Ebook The washington manual of surgery: Part 1

UnitedVRG - Tahir



FRONT OF BOOK

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Cover
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Authors
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Foreword
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Preface
TABLE OF CONTENTS

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1 - General and Perioperative Care of the Surgical Patient
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2 - Common Postoperative Problems
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3 - Nutrition for the Surgical Patient
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4 - Fluid, Electrolytes, and Acid-Base Disorders
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5 - Anticoagulation, Hemostasis, and Transfusions
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6 - Anesthesia
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7 - Critical Care
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8 - Burns
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9 - Wound Care
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10 - Head, Neck, and Spinal Trauma
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11 - Chest Trauma
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12 - Abdominal Trauma
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13 - Extremity Trauma
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14 - Common Surgical Procedures
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15 - Acute Abdomen
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16 - Esophagus
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17 - Stomach
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18 - The Surgical Management of Obesity
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19 - Small Intestine
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20 - Surgical Diseases of the Liver
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21 - Surgical Diseases of the Biliary Tree
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22 - Surgical Diseases of the Pancreas
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23 - Spleen
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24 - Colon and Rectum
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25 - Anorectal Disease
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26 - Cerebrovascular Disease
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27 - Thoracoabdominal Vascular Disease
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28 - Peripheral Arterial Disease
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29 - Venous and Lymphatic Disease

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30 - Hemodialysis Access
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31 - Transplantation
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32 - Pediatric Surgery
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33 - Cardiac Surgery
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34 - Lung and Mediastinal Diseases
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35 - Breast
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36 - Skin and Soft-Tissue Tumors
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37 - Fundamentals of Laparoscopic, Robotic and Endoscopic Surgery
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38 - Hernias
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39 - Diseases of the Adrenal and Pituitary Gland and Hereditary Endocrine Syndromes
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40 - Thyroid and Parathyroid Glands
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41 - Otolaryngology for the General Surgeon
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42 - Plastic and Hand Surgery
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43 - Urology for the General Surgeon
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44 - Obstetrics and Gynecology for the General Surgeon
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45 - Biostatistics for the General Surgeon
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46 - Patient Safety and Quality Improvement in Surgery
BACK OF BOOK

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Answer Key
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Index

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> Table of Contents > Authors

Editors
Mary E. Klingensmith MD1
1Department

of Surgery
Washington University
School of Medicine
St. Louis, Missouri
Chandu Vemuri MD1
1Department

of Surgery
Washington University
School of Medicine
St. Louis, Missouri
Oluwadamilola M. Fayanju MD1
1Department

of Surgery
Washington University
School of Medicine
St. Louis, Missouri
Jason O. Robertson MD1
1Department

of Surgery
Washington University
School of Medicine
St. Louis, Missouri
Pamela P. Samson MD1
1Department

of Surgery
Washington University
School of Medicine
St. Louis, Missouri
Dominic E. Sanford MD1
1Department

of Surgery
Washington University


School of Medicine
St. Louis, Missouri

Foreword by
Timothy J. Eberlein, MD
Bixby Professor and Chair of Surgery
Director, Siteman Cancer Center
Washington University
School of Medicine
St. Louis, Missouri

Contributors

Bola Aladegbami, MD
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Michael S. Avidan, MBBCh
Professor of Anesthesiology and Cardiothoracic Surgery
Washington University School of Medicine
St. Louis, Missouri
Michael M. Awad, MD, PhD
Assistant Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Joshua A. F. Balderman, MD
Resident in Vascular Surgery
Washington University School of Medicine
St. Louis, Missouri
Lauren M. Barron, MD
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri


Michael J. Beckman, MD
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Grant Bochicchio, MD
Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri

Stephanie L. Bonne, MD
Assistant Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
David G. Brauer, MD
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
L. Michael Brunt, MD
Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Sara A. Buckman, MD
Assistant Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Stephanie H. Chang, MD
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
William C. Chapman, MD
Eugene M. Bricker Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri


Chun-Cheng (Richard) Chen, MD, PhD
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri

Pamela M. Choi, MD
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Haniee Chung, MD
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Graham A. Colditz, MD
Niess-Gain Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Alana C. Desai
Assistant Professor of Urologic Surgery
Washington University School of Medicine
St. Louis, Missouri
Jose L. Diaz-Miron, MD
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Maria B. Majella Doyle, MD
Associate Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Bernard J. DuBray Jr., MD
Resident in Surgery


