EDITORIAL

C URRENT
OPINION Identifying the high-risk surgical patient
s-Melchor a,b and Ce
Javier Ripolle sar Aldecoa c,d
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Globally, approximately 313 million patients be considered high-risk [12]. The identification of
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undergo surgery annually to enhance their quality modifiable risk factors and subsequent optimization
of life and survival [1]. However, recent estimates of the preoperative phase appear to be crucial factors
reveal that 4.2 million deaths worldwide (7.7%) in decreasing the incidence of postoperative com-
occur within 30 days postsurgery, positioning post- plications. On the other hand, accurate risk assess-
operative mortality as the third leading cause of ment is essential for early detection of postoperative
death [2]. Consequently, early identification of complications and for proper planning of intraoper-
high-risk surgical patients is crucial. It facilitates ative management and postoperative care
better surgical decision-making, preoperative opti-
mization, and personalized management during
and immediately after surgery, which can signifi- IDENTIFYING HIGH-RISK SURGICAL
cantly improve outcomes. PATIENTS
Although recent advancements in anesthesia Surgical risk can arise from both patient- and oper-
and surgical techniques have reduced morbidity ation-specific factors [7,13]. For patients aged
and mortality in developed countries [3], postoper-
65 years who increasingly undergo complex
ative complications remain a significant issue, surgical procedures, identifying high-risk surgeries
particularly among high-risk patients and those is particularly critical. One study identified 227
undergoing emergency surgeries [4]. The CArdio- surgical procedures with inpatient mortality rates
vaSCulAr outcomes after major abDominal surgery exceeding 1% using a modified Delphi consensus
(CASCADE) study, an international prospective approach. Notably, procedures with the highest
cohort involving over 24 000 patients undergoing mortality rates included implantation of an exter-
major abdominal surgery in Europe, underscored nal ventricular assist device (68%), open repair of
that cardiovascular complications, though infre- thoracic aortic aneurysms (33%), pancreatectomy
quent, predominantly occur in the early postoper- (17%), esophagectomy (7%), and aortic valve
ative period [5]. Such complications may contribute replacement (6%). These findings highlight that
to postoperative mortality, with estimates suggest- older patients experience significantly higher hos-
ing that up to one in five deaths could be prevented pital mortality rates for high-risk operations than
with effective complication prevention strategies younger patients (6% vs. 3%) [14], underscoring the
&&
[6 ]. need for rigorous preoperative assessments and
High-risk surgical patients (HRPs) have a con- tailored surgical strategies to mitigate associated
siderably higher risk of morbidity and mortality risks.
than the general population [7]. Managing these Although chronological age is a strong risk
patients requires a multidisciplinary approach that factor for adverse surgical outcomes, it lacks the
includes meticulous preoperative assessment and a specificity needed to predict individual outcomes
comprehensive postoperative follow-up. Although or to guide care. Studies have shown that 25–40% of
Enhanced Recovery After Surgery (ERAS) protocols older adults undergoing major surgery are frail,
have shown benefits in certain surgeries [8], the which is associated with a two- to threefold increase
presence of preoperative frailty, a global syndrome in the risk of adverse outcomes. Frailty may account
of diminished physiological reserve, measured by for 25–50% of adverse postoperative outcomes in
the Risk Analysis Index (RAI), has been linked to
poor postoperative outcomes [9,10]. a
Infanta Leonor University Hospital, bUniversidad Complutense de
HRPs are defined as an increased probability of Madrid; Madrid, cRío Hortega University Hospital and dUniversidad
perioperative morbidity and mortality due to factors de Valladolid, Valladolid, Spain
such as advanced age, comorbidities, type of sur- Correspondence to Prof. Javier Ripoll
es-Melchor, Hospital Universitario
gery, and preoperative functional status [11]. The Infanta Leonor: Hospital Infanta Leonor, Madrid, Spain.
prevalence of HRPs is rising alongside an aging E-mail: [email protected]
population and increased comorbidities. By 2050, Curr Opin Crit Care 2024, 30:624–628
it is estimated that one in three surgical patients will DOI:10.1097/MCC.0000000000001209

