Overview
This resource outlines UCLA Health's approach to risk stratification for patients undergoing elective surgery, emphasizing the assessment of both surgical and patient factors to optimize perioperative outcomes.
General Principles of Preoperative Risk Stratification
- Perioperative risk depends on both the type of surgery and the patient's underlying health status.
- Combining surgical and patient risk scores helps determine the need for further preoperative evaluation.
- For non-emergency surgery, poorly controlled conditions should be optimized before the procedure.
- Optimization may address blood pressure, diabetes, nutrition, exercise, smoking cessation, and anemia.
Process for Risk Assessment
- Patients with risk scores of 7 or more are referred for in-person evaluation at the Preoperative Evaluation and Planning Center (PEPC).
- Patients scoring 4 or less require no additional screening and will be evaluated by anesthesiology before surgery.
- Intermediate scores may prompt a telephone screening by PEPC staff.
Surgical Risk Score Categories
- Score 1 (Very Low): Minimal sedation procedures, e.g., simple eye or dental procedures.
- Score 2 (Low): Procedures with minimal physiologic effect, e.g., hernia repair, diagnostic cardiac cath.
- Score 3 (Intermediate): Moderate hemodynamic risk, e.g., intracranial, spine, or intra-abdominal surgery.
- Score 4 (High): Significant risk, e.g., bowel resection, kidney transplant, major oncologic surgery.
- Score 5 (Very High): Major risk, e.g., aortic, cardiac, lung resection, or major transplant surgery.
Patient Medical Risk Score Categories
- Score 1 (Very Low): No or minor medical problems.
- Score 2 (Low): Stable chronic conditions, e.g., hypertension, asthma.
- Score 3 (Intermediate): Age ≥70, mild renal insufficiency, stable CAD, anemia.
- Score 4 (High): Recent coronary stent, CHF, insulin-dependent diabetes, moderate COPD, sleep apnea.
- Score 5 (Very High): Unstable cardiac disease, severe COPD, super morbid obesity, severe frailty.
Specific Risk Factors
- Cardiac: Unstable angina, recent MI, decompensated CHF (score 5); multiple moderate risk factors increase the score.
- Pulmonary: Severe COPD, pulmonary hypertension, need for oxygen therapy (score 5); moderate forms or significant smoking history (score 4).
- Renal: GFR ≤60 ml/min or creatinine >1.5 mg/dl gives a risk score of 3.
- Cognitive: Dementia, bed-bound, ADL impairment (score 4); age >70, frailty, weight loss (score 3).
- Pain Management: Chronic high opioid use, substance abuse, spinal devices (score 5; refer for PEPC screening).
Recommendations / Advice
- Refer patients with total risk score ≥7 to PEPC for thorough preoperative evaluation.
- Patients with any high-risk pain management factors should have targeted phone screening prior to surgery.
- Optimize controllable medical conditions before elective surgery to minimize perioperative risks.