Washington University School of Medicine
St. Louis, Missouri

J. Christopher Eagon, MD
Associate Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Leisha C. Elmore, MD
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Paul M. Evans, MD, PhD
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Oluwadamilola M. Fayanju, MD, MPHS
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Ryan C. Fields, MD
Assistant Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Bradley D. Freeman, MD
Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Patrick J. Geraghty, MD
Associate Professor of Surgery and Radiology
Washington University School of Medicine
St. Louis, Missouri

William E. Gillanders, MD
Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Andrea R. Hagemann, MD
Assistant Professor of Obstetrics and Gynecology/Gynecologic Oncology Surgery
Washington University School of Medicine
St. Louis, Missouri
Bruce Lee Hall, MD, PhD, MBA
Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
William G. Hawkins, MD
Neidorff Family and Robert C. Packman Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Matthew C. Henn, MD
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Gwendolyn Hoben, MD
Resident in Plastic and Reconstructive Surgery
Washington University School of Medicine
St. Louis, Missouri
Ashley M. Holder, MD
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Jessica L. Hudson, MD
Resident in Surgery

Washington University School of Medicine
St. Louis, Missouri


Steven R. Hunt, MD
Associate Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Kareem D. Husain, MD
Assistant Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Sashi K. Inkollu, MD
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Jeffrey Jim, MD
Assistant Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
John P. Kirby, MD
Associate Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Mary E. Klingensmith, MD
Mary Culver Distinguished Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Timothy S. Lancaster, MD
Resident in Surgery

Washington University School of Medicine
St. Louis, Missouri
Christopher P. Lawrance, MD
Resident in Surgery


Washington University School of Medicine
St. Louis, Missouri
Jennifer S. Lawton, MD
Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Jennifer A. Leinicke, MD, MPHS
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Julie A. Margenthaler, MD
Associate Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
John E. Mazuski, MD
Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Christopher M. McAndrew, MD
Assistant Professor of Orthopedics
Washington University School of Medicine
St. Louis, Missouri
Bryan F. Meyers, MD
Patrick and Joy Williamson Professor of Surgery

Washington University School of Medicine
St. Louis, Missouri
Jacob R. Miller, MD
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri


Jonathan B. Mitchem, MD
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Jeffrey F. Moley, MD
Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Matthew G. Mutch, MD
Associate Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Iheoma Nwaogu, MD, MPHS
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Timothy M. Nywening, MD
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
J. Westley Ohman, MD
Resident in Vascular Surgery

Washington University School of Medicine
St. Louis, Missouri
Kamlesh B. Patel, MD
Assistant Professor of Plastic and Reconstructive Surgery
Washington University School of Medicine
St. Louis, Missouri
Babafemi (Wande) B. Pratt, MD, MPH
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri


Varun Puri, MD, MSCI
Assistant Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Kathleen G. Raman, MD, MPH
Assistant Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Shuddhadeb Ray, MD, MPHS
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Jason O. Robertson, MD
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Jennifer A. Robles, MD
Resident in Urologic Surgery

Washington University School of Medicine
St. Louis, Missouri
Lauren T. Roland, PhD
Postdoc Research Scholar
Urologic Surgery
Washington University School of Medicine
St. Louis, Missouri
Kathryn J. Rowland, MD, MPHS
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Lindsey L. Saint, MD


Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Jacqueline M. Saito, MD
Assistant Professor of Pediatric Surgery
Washington University School of Medicine
St. Louis, Missouri
Pamela P. Samson, MD, MPHS
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Luis A. Sanchez, MD
Gregorio A. Sicard Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Dominic E. Sanford, MD, MPHS

Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
John S. Schneider, MD, MA
Assistant Professor of Otolaryngology Surgery
Washington University School of Medicine
St. Louis, Missouri
Douglas J. Schuerer, MD
Associate Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Kerri A. Serecky, MD
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri


Surendra Shenoy, MD
Associate Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Gregorio A. Sicard, MD
Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Joshua D. Sommovilla, MD
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Matthew S. Strand, MD

Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Tracey Wagner Stevens, MD
Assistant Professor of Anesthesiology
Washington University School of Medicine
St. Louis, Missouri
Lauren T. Steward, MD, MHA, MPHS
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Steven M. Strasberg, MD
Pruett Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Wen Hui Tan, MD
Resident in Surgery
Washington University School of Medicine


