**2. Preoperative surgical risk**

From the antiquity, man has tried to anticipate or predict the facts to come, that is to say the prediction of the results in cardiovascular surgery has been and continues being a goal. The stratification of the patients in different risk levels, previous to the accomplishment of a cardiovascular surgery has diverse intentions, among them the clinical decision making with respect to the accomplishment or not of the surgical procedure or the derivation of the patient for another type of treatment. It is necessary to establish preoperative conducts that can reduce the risk to cost-effectiveness, to establish the stratification of the risk sometimes is difficult, being implicit some factors of individual risk that can be interpreted of different way and has like objectives:


John and collaborators established 7 fundamental criteria like and 13 important criteria which are an influence in the morbi-mortality of the post operated patient. (**CHART 1**)

### *Age*

Every time it is more frequent than patients with age greater to 60 years, are admitted. The cardiovascular risk is increased by above of 65 years by the presence of his comorbidities, age outpost with cardiac symptoms and a key point is the selection of this type of patients, since with this secondary mortality to the surgery is determined. In these patients it is frequent the existence of important complications as they are the low cardiac cost, acute myocardial infarct of the perioperatory, surgical re-intervention by bleeding, acute renal insufficiency, pneumonia, prolonged ventilation, all these increase to the percentage of complications and mortality.

### *Gender*

Many studies exist that have determined that the woman has a greater risk of mortality after the coronary revascularization; because they have minor corporal surface and the size of the coronary glasses is smaller. As far as the sort it does not seem to be predictive of mortality in valvular procedures, mitral and aortic.


### Chart 1.

2 Special Topics in Cardiac Surgery

function and more and more by the increase of percutaneous interventions there are patients with greater risk and worse diagnosis which has modified the results in the last years, as well as a reduction in the number of surgeries per year. Mortality in Europe and the United States is lower than 2,5% with a survival that oscillates respectively between 97-80% of 1 to15 years. Its reduction increased as of the eighth year, is in relation to the average life of the grafts, its occlusion, progression of the disease and development of its comorbidities. 1,2,3.

From the antiquity, man has tried to anticipate or predict the facts to come, that is to say the prediction of the results in cardiovascular surgery has been and continues being a goal. The stratification of the patients in different risk levels, previous to the accomplishment of a cardiovascular surgery has diverse intentions, among them the clinical decision making with respect to the accomplishment or not of the surgical procedure or the derivation of the patient for another type of treatment. It is necessary to establish preoperative conducts that can reduce the risk to cost-effectiveness, to establish the stratification of the risk sometimes is difficult, being implicit some factors of individual risk that can be interpreted of different

1. Identification of patients of high risk with critical allocation, to adapt the perioperatory

2. To diminish the morbidity and mortality, establishing strategies of preoperative,

3. It is indispensable to know the heart disease suitably. (Physiopathology, diagnosis,

4. A suitable evaluation and treatment of the cardiopathy surgical patient, requires a team work and communication between: patient-surgeon, cardiologist and **intensivist**. 5. Several factors are known that modify the individual risk as they are the age, the sort, previous the cardiovascular function, the renal diseases and you will tilt, respiratory

John and collaborators established 7 fundamental criteria like and 13 important criteria

Every time it is more frequent than patients with age greater to 60 years, are admitted. The cardiovascular risk is increased by above of 65 years by the presence of his comorbidities, age outpost with cardiac symptoms and a key point is the selection of this type of patients, since with this secondary mortality to the surgery is determined. In these patients it is frequent the existence of important complications as they are the low cardiac cost, acute myocardial infarct of the perioperatory, surgical re-intervention by bleeding, acute renal insufficiency, pneumonia, prolonged ventilation, all these increase to the percentage of

Many studies exist that have determined that the woman has a greater risk of mortality after the coronary revascularization; because they have minor corporal surface and the size of the coronary glasses is smaller. As far as the sort it does not seem to be predictive of mortality in

which are an influence in the morbi-mortality of the post operated patient. (**CHART 1**)

**2. Preoperative surgical risk** 

way and has like objectives:

complications and mortality.

valvular procedures, mitral and aortic.

intraoperating and post-operative treatment.

treatment, and perioperatory complications).

function and other related factors.

problems.

*Age* 

*Gender* 

### *Cardiovascular state*

Is the most important aspect of perioperative mortality, the important factors are: severe valvular disease, reoperation, left ventricular function, infarct to the myocardium previous, cardiac insufficiency, emergency surgery and upheavals of the rate.