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 Identifying the high-risk surgical patient Ripolles-Melchor and Aldecoa

older patients. Recent evidence suggests that frailty biomarkers, enhancing preoperative risk stratifica-
is the most modifiable preoperative risk factor avail- tion and identifying patients at heightened risk for
able to clinicians [15]. A meta-analysis has identified adverse outcomes. The identification of sarcopenia
frailty as the strongest preoperative predictor of offers a pivotal opportunity to enhance patient care
postoperative complications [16]. Recognizing through prehabilitation. Prehabilitation involves
frailty as a significant predictor has shifted the focus proactive interventions aimed at improving patients’
from chronological age to the evaluation of overall physical function and overall health status before
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patient health status, including physical function surgery. These can include tailored exercise pro-
and cognitive performance. grams, nutritional support, and resistance training
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Implementing a Frailty Screening Initiative [20]. By addressing sarcopenia through prehabilita-

using the RAI has significantly increased the num- tion, patients can potentially improve their muscle
ber of referrals for preoperative evaluations among strength and endurance, which may lead to reduced
frail patients, resulting in an 18% reduction in postoperative complications, shorter recovery peri-
1-year postoperative mortality. Frail patients are ods, and improved overall outcomes. Integrating
more likely to experience readmission within prehabilitation strategies for sarcopenic patients
30–90 days [17] and often struggle to achieve early not only optimizes their preoperative condition,
ambulation or feeding postsurgery, which are key but also enhances their resilience, ultimately contri-
components of ERAS protocols. To enhance peri- buting to a more favorable surgical experience and
operative care, clinicians need tools that accurately improved recovery trajectory.
identify at-risk patients, including those with age- To improve perioperative care, clinicians need
related frailty, that are easily implementable in tools that accurately identify those most susceptible
routine settings, pinpoint who might benefit from to adverse outcomes, including age-related frailty;
specific interventions, and offer actionable insights can be easily implemented in routine care settings;
for risk mitigation. Evidence shows that frailty pinpoint patients who might benefit from specific
screening not only identifies at-risk patients, but interventions or process enhancements; and offer
also enhances clinical decision-making, paving the actionable insights for effectively mitigating patient
way for targeted interventions. risk. Evidence shows that frailty screening not only
Sarcopenia, the progressive loss of muscle mass identifies at-risk patients, but also enhances clinical
and strength often associated with aging or chronic decision-making, paving the way for targeted inter-
illness, significantly impacts surgical outcomes. ventions that can mitigate risks in this vulnerable
Recent meta-analysis data underscore the severe population. As healthcare systems adapt to the
implications of sarcopenia in surgical settings, demands of an aging demographic, incorporating
showing that patients with this condition have routine frailty assessments within surgical pathways
notably worse outcomes than those without sarco- is critical for improving surgical outcomes and
penia. Specifically, sarcopenic patients had a mark- ensuring optimal patient care.
edly higher incidence of major complications [odds
ratio (OR): 4.03, 95% confidence interval (CI): 2.49–
5.57, P < 0.001], increased overall complications CHALLENGES AND FUTURE DIRECTIONS
(OR: 1.77, 95% CI: 1.40–2.24, P < 0.001), and a Despite the growing focus on frailty, formal assess-
higher 30-day mortality rate (OR: 2.38, 95% CI: ments are not yet standard for preoperative evalua-
1.56–3.63, P < 0.001). They also experience longer tions. Risk stratification has advanced from basic
hospital stays, averaging 4.54 days longer than non- tools to sophisticated models incorporating machine
sarcopenic patients (95% CI: 2.49–6.59 days, learning and latent class analysis. These advanced
P < 0.001) [18]. These findings underscore the neces- models, integrated into electronic health records or
sity of incorporating sarcopenia screening into critical care information systems, enhance clinical
preoperative assessments, especially in patients utility.
undergoing gastrointestinal oncological surgery. Traditional risk scales, such as the American
One study highlights the role of preoperative Society of Anesthesiologists (ASA) classification,
computed tomography (CT) in assessing frailty using APACHE II, and Sepsis-Related Organ Failure Assess-
skeletal muscle measurements. In a cohort of 48 444 ment (SOFA), are useful for preoperative risk strat-
abdominal surgery patients, higher muscle quantity ification, but have limitations. These scales may
and quality scores were associated with lower risks of be subjective and fail to account for all relevant
30-day readmission and mortality, while body size risk factors. Despite these limitations, traditional
and adipose tissue scores showed inconsistent asso- risk scales remain valuable, especially in patients
&
ciations [19 ]. These findings suggest that CT-derived undergoing emergency surgery, where complex pre-
muscle assessments can serve as objective frailty operative investigations might be impractical [11].

