not to operate.’ This aphorism reflects the intertwined nature of surgery, anaesthesia and critical care. Poor patient selection or preparation for a particular surgical procedure cannot be entirely compensated for by good anaesthesia or critical care. The purposes of preoperative assessment include the identification and management of individual patient risks as well as appropriate resource allocation.

Sixty per cent of patients undergoing major vascular surgery have significant coronary artery disease (CAD). Similarly, CAD is common among patients having non-vascular procedures, so an understanding of the important principles of investigation and management is important for all surgeons and anaesthetists. This section will therefore concentrate particularly on cardiovascular assessment, although other disease states are also considered.

Preoperative assessment

General preoperative assessment

When considering an individual patient, the degree of CAD is often difficult to adequately assess by history and examination alone (e.g. because of limitations in exercise capacity due to claudication, general fatigue or the time limited nature of an emergency presentation). However, a good history and examination can allow specific directed investigations to be carried out.