### *Respiratory function*

The pulmonary disease chronicle is a risk factor to prolong the mechanical ventilation, to have a more difficult weaning, and associated to the pulmonary arterial hypertension, its extubation requires major care.

### *Mortality*

The explanation of the diminution in mortality has been the present methods of myocardic protection with retrograde cardioplegia, hypothermia since the ischemia diminishes triphosphate of adenosine (ATP), altered sanguineous flow, calcium overload, reduction of intracellular calcium sensitivity, sarcoplasmatic dysfunction and the presence of free oxygen radicals. The morbidity and mortality fall significantly in spite of being increased the risk factors, the tendency of the secondary complications of comorbid sufferings have increased until in 30-40%.

The preoperative cardiovascular evaluation provides recommendations for stratification with risk and handling of proposals by the American College of Physicians: Medical history, clinical exploration, ECG, X-ray of thorax, laboratories, tests ECG to the exercise, ambulatory monitoring (Holter), ventriculography to radio nuclear, heart ultrasound, coronary angiography, thallium scintiscanning. 4.5.6.7.8.9 (**CHART 2**)

In resistance to indices of multi-factor risk, the functional classification New York Heart Association (NYHA) and the American Society of Anesthesiology (HANDLE) are used of routine by the anesthesiologist. Nevertheless, these classifications do not designate a predicting result after the surgery reason why its predictive ability in operating room is limited.

### **ASA**

Healthy patient, with a process located without systemic affection.

Intensive Care Management of Patients in the First 24 Hours After Cardiac Surgery 5

classifying stratification, transoperatory and post-operative factor risks are the following scales: Parsonnet, Tumman, Higgins, Tu, Hannan, Connor, Cleveland Clinic, EuroSCORE, Ontario Provincial Risk (OPR) among others, which vary in predicting correlation of risk of morbidity and mortality in relation to distribution of patients by risk, the average one

The basic information of data is used to improve the clinical practice producing reports with validity and application, evaluating the results, optimizing and improving the cares of the patient, the high mortality is identified in a small and specific sub-group classified like of high risk. The obtained results are used to change institutional programs diminishing mortality in patients of high risk like of smaller risk, mainly in patient put under coronary

The European for System Cardiac Operative Risk Evaluation (EuroSCORE) is a predicting logistic model of hospitable mortality in patients submissive cardiac intervention, starting off of 18 variables of risk and with a coefficient beta associated to each of them, it provides the probability of dying of each individual, this model was created and validated initially in across-sectional study of 19,030 European patients in 1999, and it has become, since then, in the used model more in the world in this type of patients. Most of the authors agree in raising that the Euroscore is a system simple additive that it provides to facultative a tool of easy handling to consider the death risk. A variant of the much more simple logistic model, denominated Euroscore additive, that awards a weight determined to each factor of risk that presents the patient, the sum of these weights exists provides the approximated probability

The interesting exercise to compare logistic Euroscore with additive already has been realized, but in fact it contributes certain confusion, and the conclusions that are obtained

The preoperative surgical risk models are made on the basis of cardiac surgery using cardiopulmonary bypass (CPB). However, it can be applied to off-pump cardiac surgery, as evidenced by Vazquez Roque, in a study in 208 patients undergoing bypass surgery without cardiopulmonary bypass and found that the mean EuroSCORE was significantly higher in patients who died. When comparing patients with and without major complications can see that the mean EuroSCORE was also significantly higher in patients with major

Without fatal perioperative morbidity results in an increase of stay in postoperative care unit and overall hospital stay, this increases resource consumption and costs per patient. The EuroSCORE proved to have a discriminating power and acceptable calibration in predicting these events, we can say that Euroscore, despite being designed a risk score based on patients who underwent cardiac surgery using CPB may be used to predict the risk of death and major complications in patients who are going to be revascularized without the use of cardiopulmonary bypass. This is a novel technique that still suffers from risk scores based on the preoperative characteristics of their own patients. The study uses databases Euroscore retrospective studies, to provide predictive models of morbidity, mortality and prolonged stay in the postoperative intensive care unit, which can be used to improve the quality of postoperative care in different institutions is a tool to categorize patients for

hoped, and the averageobservada.10, 11.12.13 (**Chart 3**)

revascularization diminishing the mortality from 4,5% to 1,5%.

**3. Stratification of risk using data base** 

to die.

complications.

are understood easily observing.

cardiac surgery in several subgroups.