St. Louis, Missouri
Isaiah R. Turnbull, MD
Assistant Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Chandu Vemuri, MD
Assistant Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Thomas J. Wade, MD

Fellow in Minimally Invasive Surgery
Washington University School of Medicine
St. Louis, Missouri
Brad W. Warner, MD
Jessie L. Ternberg, MD, PhD Distinguished Professor of Pediatric Surgery
Washington University School of Medicine
St. Louis, Missouri
Jason R. Wellen, MD, MBA
Assistant Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Ivy Wilkinson-Ryan, MD
Fellow in Obstetrics and Gynecologic Surgery
Washington University School of Medicine
St. Louis, Missouri
Robert D. Winfield, MD
Assistant Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Paul E. Wise, MD


Associate Professor of Surgery
Washington University School of Medicine
St. Louis, Missouri
Elisabeth K. Wynne, MD
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Jennifer Yu, MD, MPHS

Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri
Ahmed Zihni, MD, MPH
Resident in Surgery
Washington University School of Medicine
St. Louis, Missouri


> Table of Contents > Foreword

Foreword
Welcome to the seventh edition of The Washington Manualª of Surgery. Over the past 100 years,
an important focus of our Department of Surgery has been medical education of students,
residents, fellows, and practicing surgeons. This commitment is clearly evident in the current
edition of The Washington Manualª of Surgery.
The educational focus of our Department of Surgery has a rich tradition. The first full-time head
of the Department of Surgery at Washington University was Dr. Evarts A. Graham (1919Ñ1951).
Dr. Graham was a superb educator. Not only was he an outstanding technical surgeon, but his
insightful comments at conferences and ward rounds were well known and appreciated by a
generation of surgeons who learned at his elbow. Dr. Graham was a founding member of the
American Board of Surgery and made many seminal contributions to the management of surgical
patients. His work in the development of oral cholecystography actually helped establish the
Mallinckrodt Institute of Radiology at Washington University. Dr. Graham was among the first to
identify the epidemiological link of cigarette smoking to lung cancer and was instrumental in
raising public health consciousness about the deleterious effect on health from cigarette smoke.
Dr. Carl Moyer (1951Ñ1965) succeeded Dr. Graham. Dr. Moyer is still regarded as a legendary
educator at Washington University. He was particularly known for his bedside teaching
techniques, as well as for linking pathophysiology to patient care outcomes. Dr. Walter Ballinger
(1967-1978) came from the Johns Hopkins University and incorporated the Halsted tradition of

resident education. Dr. Ballinger introduced the importance of laboratory investigation and began
to foster development of the surgeon/scientist in our department. Dr. Samuel A. Wells (19781997) is credited with establishing one of the most accomplished academic departments of
surgery in the United States. Not only did he recruit world-class faculty, but he increased the
focus on research and patient care. Dr. Wells also placed a great emphasis on educating the
future academic leaders of surgery.
As in previous editions, this seventh edition of The Washington Manualª of Surgery combines
authorship of residents, ably assisted by faculty coauthors and our senior editor, Dr. Mary
Klingensmith, who is vice-chair for education in our department. Dr. Klingensmith is joined in this
edition by a new senior editor, Dr. Chandu Vemuri. This combination of resident and faculty
participation has helped to focus the chapters on issues that will be particularly helpful to the
trainee in surgery. This new edition of the manual provides a complete list of updated references
that will serve medical students, residents, and practicing surgeons who wish to delve more
deeply into a particular topic. This manual does not attempt to extensively cover pathophysiology
or history, but it presents brief and logical approaches to the management of patients with
comprehensive surgical problems. In each of the chapters, the authors have attempted to provide


the most up-to-date and important diagnostic and management information for a given topic, as
well as algorithms for quick reference. We have attempted to standardize each of the chapters so
that the reader will be able to most easily obtain information regardless of subject matter.
The seventh edition has undergone a reorganization of chapters with an emphasis on clarity and
consistency. As with the past edition, evidence-based medicine has been incorporated into each
of the chapters, with updated information and references to reflect current knowledge and
practice. All of the sections have been updated
P.ix
and rewritten to reflect the most current standards of practice for each topic. These updates have
been carefully edited and integrated so that the volume of pages remains approximately the
same. Our goal is to keep this volume concise, portable, and userfriendly. I am truly indebted to
Drs. Klingensmith and Vemuri for their passion for education and devotion to this project.
Additionally, I am proud of the residents in the Department of Surgery at Washington University

who have done such an outstanding job with their faculty co-authors in this seventh edition. I
hope that you will find The Washington Manualª of Surgery a reference you commonly utilize in
the care of your patient with surgical disease.
Timothy J. Eberlein, MD
St. Louis, Missouri


