Answer: D. Moderate pulmonary hypertension
Perioperative cardiac risk includes insulin-dependent diabetes and chronic kidney disease with a serum creatinine level of >2 mg/dL.1 Hence, options A and B would not independently define this patient as high risk.
COPD is a significant risk factor for postoperative pulmonary complications such as pneumonia, prolonged ventilation, and reintubation, with event rates of approximately 6.5%, 8.8%, and 5.5%, respectively.2 Despite an increase in postoperative mortality with an odds ratio of 1.29,2 COPD is rarely if ever an absolute contraindication to surgery, regardless of pulmonary function.3 However, mortality and morbidity are markedly increased in patients with pulmonary hypertension.
For example, in patients with pulmonary hypertension undergoing low to intermediate risk orthopedic surgery, mortality was markedly increased with an odds ratio of 3.72 for hip replacement and 4.55 for knee replacement.4 Unfortunately, there is not much that can be done to improve perioperative risk in these patients. The indication for surgery should be strongly reviewed and risk benefit analysis should be performed before proceeding with surgery. Further preoperative oxygenation, fluid balance, and vital signs should be monitored carefully. Most importantly, patients on medical therapy for pulmonary arterial hypertension should continue taking those medications if possible.5
- Devereaux PJ, Goldman L, Cook DJ, Gilbert K, Leslie K, Guyatt GH. Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. CMAJ. 2005;173(6):627-634.
- Gupta H, Ramanan B, Gupta PK, et al. Impact of COPD on postoperative outcomes: results from a national database. Chest. 2013;143:1599-1606.
- Yamakage M, Iwasaki S, Namiki A. Guideline-oriented perioperative management of patients with bronchila asthma and chronic obstructive pulmonary disease. J Anesth. 2008;22(4):412-428.
- Grant PJ, Cohn SL, Jaffer AK, Smetana GW. Update in perioperative medicine 2011. J Gen Intern Med. 2011;26(11):1358-1363.
- Pilkington SA, Taboada D, Martinez G. Pulmonary hypertension and its management in patients undergoing non-cardiac surgery. Anaesthesia. 2015;70(1):56-70.