From the Guidelines
Preoperative care for cardiovascular and respiratory function should focus on optimizing the patient's condition to minimize surgical risks, with a particular emphasis on continuing most cardiovascular medications, smoking cessation, and respiratory optimization through maintenance inhalers and incentive spirometry training, as recommended by the most recent guidelines 1.
Key Recommendations
- Patients should continue most cardiovascular medications up to the day of surgery, particularly beta-blockers, statins, and antihypertensives, to prevent rebound hypertension and tachycardia, while holding ACE inhibitors and angiotensin receptor blockers on the morning of surgery to avoid intraoperative hypotension.
- For patients with coronary artery disease, aspirin should generally be continued perioperatively unless bleeding risk is very high.
- Respiratory optimization includes smoking cessation at least 4-8 weeks before surgery, as this reduces postoperative pulmonary complications.
- Patients with asthma or COPD should continue their maintenance inhalers and may benefit from a short course of oral steroids if symptoms are not well-controlled.
- Incentive spirometry training should begin preoperatively, with patients practicing 10 deep breaths hourly while awake.
Rationale
These interventions help maintain cardiovascular stability during anesthesia and reduce the risk of postoperative respiratory complications by optimizing baseline function and reducing inflammation, as supported by the guidelines from the European Society of Cardiology and the European Society of Anaesthesiology 1.
Additional Considerations
- Patients with COPD should have their pulmonary function optimized, including the use of beta-adrenergic agonists and anticholinergic agents, and may benefit from a short course of oral steroids if symptoms are not well-controlled 1.
- Patients with obesity hypoventilation syndrome should be screened for sleep-disordered breathing and pulmonary hypertension, and may benefit from positive airway pressure therapy and perioperative planning to reduce the risk of postoperative complications 1.
- Patients undergoing non-cardiothoracic surgery should be evaluated for the presence of significant risk factors for postoperative pulmonary complications, including chronic obstructive pulmonary disease, age older than 60 years, and congestive heart failure, and should receive pre- and postoperative interventions to reduce pulmonary risk 1.
From the Research
Preoperative Care for Cardiovascular and Respiratory Function
The preoperative care for patients undergoing surgery involves a comprehensive assessment of their cardiovascular and respiratory function to minimize the risk of postoperative complications.
- Cardiovascular function:
- A focused history and physical examination are required to identify signs and symptoms of ischemic heart disease, heart failure, and severe valvular disease 2.
- Risk calculators, such as the Revised Cardiac Risk Index, can identify individuals with low risk (<1%) and higher risk (≥1%) for perioperative major adverse cardiovascular events 2.
- Statins are associated with fewer postoperative cardiovascular complications and lower mortality, and should be considered preoperatively in patients with atherosclerotic cardiovascular disease undergoing vascular surgery 2.
- Respiratory function:
- Postoperative pulmonary complications are common and can be associated with increased mortality and hospital stay 3.
- Smoking and respiratory diseases, including asthma, chronic obstructive pulmonary disease, and obstructive sleep apnea, are associated with developing postoperative pulmonary complications 3.
- Preoperative smoking cessation, supervised exercise programs, and specific respiratory interventions, such as deep breathing exercises and incentive spirometry, can help reduce postoperative pulmonary complications 3, 4.
Recommendations for Preoperative Care
Based on the available evidence, the following recommendations can be made for preoperative care:
- Patients with cardiovascular disease should undergo a comprehensive assessment of their cardiovascular risk, and statins should be considered preoperatively in patients with atherosclerotic cardiovascular disease undergoing vascular surgery 2.
- Patients with respiratory disease should undergo a comprehensive assessment of their respiratory function, and preoperative interventions, such as smoking cessation and supervised exercise programs, should be considered to reduce the risk of postoperative pulmonary complications 3, 4.
- Preoperative testing, such as stress testing, may be considered in patients at higher risk for major adverse cardiovascular events, but routine coronary revascularization is not recommended without specific indications independent of planned surgery 2.