> Table of Contents > Preface

Preface
As with the previous six editions, this seventh edition of The Washington Manualª of Surgery is
designed to complement The Washington Manual of Medical Therapeutics. Written by resident
and faculty members of the Department of Surgery, it presents a brief, rational approach to the
management of patients with surgical problems. The text is directed to the reader at the level of
the second- or third-year surgical resident, although surgical and nonsurgical attendings, medical
students, physician assistants, nurse practitioners, and others who provide care for patients with
surgical problems will find it of interest and assistance. The book provides a succinct discussion of
surgical diseases, with algorithms for addressing problems based on the opinions of the physician
authors. Although multiple approaches may be reasonable for some clinical situations, this
manual attempts to present a single, effective approach for each. We have limited coverage of
diagnosis and therapy; this is not an exhaustive surgical reference. Coverage of pathophysiology,
the history of surgery, and extensive reference lists have been excluded from most areas.
This is the seventh edition of the manual; the first edition was published in 1997, followed by
editions in 1999, 2002, 2005, 2007, and 2012. New to this volume is a set of multiple-choice
review questions at the end of each chapter so that readers can self-assess their knowledge.
Additionally, we have added chapters on ÒBiostatistics for the General Surgeon,Ó ÒQuality
Improvement and Patient Safety,Ó and ÒFundamentals of Endoscopic, Laparoscopic, and Robotic
SurgeryÓ; many chapters have been consolidated and reorganized to best reflect the nature of
surgical practice. In addition, chapters have been updated with evidence-based medicine, with
the latest information and treatment algorithms in each section. In many chapters, additional

treatment algorithms have been added for quick reference. As with previous editions, this seventh
edition includes updates on each topic as well as substantial new material.
This is a resident-prepared manual. Each chapter was extensively updated and revised (or
authored) by a resident with assistance from a faculty coauthor. Editorial oversight for the manual
was shared by four senior resident coeditors (Lola Fayanju, MD, Chapters 35, 36, 38, 39, 40, 41,
42, 43, 44, 45 and 46; Pamela Samson, MD, Chapters 6 and 7, 26, 27, 28, 29, 30 and 31, 33 and
34; Dominic Sanford, MD, Chapters 15, 16, 17. 18, 19, 20, 21, 22, 23, 24 and 25 and 37; and
Jason Robertson, MD, Chapters 1, 2, 3, 4 and 5, 8, 9, 10, 11, 12, 13 and 14 and 32). Additionally,
Dr. Chandu Vemuri, assistant professor and vascular surgeon extraordinaire, provided some
editorial and leadership assistance for this edition. The tremendous effort of all involvedÑ
residents and faculty members and particularly the senior resident coeditorsÑis reflected in the
quality and consistency of the chapters.
I am indebted to the former senior editor of this work, Gerard M. Doherty, MD, who developed
and oversaw the first three editions, then handed over to me an exceptionally well-organized


project. I am grateful for the continued tremendous support from Wolters Kluwer Health, who
have been supportive of the effort and have supplied dedicated assistance. Keith Donnellan has
been tremendously helpful, and Brendan Huffman has been a terrific developmental editor,
keeping me in line and on schedule.
Finally, I am grateful to have a fantastic mentor and leader in my department chair, Timothy J.
Eberlein, MD. He is an inspiration for his leadership, and dedication. To my family, thank you for
all you do to keep it all fun and interesting.
M. E. K.


