Professor John Kinsella

Head of Anaesthesia Pain and Critical Care University of Glasgow, Scotland and Glasgow Royal Infirmary

Preoperative prediction of risk is routinely practiced. This allows patients who are undergoing procedures to be characterized and performance and outcomes audited. Scores are also used to identify high or low risk groups for clinical studies. Such scores include ASA grading, modified cardiovascular risk scores and POSSUM.

The reliable quantification of risk for an individual is more problematic. Scores related to specific complications such as airway difficulty are only moderately reliable. The routine use of many investigative tools such as pulmonary function tests, ECHOcardiography and arterial blood gases have been shown to be of limited value and even then only in specific groups of patients.

In order to investigate the possible role of cardiopulmonary exercise testing in predicting the outcome of major upper gastrointestinal surgery we developed a research program to assess whether we could use this test and the previously defined thresholds to identify patients at high risk. Prior to this we had extensive experience of using CPEX to evaluate patients with respiratory disease and prior to and after cardiac transplantation.

We performed an initial cohort study and then on the basis of the findings instituted routine CPEX for these patients. Our findings were that the majority of the patients presenting for major upper gastrointestinal surgery in a tertiary referral teaching hospital in the West of Scotland had a mean anaerobic threshold was much lower than the cut off defined in previous studies (8.9 vs 11)and despite this the overall mortality was low. CPEX is now used as part of the evaluation and to plan the perioperative management but we are unable to use this as a method of selecting or excluding patients for surgery. In addition we use CPX as a method of longitudinally monitoring the changes in patient’s fitness following other interventions such as chemotherapy.

The presentation will review the current literature of the value of CPX in the perioperative period, describe or experiences with patients with low an aerobic thresholds and identify areas of future research. Our experiences in perioperative optimization trails will also be presented.