Skip to Main Content


Cardiovascular and pulmonary complications continue to account for major morbidity and mortality in patients undergoing noncardiac surgery. Emerging evidence-based practices dictate that the internist should perform an individualized evaluation of the surgical patient to provide an accurate preoperative risk assessment and stratification to guide optimum perioperative risk-reduction strategies. This chapter reviews cardiovascular and pulmonary preoperative risk assessment, targeting intermediate- and high-risk patients to strategically guide perioperative therapies to improve outcome. It also reviews perioperative management and prophylaxis of diabetes mellitus, endocarditis, and venous thromboembolism.


Mortality is low with safe delivery of modern anesthesia, especially in low-risk patients undergoing low-risk surgery (Table 8-1). Inhaled anesthetics have predictable circulatory and respiratory effects; all decrease arterial pressure in a dose-dependent manner by reducing sympathetic tone, causing systemic vasodilation, myocardial depression, and decreased cardiac output. Inhaled anesthetics also cause respiratory depression with diminished responses to both hypercapnia and hypoxemia in a dose-dependent manner, and they have a variable effect on heart rate. In combination with neuromuscular blockade, inhaled anesthetic agents also cause reduction in functional residual lung capacity due to loss of diaphragmatic and intercostal muscle function. This decreases lung volume, which may lead to atelectasis in the dependent lung regions and, in turn, may result in arterial hypoxemia from ventilation-perfusion mismatch as well as an increased risk of postoperative pulmonary complications.

Table Graphic Jump Location
Table 8-1 Surgery: Gradation of Risk of Common Noncardiac Surgical Procedures

Several meta-analyses have shown that overall mortality was lower in patients receiving neuroaxial anesthesia (epidural or spinal) as compared to general (inhaled) anesthesia. Lower rates of venous thrombosis, pulmonary embolism, pneumonia, and respiratory depression were also observed in patients who were provided neuroaxial anesthesia; however, there were no significant differences in cardiac events between the two approaches. A combination of neuroaxial blockade and general anesthesia is useful when it is desired to reduce general anesthesia requirements. Evidence from a meta-analysis of randomized controlled trials also supports postoperative epidural analgesia for the purpose of pain relief for more than 24 h.


Simple, standardized preoperative screening questionnaires, such as the one shown in Table 8-2, have been developed for the purpose of identifying patients at intermediate or high risk who may benefit from a more detailed clinical evaluation. Evaluation of such patients for operation should always begin with a thorough history and physical examination and with a 12-lead resting ECG, in accordance with the American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations. The history should focus ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.


About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessMedicine Full Site: One-Year Subscription

Connect to the full suite of AccessMedicine content and resources including more than 250 examination and procedural videos, patient safety modules, an extensive drug database, Q&A, Case Files, and more.

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessMedicine

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.