> Table of Contents > 1 - General and Perioperative Care of the Surgical Patient

1
General and Perioperative Care of the Surgical

Patient
Joshua D. Sommovilla
Mary E. Klingensmith

I. PREOPERATIVE EVALUATION AND MANAGEMENT
A. General Evaluation of the Surgical Patient. The goals of preoperative evaluation are to
(1) identify the patient's medical problems and functional status; (2) determine if further
information is needed to characterize the patient's medical status; (3) estimate the patient's level
of risk for the planned procedure; and (4) establish if the patient's condition is medically
optimized. Much of this can be accomplished with a thorough history and physical examination.
For minor surgical procedures and procedures on young, healthy patients, routine diagnostic
testing is often unnecessary. For patients with existing comorbidities, or in patients undergoing
certain complex procedures, preoperative laboratory studies and imaging should be decided on an
individual basis.
B. Specific Considerations in Preoperative Management
1. Cardiovascular disease is one of the leading causes of death after noncardiac surgery.
Patients who experience a myocardial infarction (MI) after noncardiac surgery have a hospital
mortality rate of 15% to 25% (CMAJ. 2005;173:627). A study of 4,315 patients older than 50
years of age undergoing nonemergent, noncardiac surgery with expected postoperative stays
greater than 48 hours found that major perioperative cardiac events occur in 1.4% of patients
(Circulation. 1999;100:1043). Risk stratification for major adverse cardiac events (MACE, defined
as death, Q-wave MI, and need for revascularization) by the operating surgeon, anesthesiologist,
and consulting internist is important.
a. Risk factors. A number of patient factors have been identified and are associated with
perioperative cardiac morbidity and mortality. These include age above 70 years, unstable angina,
recent (prior 6 months) MI, untreated CHF, diabetes mellitus, valvular heart disease, cardiac
arrhythmias, peripheral vascular disease, and functional impairment. Factors related to the
surgical procedure under consideration also convey risk. In their most recent guidelines published
in 2014, the American Heart Association has condensed procedures into two risk levels: low risk
(MACE risk <1%) and elevated risk (MACE risk >1%). The category of intermediate risk is no

longer used, as the management of patients undergoing these and elevated risk procedures is
similar.


P.2
b. Cardiac risk indices/calculators. Several tools have been created to aid in predicting
preoperative risk of a MACE. The Revised Cardiac Index is one such tool, and its criteria are
shown in Table 1-1. The American College of Surgeons NSQIP Surgical Risk Calculator combines
cardiac and noncardiac factors to calculate risk of overall postoperative complications and can be
found at riskcalculator.facs.org.
c. Functional status. Patients with poor functional status are at significantly elevated risk of
perioperative cardiac events. This can usually be assessed from a patient's activities of daily living
(ADLs) and is often expressed in metabolic equivalents (METs), with 1 MET equaling the resting
oxygen consumption of an average 40-year-old male (Table 1-2). Functional capacity can be
classified as excellent (>10 METs), good (7 to 10 METs), moderate (4 to 6 METs), or poor (<4
METs). Moderate functional capacity is classified as the ability to perform usual ADLs.
d. Preoperative testing. Specific preoperative workup is based on several factors including
medical history, urgency of surgery, risk
P.3
of surgical procedure, patient functional status, and goals of care. A treatment algorithm guiding
the preoperative cardiac workup is shown in Figure 1-1. When it is determined that a patient
requires further testing prior to surgery, a multidisciplinary approach including a cardiologist is
employed to determine which noninvasive or invasive measures should be taken to optimize the
patient.

TABLE 1-1 Revised Cardiac Risk Indexa
Risk Factor

Comment

High-risk
surgery

Intrathoracic, intraperitoneal, major vascular

Ischemic heart
disease

History of myocardial infarction, positive exercise stress test,
angina, nitrate therapy, electrocardiogram with abnormal Q waves

History of CHF

History of CHF, pulmonary edema, or paroxysmal nocturnal
dyspnea, bilateral rales, S3 gallop, chest x-ray showing pulmonary
vascular redistribution


History of
cerebrovascular
disease

History of transient ischemic attack or stroke

Preoperative
insulin therapy
for diabetes
Preoperative
serum
creatinine >2

mg/dL
aRates

of major cardiac complication with 0, 1, 2, or 3 of these factors were 0.4%,
0.9%, 7.0%, and 11.0%, respectively.
Adapted from Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective
validation of a simple index for prediction of cardiac risk of major noncardiac surgery.
Circulation. 1999;100:1043.

TABLE 1-2 Assessment of Functional Status
Functional
Capacity

MET
Range

Example Activities

Poor

<4

Sleeping, writing, watching TV, walking 2-3 mph on flat
land, golfing with a cart

Moderate

4-7

Climbing a flight of steps, slow bicycling, sexual activity

Good

7-10

Jogging, calisthenics

Excellent

>10

Rope jumping