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Preoperative Evaluation of the Noncardiac Surgical Patient
Andrew Grimes, MD
Stacy Jones, MD
image BASICS
DESCRIPTION
  • Preoperative medical evaluation should determine the presence of established or unrecognized disease or other factors that may increase the risk of perioperative morbidity and mortality in patients undergoing surgery.
  • Specific assessment goals include the following:
    • Conducting a thorough medical history and physical exam to assess the need for further testing and/or consultation
    • Recommending strategies to reduce risk and optimize patient condition prior to surgery
    • Encouraging patients to optimize their health for possible improvement of both perioperative and long-term outcomes
  • Synonym(s): preoperative diagnostic workup; preoperative preparation; preoperative general health assessment
EPIDEMIOLOGY
Overall patient morbidity and mortality related to surgery is low. One large study of inpatients looking at 30-day mortality in the United States showed a rate of 1.32%. This rate varies by type of procedure and varies by country. Preoperative patient evaluation and subsequent optimization of perioperative care can reduce both postoperative morbidity and mortality.
RISK FACTORS
  • Functional capacity (1): Exercise tolerance is one of the most important determinants of cardiac risk:
    • Self-reported exercise tolerance may be an extremely useful predictive tool when assessing risk. Patients unable to meet a 4 metabolic equivalent (MET) demand (defined in the “Diagnosis” section) during daily activities have increased perioperative cardiac and long-term risks.
    • Patients who report good exercise tolerance require minimal, if any, additional testing.
  • Levels of surgical risk
    • An increased risk for major adverse cardiac events (MACE) is associated with procedures that are intrathoracic, intra-abdominal, or vascular procedures that are suprainguinal in nature (1).
  • Clinical risk factors (1): history of ischemic heart disease, the presence of compensated heart failure or a history of prior congestive heart failure (CHF), cerebrovascular disease, diabetes mellitus (DM), and renal insufficiency; these risk factors plus surgical risk can dictate the need for further cardiac testing.
  • Age: Patients >70 years of age are at higher risk for perioperative complications and mortality and have a longer length of stay in the hospital postoperatively. (likely attributed to increasing medical comorbidities with increasing age) Age alone should not be a deciding factor in the decision to proceed or not proceed with surgery.
image DIAGNOSIS
PHYSICAL EXAM
  • Assess vital signs, including arterial BP bilaterally.
  • Check carotid pulses; auscultate for bruits.
  • Examine lungs by auscultating all lung fields and listening for rales, rhonchi, wheezes, or other sounds indicating disease.
  • Examine cardiovascular system by auscultating heart and noting any irregular rhythms or murmurs; precordial palpation.
  • Palpate abdomen.
  • Examine airway and mouth for ease of intubation, neck mobility, and size of tongue; note any lesions or dental deformities.
  • If a regional anesthesia technique is being contemplated, perform a relevant, focused neurologic exam.
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • Laboratory testing should not be obtained routinely prior to surgery unless indicated (6)[C]. Specific tests should be requested if the evaluator suspects findings from the clinical evaluation that may influence perioperative patient management.
  • Labs performed within the past 4 months prior to evaluation are reliable unless the patient has had an interim change in clinical presentation or is taking medications that require monitoring of plasma level or effect.
  • P.845

  • CBC (6)[C]
    • Hemoglobin: if a patient has symptoms of anemia or is undergoing a procedure with major blood loss; extremes of age; liver or kidney disease
    • WBC count: if symptoms suggest infection or myeloproliferative disorder or the patient is at risk for chemotherapy-induced leukopenia
    • Platelet count: if history of bleeding, myeloproliferative disorder, liver or renal disease, or the patient is at risk for chemotherapy-induced thrombocytopenia
  • Serum chemistries (electrolytes, glucose, renal and liver function tests): should be obtained for extremes of age; in known renal insufficiency, CHF, liver dysfunction, or endocrine abnormalities; or the patient is on medications that alter electrolyte levels, such as diuretics
  • PT/PTT: if history of a bleeding disorder, chronic liver disease, or malnutrition, or those with recent or chronic antibiotic or anticoagulant use
  • Urinalysis: Routine urinalysis is not recommended preoperatively.
  • Pregnancy test: controversial; should be considered for all female patients of childbearing age
  • CXR is not generally indicated. It can be considered in patients with recent upper respiratory tract infection and in those with suspected cardiac or pulmonary disease (because there is a likelihood for unanticipated findings), but these indications are not considered unequivocal.
Diagnostic Procedures/Other
  • ECG (1)[C]
    • Preoperative resting 12 lead ECG is reasonable for patients with known coronary disease, known peripheral vascular disease, significant arrhythmia, or known significant structural heart disease.
    • ECGs are not indicated for asymptomatic patients undergoing low-risk procedures.
  • The AHA guidelines recommend using the Revised Cardiac Risk Index or the ACS NSQUIP online risk calculator to make an estimate of risk of MACE in the perioperative period. If the risk of MACE is low (<1%), then proceed with surgery. If the risk is >1%, the functional capacity needs to be considered. For patients with a functional capacity of >4 METS, then proceed with surgery. If the functional capacity is <4 METs or unknown, consider pharmacologic stress testing if it will change management (1).
