ESTIMATION OF SURGICAL RISK

Even in the study of comparable groups of patients and operations, a certain amount of risk cannot be accounted for. Moses noted that correcting for age, physical status, type of operation including urgency, did not equalize the risk between institutions performing the same operations. There was a 24-fold difference in the 6 week mortality that could only be reduced to a 10-fold difference by controlling the above variables. Nearly every major medical illness, even when not likely to increase surgical mortality, will need in some way to be taken into account by the surgeon and anesthetist. Much remains to be learned about the relative contribution of the experience of the surgeon and the anesthesiologist, the toxicity of anesthetic agents, the availability of advanced intraoperative and postoperative monitoring devices, and their impact on surgical risk. Given the prominent role of cardiac mortality, the study of routine postoperative monitoring for arrythmia and infarction in high risk patients or the usefulness of central hemodynamic monitoring in potentially reducing cardiac surgical risk would be helpful. Yet despite the lack of formal study, it is also clear that older and sicker patients, who two decades ago would have been considered inoperable, can today have surgery with acceptable risk. The challenge to the internist consultant is to aid the surgical team in identifying problems and preventing and treating postoperative complications in patients with chronic illness or marginal physiologic reserve.