From the Guidelines
A comprehensive preoperative assessment is crucial before surgery to identify potential risks and optimize patient outcomes, and should include a thorough medical history review, physical examination, and relevant laboratory tests, as recommended by the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery 1.
Key Components of Preoperative Assessment
The assessment should include:
- A thorough medical history review to identify potential risk factors, such as cardiovascular disease, diabetes, and hypertension
- A physical examination to evaluate the patient's overall health and identify any potential issues
- Relevant laboratory tests, such as complete blood count, basic metabolic panel, coagulation studies, electrocardiogram, and chest X-ray, to identify any potential abnormalities
Risk Assessment and Management
The preoperative assessment should also include a risk assessment to identify patients who are at high risk for perioperative adverse outcomes, and develop strategies to mitigate these risks, as recommended by the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1.
Communication and Shared Decision Making
Effective communication among all relevant parties, including the surgeon, anesthesiologist, primary caregiver, and consultants, and the patient, is crucial to ensure that the patient is fully informed and engaged in the decision-making process, as emphasized in the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1.
Use of Risk Calculators
Risk calculators, such as the RCRI, the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) perioperative MI and cardiac arrest (MICA) risk calculator, and the universal American College of Surgeons NSQIP surgical risk calculator, can be used to estimate the likelihood of perioperative adverse outcomes and guide management decisions, as recommended by the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery 1.
From the Research
Goals of Preoperative Medical Assessment
- The ultimate goals of preoperative medical assessment are to reduce the patient's surgical and anesthetic perioperative morbidity or mortality, and to return him to desirable functioning as quickly as possible 2.
- Preoperative assessment should identify high-risk patients and stratify them to individualized monitoring and treatment throughout all phases of perioperative care 3.
Preoperative Evaluation
- A history and physical examination, focusing on risk factors for cardiac and pulmonary complications and a determination of the patient's functional capacity, are essential to any preoperative evaluation 2.
- Laboratory investigations should be ordered only when indicated by the patient's medical status, drug therapy, or the nature of the proposed procedure and not on a routine basis 2, 4.
- Persons without concomitant medical problems may need little more than a quick medical review, while those with comorbidity should be optimized for the procedure 2.
Preoperative Optimization
- Preoperative assessment typically equates to evaluating and accepting the presenting condition of the patient, but it does not allow for meaningful preoperative management of modifiable medical conditions 5.
- A collaborative preoperative clinic can be implemented with the primary goal of improving patient outcomes by identifying and managing modifiable risk factors 5.
- Combining beta-blockers and ACE inhibitors can be an effective treatment for patients with cardiovascular diseases, and can help reduce perioperative morbidity and mortality 6.
Communication and Collaboration
- Collaborative efforts and adequate communication between the medical and surgical teams are necessary to ensure appropriate patient management before surgery 4.
- Proper consultations with appropriate medical services should be obtained to improve the patient's health, and these consultations should ideally not be done in a "last second" fashion 2.