Perioperative Monitoring in High-Risk Surgical Patients: A Step-by-Step Approach

Abstract

Perioperative mortality is still higher than expected, particularly amongst high-risk patients. This is due to dual factors. The first is the result of the development of intraoperative hypotensive episodes, albeit brief ones. The second is correlated with tissue hypoperfusion, often clinically “silent” and more severe in high-risk patients. Patient management aimed at improving the outcome includes a series of interconnecting moments like the links in a chain. The first step is to identify high-risk patients using both the severity score and serological markers, such as atrial natriuretic peptides and troponin. During the intraoperative phase, monitoring is based on two important points. The first point is to prevent hypotensive episodes with continuous arterial pressure monitoring. The second one consists in using hemodynamic monitoring devices to optimise the supply of oxygen to the peripheral tissues. Whichever device is used, it should not be separated from a proactive management protocol, where the first step is to assess fluid responsiveness. Hemodynamic monitoring enables a patient-tailored administration of fluids and vasoactive drugs if necessary. Finally, during the postoperative period, the patient should be carefully monitored according to an accurate and shared monitoring plan to detect, as early as possible, his clinical deterioration.