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 The surgical patient

The most popular presurgical tool available to minimizing unnecessary interventions. AI’s ability
identify high-risk patients is the National Surgical to standardize risk assessments reduces human bias,
Quality Improvement Program (NSQIP) Surgical ensuring more equitable decision making.
Risk Calculator (SRC), a predictive model developed However, challenges persist with AI, including
by the American College of Surgeons [11]. Since its the complexity and opacity of algorithms. Many AI
inception, the NSRC has been validated in various models operate as “black boxes,” providing predic-
patient populations and clinical scenarios. Research tions without clear explanations, which can hinder
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indicates that the accuracy of NSRC can differ clinicians’ trust. Enhancing algorithm transparency
depending on the patient population and the sur- and developing interpretable models are essential
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gical subtype. Although NSRC is a valuable tool, for integrating AI into clinical practice. Addition-
significant knowledge gaps exist regarding its imple- ally, robust AI models require large, high-quality
mentation [21]. datasets that may not always be available. Address-
ing algorithmic bias through careful data curation
and inclusion of diverse datasets is crucial. Ethical
THE ROLE OF ARTIFICIAL INTELLIGENCE issues, such as patient privacy and autonomy, also
Artificial Intelligence (AI) has emerged as a trans- need to be addressed as AI becomes more integrated
formative tool for preoperative and perioperative into medical decision making.
management. By leveraging extensive patient data
and sophisticated algorithms, AI enhances risk pre-
diction, improves patient stratification, and opti- BIOMARKERS IN RISK ASSESSMENT
mizes individualized care strategies. Unlike In certain high-risk patients, particularly those
traditional models, AI learns from examples and undergoing emergency surgery, it may be challeng-
continuously improves with new data, thereby ing to perform complex preoperative investigations,
allowing for more precise risk stratification. such as exercise tests or biomarker assays. In these
AI models analyze large datasets, including dem- cases, simpler biomarkers can provide a more precise
ographics, medical history, surgical details, and perioperative risk assessment than current risk
intraoperative data to predict surgical risk more stratification models.
accurately. Machine-learning algorithms identify Biomarkers are molecules present in blood or
patterns and correlations that traditional models other body fluids that can reflect the presence or risk
may miss. For instance, AI can integrate electronic of developing complications. In high-risk surgical
health records (EHRs) with real-time monitoring to patients, various biomarkers have proven useful for
generate dynamic risk assessments. A prognostic predicting perioperative complications and mortal-
study involving 1 477 561 patients across 20 hospi- ity. Cardiac troponins, long considered the preferred
tals evaluated an automated machine learning biomarker for detecting myocardial injury, play an
model, which demonstrated outstanding perform- unclear role in preoperative cardiac risk assessment.
ance with an area under the receiver operating With the advent of high-sensitivity assays, cardiac
characteristic curve (AUROC) for mortality of troponin can now be detected at low levels in most
0.972. This model outperformed traditional tools healthy individuals, and is often chronically ele-
such as the NSQIP SRC, suggesting superior accuracy vated in patients with stable cardiovascular disease.
in predicting surgical mortality and complications The PREVENGE meta-analysis indicated that ele-
[22]. vated preoperative high-sensitivity cardiac troponin
AI also extends beyond predicting postoperative (hs-cTn) levels are associated with an increased risk
complications to provide early warnings of adverse of major adverse cardiac events (MACE) and both
events. The Flexible Surgical Set Embedding (FLEX) short- and long-term mortality after noncardiac
score, a machine learning method for assessing pre- surgeries. Specifically, patients with elevated preop-
operative risk using patient characteristics, Current erative hs-cTn levels (defined as above the 99th
Procedural Terminology (CPT) codes, and Interna- percentile of the upper reference limit in a healthy
tional Statistical Classification of Diseases, 10th population) had nearly three times the risk of devel-
Revision (ICD-10) codes, was validated using a oping postoperative MACE [relative risk (RR) 2.92,
multicenter database. FLEX effectively captures 95% CI 1.96–4.37] and more than five times the risk
nonlinear relationships and interactions, offering of short-term mortality compared to those with
personalized insights into the impact of individual normal hs-cTn levels (RR 5.39, 95% CI 3.21–9.06).
comorbidities on risk [23]. This approach allows Incorporating hs-cTn measurement into preopera-
targeted preoperative counseling, specific pharma- tive risk assessment improved cardiovascular risk
cological treatments, and enhanced monitoring discrimination and patient classification compared
protocols, thereby improving outcomes and with the Revised Cardiac Risk Index (RCRI) [24].