  • PFTs: Definitive data regarding the efficacy of preoperative testing are lacking. The most important factor is preoperative optimization of patients with chronic obstructive pulmonary disease (COPD) or reactive airways disease with indicated use of antibiotics, bronchodilators, and inhaled corticosteroids. Spirometry can help guide therapy. Upper abdominal and thoracic surgery have a higher risk of postoperative pulmonary complications.
image TREATMENT
MEDICATION
  • Reducing cardiac risk
    • Elective surgery should be delayed or canceled if the patient has any of the following: unstable coronary syndromes (unstable or severe angina), recent myocardial infarction (MI) (<30 days), decompensated heart failure, significant arrhythmias, or severe valvular disease.
    • Active HF should be treated with diuretics, afterload reduction, and &bgr;-adrenergic blockers.
    • Perioperative &bgr;-blockade has been shown to reduce mortality and the incidence of perioperative MIs in high-risk patients. Studies conflict, however, in which patients need to be treated, the dosage and timing of treatment, and for what surgeries. Patients chronically on &bgr;-blockers should have the medication continued in the perioperative period. When &bgr;-blockers are discontinued in the perioperative period, 30-day mortality increases. &bgr;-Blockers are reasonable for vascular surgery patients with at least one clinical risk factor. It is not recommended to start &bgr;-blockers on the day of surgery in &bgr;-blocker naïve patients (1).
    • Perioperative statin use may have a protective effect on reducing cardiac complications. Currently, the American Heart Association (AHA) has a class I indication for perioperative statin therapy for patients already on statins prior to their surgery. There is also evidence that vascular surgery patients benefit from perioperative statins.
    • A recent review looked at prophylactic use of aspirin in the perioperative period and did not find a significant effect on perioperative mortality or risk for MI in patients undergoing noncardiac surgery and may be associated with an increased risk of perioperative bleeding. There were important exclusion criteria including patients with recent stent placement (7).
  • Reducing pulmonary risk
    • Recommend cigarette cessation for at least 8 weeks prior to elective surgery.
    • Patients with asthma should not be wheezing and should have a peak flow of at least 80% of their predicted or personal-best value.
    • Treatment of COPD and asthma should focus on maximally reducing airflow obstruction and is identical to treatment of nonsurgical patients.
    • Lower respiratory tract infections (bacterial) should be treated with appropriate antibiotic therapy.
REFERENCES
1. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing non cardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American College of Surgeons, American Society of Anesthesiologists, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society of Vascular Medicine Endorsed by the Society of Hospital Medicine. J Nucl Cardiol. 2015;22(1):162-215.
2. Crossley GH, Poole JE, Rozner MA, et al. The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors: facilities and patient management this document was developed as a joint project with the American Society of Anesthesiologists (ASA), and in collaboration with the American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Heart Rhythm. 2011;8(7):1114-1154.
3. Adesanya AO, Lee W, Greilich NB, et al. Perioperative management of obstructive sleep apnea. Chest. 2010;138(6):1489-1498.
4. Chung SA, Yuan H, Chung F. A systematic review of obstructive sleep apnea and its implications for anesthesiologists. Anesth Analg. 2008;107(5):1543-1563.
5. American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology. 2014;120(2):268-286.
6. Apfelbaum JL, Connis RT, Nickinovich DG, et al. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012;116(3):522-538.
7. Devereaux PJ, Mrkobrada M, Sessler DI, et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med. 2014;370(16):1494-1503.
Additional Reading
&NA;
  • Akhtar S, Barash PG, Inzucchi SE Scientific principles and clinical implications of perioperative glucose regulation and control. Anesth Analg. 2010;110(2):478-497.
  • Chung F, Subramanyam R, Liao P, et al. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J Anaesth. 2012;108(5):768-775.
  • Lander JS, Coplan NL. Statin therapy in the perioperative period. Rev Cardiovasc Med. 2011;12(1):30-37.
  • Pearse RM, Moreno RP, Bauer P, et al. Mortality after surgery in Europe: a 7 day cohort study. Lancet. 2012;380 (9847):1059-1065.
  • Semel ME, Lipsitz SR, Funk LM, et al. Rates and patterns of death after surgery in the United States, 1996 and 2006. Surgery. 2012;151(2):171-182.
See Also
&NA;
Algorithm: Preoperative Evaluation of the Noncardiac Surgical Patient
Codes
&NA;
ICD10
  • Z01.818 Encounter for other preprocedural examination
  • Z01.811 Encounter for preprocedural respiratory examination
  • Z01.812 Encounter for preprocedural laboratory examination
Clinical Pearls
&NA;
  • The preoperative evaluation should include medical record evaluation, patient interview, and physical exam.
  • The minimum for the physical exam includes airway, pulmonary, and cardiovascular exams.
  • Functional capacity, the level of surgical risk, and clinical risk factors determine if further cardiac testing is needed.
  • No preoperative tests are routine.
  • Active cardiac conditions should lead to delay or cancellation of nonemergent surgery.