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 Identifying the high-risk surgical patient Ripolles-Melchor and Aldecoa

These findings underscore the importance of includ- limitations [28]. CPET, which is considered the gold
ing hs-cTn measurements in preoperative risk eval- standard, is constrained by high costs, the need for
uation to identify high-risk patients and to optimize specialized equipment, and trained personnel. Addi-
perioperative management. tionally, both 6MWT and CPET may not fully cap-
The European Society of Anesthesiology (ESA) ture a patient’s day-to-day functional capacity due
guideline for the use of cardiac biomarkers in peri- to the “white-coat effect.”
operative risk evaluation suggests that routine meas- Wearable technologies are a promising alterna-
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urement of preoperative cardiac troponins may tive. These devices enable continuous, noninvasive
assist in evaluating the risk of adverse outcomes, monitoring of physiological parameters, such as
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such as 30-day all-cause mortality, particularly in heart rate and physical activity, providing a more
high-risk patients. However, the certainty of the comprehensive and representative assessment of
evidence remains low, necessitating a thoughtful functional capacity [29]. The WELCOME study dem-
approach to shared decision-making with patients onstrated the utility of wearable devices in preop-
regarding their potential risks and benefits in the erative assessment. With a limited number of
context of surgery. Furthermore, for B-type natriu- patients, the study found that daily steps and
retic peptides, evidence indicates a moderate pre- VO2max data recorded by wearables correlated
dictive value for major adverse cardiac events, strongly with the 6MWT performance (R ¼ 0.56,
reinforcing the importance of integrating these bio- P ¼ 0.001) and clinical evaluation scales [30]. This
markers into clinical risk-scoring systems to suggests that wearables can offer insights compara-
enhance prognostic capabilities within this patient ble to traditional methods, thus enhancing both the
population [25]. A recent study found that elevated precision and accessibility of functional capacity
preoperative pro-BNP levels, with a cutoff of 143 pg/ assessments. Incorporating wearables into preoper-
ml, predicted postoperative cardiovascular compli- ative evaluations could address the limitations of
cations with an area under the curve (AUC) of 0.891, conventional methods by providing continuous,
indicating high discriminative power. The sensitiv- personalized data that improve risk stratification
ity was 91%, showing the effectiveness of pro-BNP in and clinical decision-making.
identifying the most true positives for cardiovascu-
lar complications, while the specificity was 75%,
indicating adequate identification of patients with- CONCLUSION
out complications [26]. Despite the potential bene- Effective management of high-risk surgical patients
fits of using cardiac biomarkers, the overall quality requires a multifaceted approach that combines
of evidence regarding their effectiveness in routine advanced risk prediction models, biomarker assess-
clinical practice remains limited, leading to the need ments, and frailty evaluations. The integration of
for further clinical research. Specific management artificial intelligence into preoperative and perio-
strategies based on biomarker elevations, especially perative care marks a significant advancement,
combined pre and postoperative measurements, enhancing predictive accuracy and enabling per-
should principally occur within research frameworks sonalized risk management. As technology and
to clarify their impact on patient outcomes. Cardiac research progress, adopting these innovations is
troponins and BNP offer valuable insights into car- essential for improving patient outcomes and
diac risk strata. Careful implementation paired with minimizing postoperative complications. Future
ongoing evaluation is essential to optimize patient management of high-risk surgical patients will
safety during high-risk surgical interventions. benefit from a synergistic approach that merges
comprehensive risk assessment with tailored care
strategies supported by the latest technological
THE ROLE OF FUNCTIONAL CAPACITY IN advancements.
PREOPERATIVE ASSESSMENT AND THE
POTENTIAL OF WEARABLE TECHNOLOGY
Acknowledgements
Functional capacity is a critical aspect of preoper- None.
ative risk assessment that significantly influences
postoperative outcomes [27]. Evaluating physical
Financial support and sponsorship
capabilities and cardiorespiratory function provides
insight into a patient’s ability to handle surgical None.
stress and recover postoperatively. Traditional
methods such as the 6-min walk test (6 MWT) Conflicts of interest
and cardiopulmonary exercise test (CPET) have There are no conflicts of interest.

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 The surgical patient

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